Background
Children in the lowest socioeconomic groups are known to have worse oral health than those in the highest stratum [
1]. In the Australian context of this research, data show the rate of mean number of decayed, missing and filled deciduous teeth (dmft) of children from the lowest socioeconomic status areas are about 70% higher than for those from the highest socioeconomic status areas [
2]. In a recent prospective Western Australian (WA) study of 105 refugee pre-school children following resettlement in Australia, 77% of the families lived in a suburb in the lowest two socioeconomic quartiles (Socio-Economic Indexes for Areas (SEIFA)) [
3]. Of these refugee children, (mean age three years), 62% had at least one tooth with untreated dental caries (decay) and they had a mean dmft of 5.2 (SD 4.1), compared to overall Australian children aged five to six years who had 41.3% with untreated dental caries and a mean dmft of 2.0 [
4].
However, socioeconomic disadvantage is just one of the complex factors that interact to contribute to poor oral health [
1]. Many refugee children already have severe dental disease when they enter Australia, often progressively worsening after resettlement [
5]. Refugee families face many barriers in accessing appropriate health care post-resettlement [
6] and are less likely than non-refugee children to access dental health services [
5]. In the WA study referred to previously, in a 12 month period less than half of the pre-school refugee children with untreated decay saw a dentist, and, compounding the difficulties they faced, 45% had severe disease that required costly specialist dental management [
4].
However, despite this, many health professionals lack a clear understanding of these barriers and of refugee families’ perceptions of oral health in their children. The fundamental premise of this research was that in order to improve the dental health care of the children we first need to understand refugees’ perceptions of oral health and explore their experiences of dental health services. In this way, the barriers and enablers with regard to their utilisation of services in Australia could be identified. The study focused on refugees in new and emerging communities. These are people who are sometimes identified as “high need clients”; due to the length of time spent in refugee camps, their lack of personal support networks in Australia and the additional assistance and resources needed to address the settlement challenges they face. Some communities may share these characteristics for up to ten years [
7]. Australia uses the United Nations High Commission for Refugee (UNHCR) definition for a refugee as someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country [
7]”.
Refugees from new and emerging communities are not homogenous. There are some comparative studies on the effect of different cultures on oral health care for young children which may help identify why the refugee families are not accessing the services that are available [
8]. It has been suggested that improvements in health outcomes within a multicultural population may be attained by identifying the knowledge and behaviours that offer most opportunity for improvement in clinical outcomes [
9‐
11]. For example, it has been shown that the level of behavioural and psychological acculturation within the Vietnamese population living in Australia was an important intervening variable in three outcome measures of oral health. The middle level of acculturation had the worst outcomes. The authors suggested that a reason for this was that cultural belonging was a protective factor and the middle level group may not fit into either culture [
9]. Other studies have demonstrated that cultural or parental perspectives affect oral health in refugee populations [
12‐
18]. Nevertheless, there is still minimal qualitative data on the effect of traditional practices and of transit and resettlement experience on the behavioural and psychological adaptation required for refugees to value and adequately manage early childhood oral health.
Demonstrations of “the capacity to manage (their own) health and wellbeing have become central components of citizenship in post-industrial societies [
19]”. Measuring this capacity has led the concept of health literacy. “Health literacy” refers to accessing, understanding and using information to make health decisions [
20,
21]. For example, in a Canadian study of immigrant women participants said to have high health literacy asked more specific questions about diet-related cancer prevention than women with low health literacy. The authors concluded that, to optimise their understanding, both groups needed specific, culturally sensitive information at the right level for their current level of literacy [
22]. Similarly, a study of Australian migrant women concluded that new immigrants require a staged introduction to new food specific information [
23]. However, despite the importance of health literacy levels, strategies for assessing these by dental teams remain largely unexplored [
24].
