Informing a culturally appropriate approach to oral health and dental care for pre-school refugee children: a community participatory study

'The Letter Says I May or May Not Be Eligible… It Is a Big Doubt and Frustrating:' A Qualitative Study on Barriers and Facilitators to Children's Oral Healthcare From the Perspective of Karen Refugee Parents in Victoria

BACKGROUND

Australia has a longstanding tradition of resettling refugees and individuals in humanitarian need. Among these, the Karen community from Southeast Asia is rapidly growing in Australia. The absence of data on the barriers they face in accessing dental services is concerning. This study explores the barriers and facilitators Karen refugees encounter when seeking oral healthcare for their children in Australia, aiming to understand their experiences.

METHODS

Using a qualitative research design with a phenomenological approach, we conducted semi-structured interviews with 23 parents (17 females and 6 males) who had been in Australia for 1-17 years. Each interview, lasting between 35 and 60 min, was audio-recorded and transcribed verbatim. The transcripts were thematically analysed through an inductive, data-driven approach, focusing on open coding and participant-based meanings.

FINDINGS

Nine main themes were identified. At the individual level, cultural practices, parental behaviours and perceptions were the primary barriers. At the organisational level, long waiting lists in the public dental system were significant barriers. Additionally, a lack of knowledge about financial benefits and government support for children's dental care deterred refugees from seeking dental services. The results also highlighted the strengths of support networks, free dental care for children and school-based dental care programmes. Parents reported experiences of inadequate oral healthcare, citing issues such as insufficient cultural sensitivity training among dental service providers, interpreter problems and shortages. These experiences revealed gaps in the provision of oral healthcare services.

CONCLUSION

When designing tailored oral health promotion programs, all stakeholders must consider the lived experiences of refugees as valuable sources of information.

PATIENT OR PUBLIC CONTRIBUTION

The authors thank the parents and carers from the Karen refugee community for sharing their experiences with the oral healthcare of their children. Recruitment was facilitated by the Karen Organisation of Bendigo and Bendigo Community Health Services. An interpreter from the Karen refugee community assisted in all the interviews.

Newcomers' perceptions of their experiences with oral health care in Canada and the United States

Background

Recently, an increasing number of immigrants and asylum seekers and refugees (ASRs) have settled in both Canada and the United States. The poor oral health status prevalent among this population is a significant issue. Oral health professionals in both countries should understand newcomers' experiences with oral health care services to become more culturally competent. This narrative review aims to explore the experiences of immigrants and ASRs with oral health care in Canada and the United States and identify research gaps for future qualitative studies.

Methods

This review was conducted from January to April 2024 using Arksey and O'Malley's framework and the PRISMA-ScR guideline. Four electronic databases (PubMed, CINAHL, DOSS, and EMBASE) were searched using keywords grouped under 2 themes: "immigrants" and "oral health service." Only peer-reviewed qualitative articles published in English within the last 10 years were selected.

Results

Of 1349 original studies identified, 8 articles were included and reviewed. Three main themes emerged from newcomers' perspectives on their experience with oral health care in Canada and the United States: quality of care and professional behaviours, concerns about pediatric oral health care, and challenges in accessing care.

Discussion and Conclusion

There is a need to improve cultural sensitivity and cross-cultural communication skills curricula in professional oral health education. Furthermore, making dental insurance more affordable, clarifying coverage for newcomers, and promoting collaboration between stakeholders and policymakers are essential to addressing the oral health concerns of immigrants and ASRs. Future research should prioritize primary interviews to gain more insights into newcomers' experiences when accessing oral health care.

Study protocol for a pilot quasi-experimental study on oral health education for nurses and community health workers in Nigeria

Introduction

The primary health care system provides an ideal setting for the integration of oral health into general health care as well as equitable access to oral health care. However, the limited oral health knowledge of primary health care workers necessitates appropriate training before they can participate in health promotion efforts. This pilot training was designed to examine the impact of the Oral Health Education module for Nurses and Community Health Care Workers on their oral health awareness and referral practices.

Methods

This study will utilize a quasi-experimental design (pre-and post with a non-equivalent control group) to assess the impact of a five-day pilot oral health education program on the knowledge and referral practices of Nurses and Community Health Workers in primary health care centers in three states in Nigeria-(Lagos, Oyo, and Kano). The training modules were developed based on the six iterative steps described in the intervention mapping framework - needs assessment, highlighting program objectives and outcomes, selection of theory and mode of intervention, designing program based on theory, designing implementation plans, and developing an evaluation plan. Only the intervention group will participate in the full educational training sessions but both groups will complete the pre-and post-intervention questionnaires.

Discussion

This pilot training combined the standardized training modules from the recently launched "Oral Health Training Course for Community Health Workers in Africa" and a newly developed maternal and child oral health module by our group using an evidence-based approach. To the best of our knowledge, this is the first program to examine the impact of the standardized OpenWHO modules. The success of this training will lay the foundation for developing a sustained channel for providing oral health education at the primary health care level in Nigeria, West Africa, and Africa.

Facilitators and barriers to asylum seeker and refugee oral health care access: a qualitative systematic review

Objectives Asylum seekers and refugees (ASRs) encounter barriers when accessing oral health care (OHC). A qualitative systematic review was conducted to understand the perceptions, attitudes, behaviours and experiences of ASRs regarding their OHC. Themes were extracted to identify the barriers and facilitators ASRs face when accessing OHC.Data sources PubMed, APA PsycInfo, Cochrane Database, Web of Science and CINAHL were searched on 4 and 5 October 2022.Data selection Primary studies including ASRs of any age or nationality were included. Qualitative data of ASRs' lived experiences of oral health (OH) and accessing OHC were extracted. The Critical Appraisal Skills Programme quality appraisal tool was applied.Data synthesis Data findings were extracted and meta-aggregation performed using inductive reasoning. A total of 13 primary qualitative studies were included. Three barriers were identified, including difficulty accessing treatments and appointments, cultural and language changes, and ASRs' lack of OHC knowledge or incongruous beliefs surrounding OH. Two facilitators were identified as good OH education and support from care providers or government.Conclusions Decision-makers should adapt policy to facilitate access to OHC and educate ASRs on OH. More research is needed to understand the barriers and facilitators to OHC for other people groups who experience health inequalities.

