The role of indigenous health workers in promoting oral health during pregnancy: a scoping review

Globally, Indigenous populations experience inequality in health status across the lifespan compared to their non-Indigenous counterparts [1]. While the factors which contribute to these inequities vary across continents, the inherent issues are remarkably similar. They are attributed to a combination of socioeconomic factors, colonisation, globalisation, migration, trans-generational loss of culture and disconnection from the land [2]. Although there have been some improvements in health outcomes in recent years, the gap in Australia remains significant [3].

In Australia, the Aboriginal and Torres Strait Islander people have poorer outcomes in maternal and infant health. A number of reports focusing on Indigenous people in Australia, New Zealand, Canada and the United States have shown that among pregnant women, the rates of gestational diabetes and the risk of developing Type 2 diabetes are higher compared to non-Indigenous women [4, 5]. Further, infants who are born to Australian Aboriginal and Torres Strait Islander mothers are also more likely to be born pre-term and of low birth weight [6] compared to Australians of other descents. In addition, Aboriginal and Torres Strait Islander children are twice as likely to develop early childhood caries (ECC) in their deciduous teeth and caries in their permanent dentition, compared to other children [7]. ECC is the most common chronic childhood disease worldwide and affects various aspects of the child’s functioning and quality of life [8]. Although typically overlooked, some evidence supports that maternal oral health may be associated with these health outcomes [9, 10].

During pregnancy, physiological factors such as hormonal variations, incidence of nausea and vomiting and dietary changes, increase the risk of pregnant women to dental problems such as dental decay and periodontal diseases [11, 12]. This is further exacerbated by sub-optimal diabetes control that has been associated with higher salivary glucose secretion, thus contributing to plaque accumulation [13, 14]. Poor maternal oral health has also been linked with increased adverse birth outcomes such as preterm birth, low infant birth weight and preeclampsia [15, 16]. Periodontal disease has also been shown to affect glycaemic control and contribute to diabetes complications [17]. Furthermore, maternal dental decay can also contribute to ECC as some babies can acquire their oral flora from carers, especially mothers, in addition to fomites such as feeding utensils which can facilitate bacteria transmission [18, 19].

Indigenous Australian pregnant women have a higher prevalence of dental pain relative to the general population and are more likely to avoid certain food due to these problems [20]. In light of the importance of maternal oral health, all pregnant women in Australia are encouraged to have an oral health check and education with their antenatal care provider, including treatment with a dental professional if required [21], similar to the United States, whereby women are advised to consult a dentist early during pregnancy and are provided oral health education, risk assessment and referral during antenatal care [22]. Regrettably, Indigenous mothers are more likely to attend their first antenatal visit later in the pregnancy, and these visits are less frequent than that of non-Indigenous pregnant women [23, 24]. The literature also reports a trend of underutilisation of preventive health services, including dental services [25, 26]. While financial cost is a main barrier to health service utilisation for this population [27], underlying social and historical factors continue to contribute to their distrust of healthcare professionals and the health system [28].

In view of the current challenges in accessing oral healthcare for Indigenous pregnant women worldwide, it is timely to explore alternative care providers to facilitate dental health-seeking behaviours. Indigenous Health Workers (IHWs) are well-placed to fill this gap because of their insight into the specific cultural needs and protocols of their communities, the importance of family networks and the impacts of colonisation on their health status and access to health services. IHWs in Australia originated from the Northern Territory during the 1950s where they were initially professionally employed as leprosy health workers, and later segued into their role as medical assistants. During the 1970s, they were recognised as important cultural brokers within their communities [29] as they were able to bridge the disconnect with non-Indigenous health professionals, and facilitate the process of accessing mainstream services by crossing the cultural barriers [29, 30]. This resulted in the development of the Aboriginal-controlled health services in Australia. In the non-dental health context, IHWs in Australia have been successful in leading culturally-appropriate health promotion and educational activities, in addition to being advocates for Indigenous communities [31‐33]. Nevertheless the roles and functions of IHWs are often not well-defined as their roles are usually contingent on the local community’s needs, crossing the boundaries of clinicians, social support workers, cultural mentors and managers [29]. Despite the effectiveness in promoting primary healthcare among their Indigenous communities, a paucity in awareness by other healthcare workers, employers and organisations of their broad skillset may have contributed to the limited opportunity for training and career development [29]. Thus, the role of IHWs in promoting oral health for pregnant Indigenous women has received little attention.

Database searches yielded 1640 records. After 1405 duplicates and records screened by titles were excluded, 235 abstracts were screened for relevance; identifying 63 pertinent records. The full texts of the 63 papers were reviewed using inclusion and exclusion criteria. Three government-published documents were also included. Twenty-two articles were identified in this scoping review in relation to the potential role of IHWs in promoting oral health, training programs and potential oral health screening tools that can be used by IHWs for women during the antenatal period (Fig. 1). Studies were based in the United States (n = 7), Canada (n = 2), Australia (n = 11), Turkey (n = 1), and India (n = 1). These papers were clustered into three broad focus areas: i) role of IHWs in promoting maternal oral health (n = 12); ii) antenatal oral health training programs for IHWs (n = 7); and iii) potential antenatal oral health screening tools suitable for IHWs (n = 5) (Table 1).

A review of the literature indicated that some IHWs have had roles in improving oral health outcomes of pregnant women, particularly in South Australia. However, there are currently no ‘proof of concept’ interventions, training programs or screening tools that can provide IHWs with the knowledge and skills to promote maternal oral health and refer pregnant women appropriately to dental services. While one study by Mathu-Muju et al. [38] trained IHWs to promote oral health among pregnant women, it focussed on reducing rates of ECC in children.