Others have suggested that more understanding of the construct of health care empowerment, i.e. an increasing involvement of patients and clients in their own health care, is needed. Assuming people have a desire for choice and control over their own health, they can become engaged, informed, collaborative, committed and tolerant of uncertainty [
25,
26]. The construct is influenced by the interplay of cultural, social, and environmental factors, personal resources and intrapersonal factors. Critically, the refugee population cannot be at this level of empowerment whilst experiencing the stress of resettlement. Therefore, service providers need to consider the refugee experience and its impact on health behaviours of this population [
8,
27].
The present study explores the perceptions of new and emerging refugee communities in Western Australia with regard to their experiences of dental health services, in order to increase understanding of and improve oral health literacy within these communities. It is intended to provide valuable information for the planning and delivery of culturally responsive pre-school oral health and oral health promotion strategies.
Aims
The purpose of this study was to explore how humanitarian entrant refugees understand and make sense of good oral health in pre-school aged children. The three research questions that guided the study were:
a)
What are refugee carers’ knowledge of and understanding of oral health in children, with specific reference to the causes, impact and prevention of early childhood caries (ECC)?
b)
Are there any issues with current access to services for the treatment of ECC?
c)
What are the main barriers and enablers for these refugee families to achieving adequate oral health in early childhood?
Methods
Study design and methodology
The methodological approach used for this research study was a community-based participatory qualitative study, using focus groups supplemented by individual interviews. This approach was chosen to promote engagement and capacity building strategies in the community through participants’ sharing of experience and expertise, thereby cultivating community ownership of the research outcomes [
28‐
30].
Community involvement was fostered, firstly, by the employment of a research assistant from the community, who was trained in basic qualitative research techniques by an experienced research team facilitator, and, secondly, by the establishment of a community reference group (CRG).
The sixteen CRG members included bilingual representatives from four new and emerging communities, refugee service agencies, health promotion and community refugee health professionals. The CRG worked with research team members to develop the terms of reference for the study, named the study “Beginning with Healthy Teeth” (BHT) and advised on questions, recruitment, methodology and translation of findings in a culturally appropriate way [
31].
Data collection
The sampling was purposive. The inclusion criteria were parents, grandparents, or guardians of humanitarian entrant or asylum seeker children aged less than five years from new and emerging refugee communities. Recruitment of focus group members was through invitation by CRG bicultural workers and community representatives. An invited sample of community refugee child health nurses was interviewed to enhance the understanding of refugee oral health issues.
Focus group interviewing was used because this has been shown to facilitate gathering of richer data, and to be culturally safer, than individual interviews in migrant and refugee women [
31,
32]. Focus groups also encourage storytelling, which is central to participatory action research [
29]. At the beginning of the focus group, participants were asked to respect one another’s confidentiality and opinions.
For the focus groups a semi-structured technique was used. The questions were based on participants’ ideas and experiences related to pre-school oral health beliefs, utilisation of dental services, and early feeding and family nutrition practices pre- and post-settlement. Focus groups were conducted in the participants’ own languages and translated into English by interpreters during the focus group.
The audio recordings were transcribed verbatim into English and all identifying data were removed at this point. Data collection continued until saturation, which “occurs when researchers sense they have seen or heard something so repeatedly that they can anticipate it”, was reached [
33]. A research diary was kept by the researchers conducting the focus groups to provide evidence of the research process and enable reflection on personal positions and biases that could influence the analysis [
34].
The demographic data collected from the interview groups included education level, occupational status, ethnicity, transit country, years since arrival in Australia, language(s) spoken and age group.
Data analyses
Demographic data describing the participants were analysed using SPSS Statistical Software Version 19. Iterative inductive thematic analysis was used to code, sieve, group and interpret the data and elucidate themes [
34] utilising NVivo (Version 9) computer assisted qualitative data analysis software of the combined qualitative data transcripts and written notes. Two of the researchers analysed data independently at each stage of the process, and discussed similarities and differences before the next iteration. Data were tagged by ethnicity, and for common themes and differences and questions for further analysis. The interpretation of the data was then reviewed by the researchers for clusters by ethnicity and for cultural soundness by community representatives of each ethnic group. Finally the transcripts and analysis were reviewed, common themes and differences integrated, and findings compiled. The draft report was presented back to the CRG by the researchers at the completion of the study for their recommendations.