Canadian immigrants' oral health and oral health care providers' cultural competence capacity

Background

Immigrants to Canada count among the socially disadvantaged groups experiencing higher rates of oral disease. Culturally competent oral health care providers (OHCPs) stand to be allies for immigrant oral health. The literature reveals limited knowledge of practising OHCPs' cultural competency, and little synthesis of the topic has been completed. A scoping review is warranted to identify and map current knowledge of OHCPs' understanding of culturally competent care along with barriers and facilitators to developing capacity.

Methods

This study was conducted between December 2022 and April 2023 using Arksey and O'Malley's 5-step framework and PRISMA-ScR checklist. Four databases were searched using keywords related to 4 themes: population, provider, oral health, and cultural competence. Peer-reviewed articles published in English in the last 10 years were included.

Results

Search results yielded 74 articles. Title and abstract review was completed and an author-developed critical appraisal tool was applied. Forty-six (46) articles were subject to full-text review and 14 met eligibility criteria: 7 qualitative and 7 quantitative. Six barriers and six facilitators at individual and systemic levels were identified, affecting oral care for immigrants and providers' ability to work cross-culturally.

Discussion

Lack of cultural or linguistically appropriate resources, guidance, and structural supports were identified as contributing to low utilization of services and to lack of familiarity between providers and immigrants.

Conclusion

OHCPs' cultural competency development is required to improve oral health care access and outcomes for diverse populations. Further research is warranted to identify factors impeding OHCPs' capacity to provide culturally sensitive care. Intentional policy development and knowledge mobilization are needed.

Parental recall bias in observational studies: Child dental service use

BACKGROUND

Parents are frequently used to recall events of exposure and disease as a proxy for their children in observational health research.

AIM

To assess the validity of parental recall of children's utilisation of dental services.

DESIGN

Parents in the Longitudinal Study of Australian Children (LSAC) were asked to recall their children's overall dental service use in the previous year and whether the study child had received fillings or extractions due to decay in the previous 2 years. True positives were identified through parents who correctly recalled child dental service utilisation with actual dental treatment received in a linked dataset.

RESULTS

Of the 10 090 participants from the LSAC, 1290 study children had linked dental treatment data eligible for inclusion in this study. The absolute true-positive rate for parental recall of dental service use in the previous year was 82% (n = 1263). Overall true-positive percentages were lower for recall of fillings (40%) and extractions (7%) in the previous 2 years. Increasing number of recall days was associated with the rate of true-positive recall adjusted for other factors in all three models.

CONCLUSION

Accuracy of parental recall for tooth fillings and extractions was low. The use of parental recall for specific dental treatment over a time span of 2 years in further research is not recommended.

Accessibility to dental services by immigrant and refugee children residing in Turkey

BACKGROUND

Turkey is hosting the world's largest immigrant population under temporary and international protection. Due to the social inequalities contributing to early childhood dental caries, the effectiveness of dental care service for immigrant children should be evaluated.

AIM

To evaluate the accessibility of immigrant and refugee children residing in four different regions of Turkey to oral health products and dental treatment services.

DESIGN

A questionnaire consisting of 21 questions was administered: The first six questions elicited demographic data, and the remaining 15 questions asked about oral health habits, access to oral hygiene materials, and dental treatment services. Participants included the parents of 430 children under the age of 18, who were registered with migrant associations in the regions where they lived (Istanbul, Samsun, Hatay, or Ankara).

RESULTS

The majority of the participants were from Syria and Iraq. Of the participants, 42.1% reported that their children's oral hygiene habits had changed negatively after they migrated, 71.9% reported that they had not been to the dentist in the last year, and 82.8% reported that they had not been to the dentist for more than 12 months. Access to oral and dental hygiene products was not difficult for 68.4%. About 62.6%, however, reported that they had difficulty accessing dental treatment.

CONCLUSION

The findings showed that this disadvantaged group had difficulty accessing dental treatment. Therefore, there is a need for national and international health strategies to ensure that immigrant and refugee children have effective access to dental treatment.

Evaluation of a tailored oral health promotion intervention for Syrian former refugees in New Zealand

To investigate a health promotion strategy to improve oral health among former refugees in New Zealand. Former refugees were recruited (n = 63) and answered a questionnaire about their oral home care, smoking, sugar consumption and use of dental services. Participants then joined either focus group sessions to co-design oral health educational material (n = 39) or to be dentally examined for oral hygiene, periodontal health, gingivitis and dental caries and receive motivational instructions to improve their oral health habits (n = 20). Health messages using dual-language leaflets (covering oral home care, smoking, diet and access to services) were subsequently individually delivered monthly to all participants via a mobile phone application. After 6 months, follow-up questionnaires were sent to all participants and those who had been dentally examined were re-examined. Half of those who did not brush twice daily at baseline (54.1%) had increased brushing to at least twice daily by follow-up; 76.9% of those who consumed sugary drinks at least twice daily, reduced their sugar intake. No smokers quit smoking, however, 52.4% reported reducing the number of cigarettes or engaging in smoking cessation activities. Among those who had been dentally examined, plaque scores, gingivitis and periodontal pocketing all decreased significantly. Culturally and linguistically tailored oral health promotion interventions led to improved oral health behaviours for this group of former refugees over a 6 months follow-up period. We expect this to not only improve the oral health quality of life for this population, but also reduce the burden on the health system.