Although there is some evidence of maternal oral health training programs and screening tools available for non-dental health professionals, certain issues require consideration prior to their use by IHWs. An important factor to consider is whether these interventions are culturally appropriate. Kreuter and colleagues [59] identified cultural appropriateness to be an essential element in interventions for Indigenous populations to reflect their unique health values, practices and behaviours. Another factor is that these programs were designed for individuals with a specific skill set to undertake oral assessments and provide oral health education. Consequently, there may be an incongruity between the educational background of IHWs and the clinical care requirements of these programs. For instance, some of the programs and tools were designed for midwives, nurses or other health professionals who typically complete tertiary level education [60]. However, in Australia, IHWs may not necessarily have the same degree of educational qualification as many complete vocational education only [61].

Despite this, a university-level education may not be a necessary pre-requisite to raise oral health awareness or to provide clinical care. In Australia, the United States and Canada, IHWs encouraged oral health within communities and played integral roles in applying fluoride varnish [38, 40, 43, 49]. Various other studies have similarly demonstrated the key role of an IHW in breaking down barriers and bridging the gap in other healthcare settings. In the Australian state, Victoria, an Aboriginal liaison officer was the key contact through whom communities could choose to engage with the service [41]. They have also acted as a foundational support and conduit in the provision of care in mental health and cardiovascular settings where they developed mental health knowledge and assessment skills; improved Indigenous people’s transition to mental health services; and more effectively delivered cardiovascular health education and care in hospitals with the expertise of other health professionals [62‐64]. These studies highlight the capacity of IHWs to educate, assess and assist pregnant women to navigate through the healthcare system.

The literature also emphasises their role in brokering between communities and other healthcare professionals, including services with GPs, midwives, nurses and dentists. Walker and colleagues [65] explored the perspectives of health personnel, excluding IHWs, on the oral health role of IHWs. Their findings demonstrated that dental and non-dental health personnel perceived IHWs to be in an important position to effectively promote oral health within their communities. Another study conducted with IHWs suggested that appropriate oral health training should be given by a team of IHWs and dentists to relay the relevant information to IHWs [66]. They also highlighted that training needed to be adopted by the team and that there should be adequate management support.

Models of care that enable effective partnerships between Indigenous women and IHWs, and that focus on continuity of care ensure that cultural needs are respected during this transition into parenthood. IHWs are integral to these partnerships as they share the same “language” as their community which facilitates effective communication [67]. This common language encourages compliance to interventions and uptake of available health services, including dental services, within the healthcare system [29, 68]. Having the same language, fosters a relationship where patients feel a sense of empowerment and feel included in decision-making during the perinatal period, which further enhances self-efficacy [69]. Conway and colleagues [70] attributed the success of their program, which aimed to provide holistic, patient-centred chronic care management to Indigenous Australians, to its focus on the patient’s story; providing patients the opportunity to make decisions about their own health.

Another important aspect in developing models of care in this area is to ensure the Aboriginal community is ready to receive oral health information from AHWs. One way of addressing this is to use motivational interviewing (MI). MI is a client-centred counselling intervention designed to elicit intrinsic behavioural change [71]. MI techniques have demonstrated significant effectiveness in improving health outcomes including blood pressure, cholesterol and body mass index [72].

Lastly, for effective transitional care and effective partnership models of care, there needs to be adequate support from the healthcare system. This may require organisational changes and sufficient resources and personnel to enact change [73, 74]. In Australia, free dental care generally is available through the public healthcare system for adults with low income. Although eligibility may not be conditional to Aboriginal and Torres Strait Islander status depending on the state, these individuals receive priority access [75]. Despite priority access, a high proportion of Aboriginal and Torres Strait Islander Australians do not regularly attend a dental service [76]. Campbell and colleagues [77] identified several barriers which can affect their access to health services which include long waiting times, distance, lack of transportation and previous experiences of racism. The lack of recruitment of Aboriginal and Torres Strait Islander staff in the healthcare system is another cited problem. It is recognised that to consolidate the Aboriginal health workforce requires specific support for the challenges they are likely to face including racism, community responsibilities, family issues, sense of isolation and stress and poor education [78]. To improve access, some Aboriginal Health Services, which provide free healthcare to their communities, are funded to provide dental care [75]. However, as not all Aboriginal Health Services receive funding for dental care, it is important to explore strategies to increase the number of Aboriginal and Torres Strait Islander dental staff and link their community to public dental services. The literature has shown great potential for capacity building IHWs to provide culturally-appropriate oral healthcare and referral to dental services within the healthcare system for pregnant women with adequate organisational support and resources.

There were a number of limitations in this review that need to be acknowledged. The strength of the evidence of the intervention studies which included IHWs were poor based on their study design quality [79] while the grey literature included may not necessarily be critically peer-reviewed. Post-hoc analyses were frequently utilised in studies and few conducted significance testing. A possible explanation for this might be associated with the challenges of developing culturally-appropriate training programs and tools since considerable time may be necessary to negotiate and build partnerships with Indigenous communities [32]. There is also the ethical challenge of conducting rigorous research while ensuring that healthcare is not compromised for this vulnerable population. It was also difficult to define the role of IHWs from country to country which therefore limited comparisons. Further, there was a paucity of evidence comparing Indigenous populations with other disadvantaged groups, which may be a more useful comparison in identifying sociocultural barriers in future studies.

IHWs over the globe have had some role in promoting oral health in the antenatal setting. Further work is necessary, however, to develop validated antenatal oral health training programs and screening assessment tools that respect Indigenous cultural values. More importantly, models of care that demonstrate and foster mutual partnerships that assist Indigenous peoples in accessing dental care require further research for implementation across the population.