Approval was obtained from the Child and Adolescent Health Service Human Ethics Committee (Princess Margaret Hospital for Children #2010EP) and the University of Western Australian Human Ethics Research Committee (RA/4/1/5640). Permission was obtained from each participant for audio recording of the focus group or interview. Interpreters were used for all focus groups and for ensuring the signed consent was understood.
Discussion
It was clear that the complex issues facing refugees resettling in Australia have led to many of them feeling overwhelmed. This is reinforced by misinformation and low health literacy in the families, leading to much misunderstanding. In addition, health professionals trying to assist the families are hampered by misunderstandings in the health system and policies and become frustrated. The recommendations developed by the CRG (see recommendations proposed by the community reference group in results section) represent opportunities to address the current situation, which can deprive refugee pre-school children of the oral health care they desperately need [
6].
These outcomes of the study demonstrated that there was a general lack of understanding in oral health services of the intrinsic resettlement and logistical difficulties that refugee family’s experience. It revealed a need, when implementing an oral health initiative/model of care, for more consideration to be given to the complex interactions between the diverse past experiences of parents, a wide range of resettlement issues and conflicting priorities, and the difficulties many refugees experience when accessing Australian dental services. Our findings suggest that an understanding by providers that a more culturally sensitive approach would simplify and support access to dental services and improve treatment rates, as well as reduce the need to treat further dental caries.
This in turn requires addressing the complex interplay of causal factors that can influence oral health decisions [
1]. Increasingly the importance of tailoring action to take into account the social determinates of oral health behaviour is being recognised. Our study findings support an understanding that a focus on behavioural change has not been particularly effective in improving refugee preschool oral health and that reorientation should occur to take into account common risk factors of the social determinates of health, including among others, prioritising disadvantaged groups, offering intensive and tailored support, improving accessibility and integration with other services [
35‐
38]. Our Opportunities for Change Model, which shows the factors that influence refugee preschool health care, provides a framework for the development of an improved approach.
The development of the model was made possible by our use of a participative community methodology. From this emerged the issues that the refugee participants and health community nurses working with them perceived to be the enablers and barriers affecting the oral health care of the preschool children. In some cases, factors emerged that could be reinforced as a means of persuading parents to adopt improved oral health care strategies. For example, some African participants valued white teeth, and could easily accept a way of ensuring this. A history of breast-feeding was common, and could be further encouraged to reduce use bottle feeding and ingestion of sweet drinks. Identifying weaning foods was problematic for some Burmese mothers and help with this could reduce the consumption of sugar rich food and drinks. Other issues like fear of the (fluoridated) tap water supply could need strong evidence to overcome. Some other issues, such as the development of healthy eating habits in children with regard to sugary foods and drinks and encouragement to resist peer pressure and advertising, are a broader issue than oral health only, and may need to be addressed in a wider public health domain.
Our methodology raised community awareness of the need and benefit of early oral health. Our community reference group made ten recommendations that they identified as being likely to improve early oral health of refugees. A key to the success of these recommendations was the establishment of a refugee liaison dental position (RLDP).
The refugee liaison position would provide a link between the dental service provider, refugee community nurses and refugee families within a cultural group. The RLDP would promote links to the established network of bilingual workers within each different broad cultural group, to provide culturally specific input and access into local established social networks, such as play groups. Such a tiered approach, using established links, would reduce costs, increase capacity and provide for specific cultural needs.
The value of link workers was identified in a UK study on young black African migrants which identified that “effective health promotion communication requires more than the mechanical translation between English and the ‘foreign’ language, but must take into account client’s lived experiences, values, beliefs and cultures [
39] p268”. In Australia, a review of refugee maternal child health services concluded that the “role played by bicultural workers should be recognised and utilised in a way that benefits clients and service providers” [
40] (p14). In another example, the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination found models that included bilingual staff with interpreters led to better quality of care [
41]. To our knowledge, dental services have not yet widely implemented these ideas.