Looking beyond: complex holistic care needs of Syrian and Iraqi refugee children and adolescents

OBJECTIVE

Protracted international conflict has seen escalating numbers of displaced and resettled Syrian and Iraqi refugees, raising concerns for their health and well-being. This paper describes the demographic and clinical profiles of recently resettled Syrian and Iraqi refugee children and adolescents across physical, psychosocial, developmental and educational domains using standardised multidisciplinary assessments.

DESIGN

A cross-sectional observational study was undertaken of initial specialist paediatric multidisciplinary Refugee Health Service assessments completed at the tertiary paediatric hospital (Western Australia) between June 2015 and September 2019.

RESULTS

Three hundred and twenty-seven children and adolescents (264 Syrian, 63 Iraqi) were assessed following resettlement. Witnessed trauma (86%) and disclosed adversity (median Refugee Adverse Childhood Experiences score 3, range 1-14) were universally high. Almost all patients had health issues identified across physical (99%), psychosocial (76%) and developmental/educational (75%) domains. Interrupted education (65%) and death of a family member (16%) were significantly associated with psychological morbidities. Common comorbidities included dental caries (78%), non-infectious disease (76%), vitamin D deficiency (72%), malnutrition (46%; overweight/obesity 23%), and psychological (32%; post-traumatic stress disorder 4.3%) and developmental (9.5%) concerns. Emerging and alarming child protection concerns were prevalent (17%), with females demonstrating especially high risks.

CONCLUSION

This is the largest comprehensive study demonstrating the complex and cross-dimensional health needs and specific vulnerabilities of resettled Syrian and Iraqi refugee children and adolescents. Early comprehensive standardised multidisciplinary paediatric assessments, and culturally safe, trauma-informed interventions and follow-up are required to optimise resettlement outcomes and promote well-being.

Pattern, frequency and causes of dental extraction among children/adolescents Syrian refugees: an observational study

Background

The Syrian conflict has had a massive impact on the dental health of refugees. Dental extraction is a good indicator of socioeconomic position and degree of oral hygiene, however there is a scarcity of evidence in the scientific literature that characterizes the reasons for extraction in refugees.

Aims and methods

The current study looked at the extraction causes and related sociodemographic variables of 322 Syrian refugees (46.3% females, 53.7% males) who were treated in a dental clinic in Zaatari camp (Jordan), from September to December 2019. All child Syrian refugees (aged 4–16) visiting the facility were eligible to participate. A validated semi-structured survey was used to collect clinical and sociodemographic data from the research sample. Chi-square test, Independent sample t-test, and ANOVA test were used to examine associations between the different variables. The significance level was set at P < 0.05.

Results

The total number of teeth extracted was 397: 25 (6.3%) permanent teeth, 371 (93.5%) primary teeth, and one mesiodens (0.2%). Overall, lower teeth were most commonly extracted (56.9%). The most common teeth that required extraction were the lower primary molars, with lower left primary second molars being the most commonly extracted (15.9%). As the level of parental education increased, the mean number of extracted teeth decreased (P = 0.035), additionally, as the frequency of toothbrushing increased extractions due to caries decreased significantly (P = 0.027).

Conclusions

Dental caries and pulpal diseases were discovered to be the most prevalent causes for primary and permanent tooth extraction, with no difference between males and females. The lower left primary molar was the most commonly afflicted tooth.

Oral Hygiene Awareness, Practices and Attitudes among Syrian Refugees in Zaatari Camp and Their Impact on Oral Health Status

PURPOSE

To characterise the oral hygiene habits, attitudes, and oral health practices in relation to sociodemographic factors among refugees in Jordan and to investigate their impact on the oral health status of these refugees.

MATERIALS AND METHODS

This cross-sectional study consisted of two parts. First, a face-to-face interview was conducted using a structured questionnaire including demographic and oral health-related questions. Second, clinical oral examination was performed using WHO criteria, DMFT and oral health indices (OHI-S). The participants were adults, aged 18 and older. All patients attending dental clinics and accompanying personnel in the waiting areas at Zaatari camp during the study period were invited to participate, with a sample size of 547 refugees (males = 212, females = 335).

RESULTS

547 adult refugees participated. 75.3% reported toothbrushing less than twice daily, while flossing was uncommon (9.5%). Toothbrushing habits were significantly associated with gender and smoking status. Untreated carious lesions had a high incidence (94.1%); the mean number of decayed teeth was 5.4 and was statistically significantly higher in males and smokers. The mean number of missing teeth was 3.2 and was significantly associated with males, age, smoking, and presence of chronic disease. Participants who reported conditions that had persisted 1 year or more and required ongoing medical attention or limited activities of daily living or both (e.g. diabetes mellitus, hypertension, heart diseases, thyroid disease, chronic renal disease, rheumatoid arthritis, anemia, peptic ulcer, or asthma) were recorded as having chronic disease. The mean number of filled teeth was 3.2 and was statistically significantly associated with age and presence of chronic disease. The mean DMFT was 11.8 and was statistically significantly higher in males, older people, smokers, and those with chronic disease. The OHI-S was 2.2. The most common complaint was pain (92.2%), and only 1.1% visited a dentist for a check-up.

CONCLUSION

The prevalence of caries was extremely high, with poor oral hygiene practices among refugees, justifying the urgent need to develop and implement targeted oral health promotion, preventive programs and curative strategies and to enable collaboration of the oral healthcare providers and funding agencies to design the most appropriate interventions for this disadvantaged population. In addition, this information can be used as a basis upon which preventive programs can be assessed for efficacy.

V, Bhole S. Diet, Nutrition, and Oral Health: What Influences Mother's Decisions on What to Feed Their Young Children?

The purpose of this study was to learn about mothers' experiences with food choices for their pre-school children in underprivileged communities in Greater Western Sydney (GWS). A total of 20 mother-child dyads living in GWS were recruited to a qualitative study from an ongoing birth cohort study. Participants' houses were visited for semi-structured interviews, which were recorded, transcribed verbatim, and analysed thematically. The interviews yielded five main themes: (i) food choices, nutrition, and health; (ii) accessibility and availability of foods (iii) buying time for parents; (iv) child's age and their preference on food choices; (v) conditioning certain behaviours by family and cultural factors. Nutrition literacy, child's preferences, unhealthy food intake by family members, child's demand, advertising and availability of harmful foods, and time constraints were all mentioned as hurdles to mothers making appropriate meal choices for their children. However, some identified facilitators were promoting parents' knowledge, increasing access to health educational materials, upskilling mothers to providing healthier alternatives, regulating the marketing of unhealth foods. Although, the present study identified critical factors that influence mothers' food choices for their young children, making healthy food choices is a complex practice as it is shaped by individual, social and environmental influences.

Burden of oral diseases and impact of protracted displacement: a cross-sectional study on Syrian refugee children in Lebanon

Introduction Very little is known about the burden of childhood oral diseases in protracted humanitarian settings.Aim This study aimed to assess the prevalence of oral diseases in Syrian refugee children living in Lebanon and to investigate their relationship with the duration of displacement.Methods Data from Miles for Smiles programme for Syrian refugee schoolchildren in Bekaa/Lebanon were used (n = 823). A dental examination was performed to assess the presence of dental caries and abscess. A clinical form was used to collect data on the presence, intensity and duration of dental pain.Results The majority (90%) had dental caries, 57% had dental pain (of which 55% had moderate/severe pain and 38% had pain for more than a month) and 9% had dental abscess. After adjusting for age and gender, children in protracted displacement were significantly more likely to have a higher number of decayed teeth compared to their counterparts who had been displaced for less than five years (RR = 1.19; 95% CI = 1.09-1.29; P <0.001).Conclusions The burden of oral diseases in Syrian refugee children living in Lebanon was high, particularly among those living in a protracted situation. There is a need for evidence-based effective public health interventions to improve this population's oral health.

How Do Mothers Living in Socially Deprived Communities Perceive Oral Health of Young Children? A Qualitative Study

This qualitative study aims to explore and gain an in-depth understanding of the knowledge and perceptions of mothers living in Greater Western Sydney (GWS), one of Australia’s most socio-economically disadvantaged regions, regarding the factors that influence oral health of young children. Mother–child dyads (n = 45) were purposively selected from a population-based cohort study in GWS. Semi-structured in-depth interviews were audio-recorded, transcribed verbatim, and subsequently analyzed using thematic analysis. Five main themes emerged from the interviews: (1) beliefs about child oral health and first set of teeth; (2) awareness and attitudes towards oral health services; (3) identification of caries risk and protective factors; (4) broader cultural and social class influences on childhood oral health practices; and (5) the influence of parental self-confidence, self-efficacy, and perceived control. Overall, mothers reported having limited knowledge and awareness on the importance of baby teeth, child’s first dental visit, and seeking oral health care. Oral health and preventative practices in children were reported to be influenced by past dental experiences, culture and social class, and parental factors. The empirical findings of this study bring our attention to the critical factors that influence child oral health and the opportunities for co-creating child oral health promotion by targeting mothers.

Barriers and facilitators to dental care access among asylum seekers and refugees in highly developed countries: a systematic review

Background

Dental diseases are prevalent among asylum seekers and refugees (ASRs). Despite significant treatment needs, access to dental care in host countries is often limited. The aim of this systematic review was to identify the barriers and enablers to dental care access for ASRs in host countries of very high development.

Methods

Five health and social care databases and eight grey literature sources of information were searched. The Critical Appraisal Skills Programme tool was used to critically appraise included studies. Thematic analysis was undertaken to identify common themes. These were then deductively organised according to Penchansky and Thomas’s modified access model. All review stages were conducted by two independent reviewers.

Results

Nine papers were included in the review. ASRs encounter significant challenges to accessing dental care in their host countries. These include affordability, communication difficulties, insufficient interpretation, limited knowledge of the healthcare systems and healthcare rights, and negative encounters with healthcare teams. The views and experiences of dental care teams providing care to ASRs were explored in only one study.

Conclusions

Both population and healthcare characteristics influence access to dental care for ASRs. Affordability, awareness and accommodation are most frequently described as barriers to dental access for this population. The diverse needs of this population need to be recognised by policy makers, commissioners and practitioners alike. Cultural competence needs to be incorporated into dental services and any interventions to improve access to dental care for this population.

Registration

PROSPERO- International prospective register of systematic reviews (CRD42019145570).

Perception and belief in oral health among Karen ethnic group living along Thai-Myanmar border, Thailand

BACKGROUND

Utilization of oral health services has been low among rural populations in Thailand, especially for minority ethnicity populations living along the borders. The aim of this study was to increase understanding of the determinants of the underutilization of oral health services among these populations.

METHODS

A qualitative study using in-depth interview and semi-structured interview was conducted among participants of Karen ethnicity living in Mae Tan Sub-district, Thasongyang District, Tak Province, Thailand. The interviews focused on exploring the participants' perceptions of oral health problems, oral health and hygiene, and oral health-seeking behaviors. The verbatim-transcribed interviews were analyzed using thematic analysis.