A further outcome of our participative community methodology was the willingness of many participants to assist with addressing the preschool oral health challenge within their community. Examples were the provision of translation services, advising on traditional foods and helping with cross-cultural understanding. Involvement at this level would be likely to further encourage local participation in preventative initiatives.
The recommendations of the CRG may be seen to fall into two broad interwoven categories: addressing lack of knowledge and understanding and addressing inadequate resources.
While the establishment of an RLDP would contribute towards the implementation of the recommendations, the dental profession can also do much to improve the service. Families in our study whose children had had a positive experience with a dental provider reported longer term improvements in family attitudes to deciduous teeth and were more likely to seek ongoing preventative care. Unfortunately, more commonly the experience was difficult, not only financially, but also because it was compounded by poor communication, transport difficulties, inconsistent use of interpreters and misunderstandings. Our study has reinforced previous research that culturally safe dental services and culturally secure dental staff, including office staff, are an important key to improving access [
42,
43]. The training of oral health care professionals and the appropriate accreditation protocols need to address this gap. Link workers can also help dental staff to understand resettlement difficulties and cultural understandings. More integration of mainstream refugee health services and dental services would also help, e.g., by reducing clinic attendance difficulties such as interpreter use, transport, miscommunication and multiple appointments. It may also increase the understanding that poor oral health can result in poor general health.
The need for improved education materials and communication was clearly established. This currently lacks co-ordination and would be one of the principal functions of an RLDP.
Limitations and further research
The strong community and stakeholder engagement throughout the data collection, data analysis and recommendations phases of the project ensured the cultural appropriateness of the research as well as establishing trustworthiness of the findings [
44,
45].
However, a limitation was that we explored the attitudes and understanding of refugee families and of community nurses, but not of dental health services toward the needs of the families, which is a clear direction for future research. We did demonstrate that from the perspective of the refugee clients the significant difficulties these families face were often not considered in service delivery.
The study was conducted in the context of an urban area of Western Australia, with a purposive sample of volunteer participants. It is qualitative in methodology, so different perspectives may be obtained in other contexts and with other participants. Nevertheless, the outcomes may be evaluated for their transferability to other situations where the experience of the participants may be of value.
Given the multifactorial and complex interacting factors reported in this study, enhancement of oral health by improving families’ ability to manage through improved sense of control and the development of health literacy during acculturation are also worthy of further study [
46,
47].
Conclusions
The participatory approach of this study has enabled a comprehensive description of the issues involved in the current failure to provide adequate dental/oral health for a cohort of preschool children that suffer high morbidity and are particularly vulnerable. The involvement of refugees themselves, as well as health care professionals provides a basis of cross-cultural understanding and hence an opportunity for all the groups to work together for the future of these vulnerable children. Action now will prevent increasing oral health problems in the future, and consequently long term saving of scarce resources will occur.
Change is already occurring with the inclusion of a dental professional in the Western Australian health care screening team for refugees. In addition, options for improved delivery of dental treatment for this group are being explored which will be inclusive of dental students; thus providing awareness of refugee issues to the next generation of dental practitioners.
Nationally, resourcing at government level and broad “higher level” issues are being addressed through recommendations to the development of the next Oral Health Plan for Australia. These issues, however, will remain challenging.
Competing interest
The authors declare that they have no competing interests.
Authors’ contribution
PN conceived, designed and coordinated the study, led the CRG, carried out the focus groups, performed data analysis and interpretation and drafted the manuscript. AA-H participated in the CRG, assisted with carrying out the focus groups, performed data analysis and interpretation, provided cultural interpretation and assisted with editing the manuscript. NK and LSS contributed to the design of the study, provided expert oral health advice, participated in the CRG, assisted with the development of the model and editing of the manuscript. SC conceived the study, contributed to the design, provided expert refugee health advice, assisted with the development of the model and editing the manuscript. All authors read and approved the final manuscript.