RESULTS

A total of 101 participants (50 adults and 51 children) with a Karen ethnic background took part in the interviews. Most participants could not identify oral health problems and did not perceive dental disease as a problem unless there was severe pain that could not be relieved by painkillers. The Karen ethnic community worked as subsistence farmers, and their busy daily activities consisted of farming, going to the forest to hunt and gather, performing housework, and taking care of their children. Dental health was given a lower priority compared with general health. The perceived value of primary teeth was low, which was identified as an underlying factor resulting in delayed oral health care seeking among this population. The participants had relied on self-care throughout their lifetimes, using either traditional medicines or modern painkillers to relieve toothaches. Fear of dental procedures among children was also described as a barrier to seeking dental health care.

CONCLUSIONS

This study found that the lifestyle and traditions of Karen people living in this area influence their oral health care and hygiene activities as well as their health-seeking behaviors. Further research should emphasize how to improve oral health promotion by providing necessary services and health education appropriately to Karen ethnic populations living along the Thai-Myanmar border.

Education intervention with respect to the oral health knowledge, attitude, and behaviors of refugee families: A randomized clinical trial of effectiveness

Objectives

The study assessed the effectiveness of an oral health educational and behavioral intervention program in improving the knowledge, attitudes, and behaviors of refugee families.

Methods

This randomized 2‐arms, controlled, single site, clinical trial assessed the dental knowledge, attitudes, and behaviors related to oral health at baseline and three times over the course of the 6 months of the intervention in recent refugee families. Participating families were educated on five topics in oral health in two 1‐hour sessions utilizing existing oral health education materials adapted to be linguistically and culturally appropriate for demonstration and instruction. Culturally competent techniques and motivational interviewing styles were also implemented during sessions. Pre/post surveys were used to assess changes to knowledge, attitudes, and behavior among refugee family participants.

Results

Out of the 66 families enrolled in the program, 52 (72 percent) completed visits over the course of 6 months. Differences between the intervention and control groups were not significant between baseline and 3 to 6 months later (P > 0.05).

Conclusions

A short‐term, culturally informed oral health educational and behavioral intervention program did not improve oral health‐related knowledge, attitudes, or behaviors in a diverse group of recent refugee families.

Promoting healthy weight for all young children: a mixed methods study of child and family health nurses' perceptions of barriers and how to overcome them

BACKGROUND

Childhood obesity is a global health concern. Early intervention to help parents adopt best practice for infant feeding and physical activity is critical for maintaining healthy weight. Australian governments provide universal free primary healthcare from child and family health nurses (CFHNs) to support families with children aged up to five years and to provide evidence-based advice to parents. This paper aims to examine factors influencing the child obesity prevention practices of CFHNs and to identify opportunities to support them in promoting healthy infant growth.

METHODS

This mixed methods study used a survey (n = 90) and semi-structured interviews (n = 20) with CFHNs working in two local health districts in Sydney, Australia. Survey data were analysed descriptively; interview transcripts were coded and analysed iteratively. Survey and interview questions examined how CFHNs addressed healthy infant feeding practices, healthy eating, active play and limiting sedentary behaviour during routine consultations; factors influencing such practices; and how CFHNs could be best supported.

RESULTS

CFHNs frequently advised parents on breastfeeding, introducing solid foods, and techniques for settling infants. They spent less time providing advice on evidence-based formula feeding practices or encouraging physical activity in young children. Although nurses frequently weighed and measured children, they did not always use growth charts to identify those at risk of becoming overweight or obese. Nurses identified several barriers to promoting healthy weight gain in infants and young children, including limited parental recognition of overweight in their children or motivation to change diet or lifestyle; socioeconomic factors (such as the cost of healthy food); and beliefs and attitudes about infant weight and the importance of breastfeeding and physical activity amongst parents and family members.

CONCLUSIONS

CFHNs require further education and support for their role in promoting optimal child growth and development, especially training in behaviour change techniques to increase parents' understanding of healthy infant weight gain. Parent information resources should be accessible and address cultural diversity. Resources should highlight the health effects of childhood overweight and obesity and emphasise the benefits of breastfeeding, appropriate formula feeding, suitable first foods, responsiveness to infant feeding cues, active play and limiting screen time.

Understanding oral health help-seeking among Middle Eastern refugees and asylum seekers in Australia: An exploratory study

OBJECTIVES

Andersen's behavioural model of healthcare utilization is one of the most commonly used frameworks for help-seeking across a broad range of health areas, including oral health. The Model has been used in a wide range of previous studies to explore and understand oral health service use among both general populations and ethnic minorities. However, no research has explored its utility in understanding refugees' and asylum seekers' oral health help-seeking. As such, this study aimed to improve understanding of Middle Eastern refugees' and asylum seekers' oral health help-seeking and to determine the utility of Andersen's Model in this context.

METHODS

Interviews were conducted with 26 participants: 20 refugees and asylum seekers, and six oral health practitioners. Results were analysed using thematic analysis.

RESULTS

The results indicated that systemic barriers were of particular concern for refugees and asylum seekers in relation to oral healthcare access. Other components supported previous research concerning the domains of the Model, with additions in relation to acculturation and previous experiences of dental care either in home or resettlement contexts.

CONCLUSIONS

Overall, this study highlights the need for a tailored approach to understanding oral health help-seeking for refugees and asylum seekers, who have particular dental care needs. Resettlement policies should consider system-level barriers to accessing dental services when considering access to health services more generally for refugees and asylum seekers.

The oral health of refugees: Issues and challenges arising from a case series analysis

OBJECTIVES

Little is known of the oral health of refugees globally. The objective of this study was to characterize the oral health and care-seeking behaviours of refugees by investigating patterns of dental services provided to Syrian refugees in Jordan and their association with their oral health status.

METHODS

Clinical records from 444 patients who had received dental treatment over a 9-month period were retrieved and analysed. Collected data included gender, age and the type and number of treatment procedures provided for each patient.

RESULTS

Of the total sample (51.8% female; 48.2% male; aged 18-60 years), pain was the most common presenting complaint (73.0%), with poor aesthetics (17.1%) the second most common presenting complaint. About 63.3% of patients received only one procedure due to patients' lack of follow-up. Over half (54.5%) of dental treatments carried out were extractions, 74.1% of which were due to dental caries; 27.4% were fillings. Endodontic treatment was the least provided procedure (18.2%).

CONCLUSIONS

The oral health status of Syrian refugees is a major concern, given the often-deplorable living conditions in camps and limited, often inadequate access to oral healthcare services. This situation dramatically negatively affects a refugee's oral health. There is an urgent need to provide targeted dental services for this at-risk population. Additional research is warranted on refugees worldwide, and on the provision of appropriate interventions to enable optimal oral health for this population.

Dental Caries Experience and Utilization of Oral Health Services Among Tibetan Refugee-Background Children in Paonta Sahib, Himachal Pradesh, India

The study was done to describe the dental caries experience and dental care utilization among Tibetan refugee-background children in Paonta Sahib, India. The study was conducted on 254 school children in a Tibetan settlement in Paonta Sahib. Examination was done as per World Health Organization Oral Health Assessment criteria (2013). Data on dental services utilization was obtained from the parents of children using a structured questionnaire. Oral examination of 254 school children aged 6-18 years revealed an overall dental caries prevalence of 79.5%. The dental caries experience was greater in the mixed dentition (84%) than secondary dentition (77.3%). The mean DMFT was associated with sex and dental visiting patterns. About 60% children had never visited a dentist before. The main reason for dental visit was tooth removal (43%). The prevalence of dental caries among Tibetan refugee-background school children was high and utilization of dental care was low. A comprehensive oral health program focusing on preventive care and oral health education is recommended.

Providing Care for Children in Immigrant Families

Children in immigrant families (CIF), who represent 1 in 4 children in the United States, represent a growing and ever more diverse US demographic that pediatric medical providers nationwide will increasingly encounter in clinical care. Immigrant children are those born outside the United States to non-US citizen parents, and CIF are defined as those who are either foreign born or have at least 1 parent who is foreign born. Some families immigrate for economic or educational reasons, and others come fleeing persecution and seeking safe haven. Some US-born children with a foreign-born parent may share vulnerabilities with children who themselves are foreign born, particularly regarding access to care and other social determinants of health. Therefore, the larger umbrella term of CIF is used in this statement. CIF, like all children, have diverse experiences that interact with their biopsychosocial development. CIF may face inequities that can threaten their health and well-being, and CIF also offer strengths and embody resilience that can surpass challenges experienced before and during integration. This policy statement describes the evolving population of CIF in the United States, briefly introduces core competencies to enhance care within a framework of cultural humility and safety, and discusses barriers and opportunities at the practice and systems levels. Practice-level recommendations describe how pediatricians can promote health equity for CIF through careful attention to core competencies in clinical care, thoughtful community engagement, and system-level support. Advocacy and policy recommendations offer ways pediatricians can advocate for policies that promote health equity for CIF.

A model explaining refugee experiences of the Australian healthcare system: a systematic review of refugee perceptions

Background

Refugees have significant unmet health needs. Delivering services to refugees continues to be problematic in the Australian healthcare system. A systematic review and thematic synthesis of the literature exploring refugee perceptions of the Australian healthcare system was performed.

Methods

Titles and abstracts of 1610 articles published between 2006 and 2019 were screened, and 147 articles were read in full text. Depending on the type of study, articles were appraised using the Modified Critical Appraisal Tool (developed by authors), the Mixed Methods Appraisal Tool, or the JBI Appraisal Checklist for Systematic Reviews. Using QSR NVivo 11, articles were coded into descriptive themes and synthesised into analytical themes. An explanatory model was used to synthesise these findings. Confidence in the review findings were assessed with GRADE-CERQual approach.

Results

The final synthesis included 35 articles consisting of one systematic review, 7 mixed methods studies, and 27 qualitative studies. Only one study was from a regional or rural area. A model incorporating aspects of engagement, access, trust, and privacy can be used to explain the experiences of refugees in using the Australian healthcare system. Refugees struggled to engage with health services due to their unfamiliarity with the health system. Information sharing is needed but this is not always delivered effectively, resulting in disempowerment and loss of autonomy. In response, refugees resorted to familiar means, such as family members and their pre-existing cultural knowledge. At times, this perpetuated their unfamiliarity with the broader health system. Access barriers were also encountered. Trust and privacy are pervasive issues that influenced access and engagement.

Conclusions

Refugees face significant barriers in accessing and engaging with healthcare services and often resorted to familiar means to overcome what is unfamiliar. This has implications across all areas of service provision. Health administrators and educators need to consider improving the cultural competency of staff and students. Policymakers need to consider engaging communities and upscale the availability and accessibility of professional language and cultural supports. Research is needed on how these measures can be effectively delivered. There is limited research in remote areas and further evidence is needed in these settings.

Electronic supplementary material

The online version of this article (10.1186/s12914-019-0206-6) contains supplementary material, which is available to authorized users.

Nutritional assessment of resettled paediatric refugees in Western Australia

AIM

Nutritional deprivation, inadequate diet and food insecurity are common refugee experiences. The growth and nutritional status of paediatric refugees following resettlement in developed countries and the related interplay with socio-economic factors remain less defined; this study aims to describe these features.

METHODS

Standardised dietary, medical and socio-demographic health assessments of new refugee patients attending a multidisciplinary paediatric Refugee Health Service (RHS) in Western Australia between 2010 and 2015 were analysed.

RESULTS

Demographic data from 1131 paediatric refugees are described (age 2 months to 17.8 years). The majority experienced socio-economic disadvantage, had limited parental education and required interpreters. Nutritional deficiencies were common but varied across ethnicities: iron deficiency (ID) (12.3%), anaemia (7.3%) and inadequate dairy intake (41.0%). A third of children (32.6%) did not consume meat. Infant breastfeeding was sustained (77.8%) in infants <12 months. Prolonged breastfeeding (44.9% aged 12-24 months) was associated with an increased risk of ID (odds ratio 4.0, 95% confidence interval 1.4-11.6). Median body mass index increased significantly for those >24 months between referral and RHS assessment (median period 1.8 months). Overall, 27.1% required additional formal dietetic follow-up, with higher nutritional concerns in refugee children <24 months compared to older patients.

CONCLUSIONS

Identification of frequent post-settlement nutritional concerns has been captured through structured multidisciplinary paediatric health screening. Specific screening for socio-economic influencing factors, including education, poverty and food insecurity, during refugee clinical assessments is recommended. Development of targeted, culturally appropriate parental education resources and interventions may improve management following resettlement. Longitudinal research assessing resettlement growth trajectories is required.

Influence of the social determinants of health on access to healthcare services among refugees in Australia

Refugees in Australia are not fully utilising the healthcare system for several reasons and this may be affecting their overall health outcomes. This qualitative systematic review examined the influence of the social determinants of health on refugees' access to healthcare services in Australia. Electronic databases were searched using terms relating to refugees, social determinants, healthcare services, barriers, enablers and Australia. Only peer-reviewed studies published in English since 2006, which focused on refugees and specifically discussed social determinants influencing refugees' access to healthcare services in Australia, were included. The studies were critically analysed using standard Critical Appraisal Skills Programme Tools. Eight studies were included in the review. Findings reveal multiple factors influence refugees' access to healthcare in Australia, and these can be conceptualised within a social-ecological model of health; that is, they operate across individual, interpersonal, environmental, organisational and policy levels. The novel finding of this review was the re-occurrence of similar influences across multiple healthcare service settings in Australia. The prevalence and re-occurring nature of the social determinants of health suggests that refugees are experiencing multilayered barriers to accessing Australian healthcare. All levels of a social-ecological model must be addressed in any attempt to break down these barriers.

Refugees, asylum-seekers and undocumented migrants and the experience of parenthood: a synthesis of the qualitative literature

OBJECTIVE

To synthesize the recent qualitative literature and identify the integrative themes describing the parenthood experiences of refugees, asylum-seekers and undocumented migrants.

METHODS

We searched seven online databases for the period January 2006 to February 2017. We included English and French published peer-reviewed articles and graduate-level dissertations, which qualitatively examined the parenthood experiences of refugees, asylum-seekers and undocumented migrants. We summarized study characteristics and performed a thematic analysis across the studies.

RESULTS

One hundred thirty eight studies met inclusion criteria. All but three were conducted in high-income countries, mainly in the US. Migrants studied were mostly undocumented from Latin America and refugees from Sub-Saharan Africa. Almost all studies (93%) included mothers; about half (47%) included fathers; very few (5%) included extended family members. We identified three integrative themes: 1) experiencing hardship and/or loss in the context of precarious migration and past traumas; 2) building resilience and strength by bridging language, norms and expectations; and 3) living transnationally: obligations, challenges and resources. Each theme contributed to shaping the parenthood experience; the transnationalism theme intersected with the themes on hardship and loss and resilience and strength.

CONCLUSION

More research is needed with fathers, extended family members, asylum-seekers and in the LMIC context. A transnational lens needs to be applied to programs, policies and future research for refugee, asylum-seeker and undocumented migrant parents. Addressing transnational concerns (family separation and reunification), acknowledging transnational resources, fostering a transnational family identity and conducting transnational and longitudinal studies are potentially pivotal approaches for this sub-population of parents.

Parental Perception of Oral Health-related Quality of Life of Syrian Refugee Children

AIMS AND OBJECTIVES

The conflict in Syria has resulted in the displacement of over 5 million people, many of whom intend to return home at the cessation of hostilities. Oral health plays a critical role in early childhood and this study aimed to qualitatively and quantitatively assess the oral health-related quality of life (OHRQoL) of these children.

MATERIALS AND METHODS

The quantitative assessment of OHRQoL was done using a validated Arabic version of the short-form Parental-Caregiver Perceptions Questionnaire-8 (P-CPQ-8). The P-CPQ-8 was administered to 22 sets of parents of children in a community center catering to urban refugees. A focus group interview and thematic analysis of nine mothers were used to gain a qualitative insight into the problems that could affect the OHRQoL of their children.

RESULTS

The P-CPQ-8 revealed that oral symptoms were the greatest concern of the parents with dental pain being the most commonly reported condition. Although mothers reported higher P-CPQ-8 scores among all domains than fathers, there were no significant differences in the concerns of the fathers and the mothers. The focus group interview raised three major themes - (1) access to dental care, (2) pain felt by the child, and (3) oral hygiene of the child.

CONCLUSION

The parents interviewed in this study were aware of the importance of oral hygiene but reported being unable to look after their children's teeth. Children who are refugees from the Syrian conflict face significant OHRQoL challenges.

Acculturation and Pediatric Minority Oral Health Interventions

Immigrant populations are growing at a fast pace in the United States. Cultural variations can have implications on oral health of children from immigrant households. Length of stay in the United States and language spoken at home, proxies for measuring acculturation, are some of the crucial factors determining the level of acculturation in families. Higher acculturation generally has a positive impact on oral health utilization. Improving cultural competency of dental teams and involving the stakeholders in intervention design and implementation are some strategies that may increase the trust of ethnic minority patients and reduce barriers to access to care.

Oral Health Intervention for Low-Income African American Men in Atlanta, Georgia

OBJECTIVES

To describe the Minority Men's Oral Health Dental Access Program (MOHDAP) intervention and report participants' outcomes and satisfaction.

METHODS

MOHDAP was designed to increase the oral health knowledge of low-income, African American men in Atlanta, GA, in 2013. A community-based participatory approach and needs assessment guided the intervention development, which consisted of 3 educational modules delivered over a 2-day period. All participants (n = 45; mean age = 50 years) were African American men. We assessed changes in oral health knowledge and attitudes at baseline and postintervention via survey.

RESULTS

After the intervention, the percentage of correct responses to questions about gingivitis increased by 24.2% (P = .01), about use of a hard (instead of a soft) toothbrush increased by 42.2% (P < .01), and knowledge of ways to prevent gum diseases increased by 16.0% (P = .03). The percentage agreeing with erroneous statements decreased 11.3% (P = .02) regarding oral health-related fatalism and oral health self-care and 17.4% (P = .05) regarding saving front versus back teeth.

CONCLUSIONS

Community-based oral health educational interventions designed for African American men may reduce oral health disparities among this population.

The oral health of refugees and asylum seekers: a scoping review

INTRODUCTION

Improving the oral health of refugees and asylum seekers is a global priority, yet little is known about the overall burden of oral diseases and their causes for this population.

OBJECTIVE

To synthesize available evidence on the oral health of, and access to oral health care by this population.

METHODS

Using a scoping review methodology, we retrieved 3321 records from eight databases and grey literature; 44 publications met the following inclusion criteria: empirical research focused on refugees and/or asylum seekers' oral health, published between 1990 and 2014 in English, French, Italian, Portuguese, or Spanish. Analysis included descriptive and thematic analysis, as well as critical appraisal using the Critical Appraisal Skills Programme (CASP) criteria for quantitative and qualitative studies.

RESULTS

The majority of publications (86 %) were from industrialized countries, while the majority of refugees are resettled in developing countries. The most common study designs were quantitative (75 %). Overall, the majority of studies (76 %) were of good quality. Studies mainly explored oral health status, knowledge and practices; a minority (9 %) included interventions. The refugee populations in the studies showed higher burden of oral diseases and limited access to oral health care compared to even the least privileged populations in the host countries. Minimal strategies to improve oral health have been implemented; however, some have impressive outcomes.

CONCLUSIONS

Oral health disparities for this population remain a major concern. More research is needed on refugees in developing countries, refugees residing in refugee camps, and interventions to bridge oral health disparities. This review has utility for policymakers, practitioners, researchers, and other stakeholders working to improve the oral health of this population.

Refugee child oral health

The number of people forced to flee their homes and move around the world is increasing rapidly. Such refugee populations are not only more likely to have poor physical, mental and social health outcomes but also to experience difficulties accessing health services in their new country. In particular, children from refugee backgrounds are at increased risk of poor oral health which in time is associated with poor adult oral health and impacts on child health (e.g. growth and development) and well-being. To date, there is little evidence about the nature and extent of their oral health problems nor interventions to improve their oral health status. This article summarises the evidence surrounding the oral health status of children from refugee backgrounds. In addition, a systematic review of the international literature over the past 10 years is presented which identifies interventions to improve the oral health of these vulnerable paediatric populations. Based on this evidence, potential strategies available to dental service providers to optimise provision of responsive dental care are discussed.

Gaps in smiles and services: a cross-sectional study of dental caries in refugee-background children

Background

Refugees are reported to experience high rates of dental disease, although there are limited data on refugee children. The aim of this study was to report on oral health in refugee-background children in Australia, and to assess their follow-up at dental services.

Methods

Cross-sectional study of opportunistic oral health screening and subsequent dental service use in refugee-background children attending a refugee health clinic in Victoria, Australia, between November 2006 – November 2010.

Results

350 patients (0 – 18 years, mean age 8 years 7 months) had oral health screening; 241 (68.9%) were born overseas, (176 Africa, 65 other countries) and 109 (31.1%) were born in Australia to African-background families. Parents were concerned about oral health in 65/341 (19.1%) children, with specific concern about caries in only 9/341 (2.6%). On assessment, 155/336 (46.1%) had visible caries and 178/345 (51.6%) had caries experience (dmft/DMFT > 0). Where parents were concerned about caries, they were likely to be present (positive predictive value = 100%), however absence of parent concern about caries was not reassuring (negative predictive value = 56.1%).

Compared to Australian-born children of African background; African-born children were more likely to be referred for further dental care (adjusted PR 1.33, 95% CI [1.02 – 1.73]), although there was no statistically significant difference in caries prevalence. African-born children were less likely to have caries compared to other overseas-born children (adjusted PR 0.73, 95% CI [0.58 – 0.93]). Overall 187/344 (54.4%) children were referred for further dental care; 91/124 (73.4%) attended any dental appointment. Attendance rates were 90% with a phone reminder system for appointments, attendance reduced when this system lapsed.

Conclusions

Oral health is an important public health issue in refugee-background children, despite low levels of parent concern and very few parent reported caries. Routine direct oral health assessment is important in refugee-background children and co-ordinated health systems may help improve their attendance at dental services.

Community Based Participatory Research to Reduce Oral Health Disparities in American Indian Children

Community based participatory research is an approach aimed to equitably involve community members, representatives, and academic researchers in all aspects of the research process. Using this methodology can help integrate cultural knowledge into interventions, supporting researchers to effectively partner with communities in addressing health disparities. The Center for Native Oral Health Research (CNOHR) collaborates with two American Indian (AI) tribes to advance oral health knowledge and practice, including the conduct of randomized controlled clinical trials of culturally sensitive behavioral interventions for primary prevention of early childhood caries (ECC). This manuscript describes the development of researcher-community partnership, and the development and implementation of the two clinical trial in the community. It also gives a detailed account of the strategies developed through the community input in recruitment and retention of the study participants and finally the lessons learnt during the study implementation.