1Elisha Riggs, 1Lisa Gibbs, 2Christine Armit, 3Mark Gussy, 4Amal El-Khoury, 5Leila Alloush, 6Saiqa, 7Saher Ali, 1Elizabeth Waters

1The McCaughey Centre, The University of Melbourne; 2Merri Community Health Services; 3School of Dentistry and Oral Health, Latrobe University, 4Arabic Welfare;

5Victorian Arabic Social Services; 6 Pakistani Community Representative,7Pakistan Association Australia Melbourne

TEETH TALES: ADDRESSING CHILD ORAL HEALTH INEQUALITIES IN REFUGEE AND

MIGRANT COMMUNITIES

20th IUHPE World Conference on Health Promotion

Monday July 12th 2010

Community Identified Issue• Merri Community Health Services

– Health Promotion Unit– Identified issues of concern

• Issues identified:– High sugar foods and drinks seen as ‘luxury’ items

– Avoidance of tap water – no fluoride intake

– Use of the miswak chewing stick

– Avoidance of toothpaste due to cultural or religious dietary restrictions

– Minimal current uptake of dental services and access barriers

City of Moreland

• Highly diverse community• 32% residents born overseas• 45% speak a language other than

English• 7th most socioeconomically

disadvantaged in Victoria• High incidence of low-incomes,

low skilled occupations, low educational attainment, high rate of unemployment

Significance of the Problem

• Early Childhood Caries (ECC) is one of the most common and costly childhood diseases

• Over the past 30 years dental caries rates have decreased for the general population

• However a clear social gradient exists and • there are significant inequalities

• Dental problems are prevalent among migrant and refugee populations in Australia and internationally

• Limited oral health data on refugee and migrant children

Research Framework

• Socio-ecological framework (Brofenbrenner 1986,

McLeroy 1988, Fischer-Owens 2007)

Research Framework• Cultural competence (NHMRC 2005)

– A set of congruent behaviours, attitudes, and policies that come together in a system, agency or among professionals

– More than awareness of cultural differences; integrates culture into the delivery of health services

– Cultural Competence Continuum (Cross et al 1989)

Cultural destructiveness

Cultural incapacity

Cultural blindness

Cultural pre-competence

Cultural competence

Cultural proficiency

Teeth Tales - Community Partnerships

• Victorian Arabic Social Services (VASS)

• Arabic Welfare (formally Australian Lebanese Welfare ALW)

• Pakistani community researcher

• Pakistan Association Australia Melbourne (PAAM)

Teeth Tales - Findings• Four themes:

– Child oral health – knowledge, practices and beliefs– Dental service experience– Migration and settlement– Community solutions

• Although there were differences and similarities across and within cultural groups, there were mostly differences between the refugee and migrant groups

• Contrasting views between community and health care professionals

• Contrasting views between health care professionals

Child Oral Health• Child oral health particularly tooth decay was an issue of

concern to everyone

• Varied levels of knowledge across all groups

• Differing practices – current and traditional, home county and new country

• Many risk and protective factors identified by both community and health professionals:– Diet, oral health practices, breastfeeding, bottle use,

dummy use, smoking, genetics, fluoride, water consumption, dental fear, pregnancy, access to oral health messages, information and dental services

Child Oral Health

Importance of child oral health:

‘Teeth are very important, if there is any problem with your teeth…it can affect the body and the stomach’ (Iraqi mother Interview)

‘We have a culture that when the milk teeth come out we make a celebration.’ (Palestinian participant)

‘I don’t know if it is just as a cultural thing that teeth are not as important… I think there might be this perception that they are only baby teeth, so it doesn’t matter because they are going to be lost anyway.’ (Dental Professional)

Child Oral HealthOral health is a health issue of increasing concern:

My grandchild is seven years old, they extracted, removed all of his teeth from the age of two and a half.’ (Iraqi grandmother Int)

‘His face was swollen and painful and I was worried.’ (Lebanese mother FG)

‘My son, he is almost three and a half years old, when I went to the dentist. Eleven of his teeth are damaged.’ (Pakistan mother FG)

‘Children with bleeding gums, children with loose teeth, black teeth. One family I saw few weeks ago the little girl she was only five and all of her teeth were black.’ (Arabic Liaison Officer)

‘I mean that’s what they do all day, every day [at the Dental Hospital] they do full clearances on three year olds, take every tooth out, they just do it all the time, the teeth are very bad at the moment, very bad.’ (Dental Professional)

Child Oral Health

Oral hygiene practices:‘She thinks they are too young for anything to be done; she thinks it is an invasion. She starts when they are about four years, shows them how to brush. Before then, nothing’ (Interpreter Iraqi FG)

‘The nurse told her that children or toddlers should start cleaning their teeth when they are two years old, she doesn’t believe in that and she hasn’t applied it to her children’ (Group facilitator Lebanese FG)

Dental Professional: They’ve never brought it up [using traditional practices] and I’ve never even thought to…I just explain to them, you know, what ideally needs to happen

Facilitator: And they’re all using toothbrushes and toothpastes? Dental Professional: I would imagine so, I don’t ask.’

Dental Service Experience

• Extensive variation between home country and new country

• Preference for home country - refugees usually can not return home

• Cost, waiting list, quality of treatment, health information and advice, appointment experience

‘When I take him to the doctor, the doctor tell me some teeth need check up and some teeth [need] filling, I say ok. He say sign here, so I sign here. When he go in, he asleep, then when he come out he has only two teeth. All gone. And I cry and I cry. I say, where are all the teeth and he tell me the teeth no good’ (Pakistani mother)

Dental Service Experience• Access – navigating the system• Appointment experience – communication: not just

interpreters

‘Please give correct information only. A lot of things we don’t know’. Lebanese FG)

‘It’s a bit embarrassing for us to say you’ve got to pay and you got to wait three years – no, we can’t get you in. Oh yes I know, I can understand you’re in pain but you have to wait, [this is whilst you are] on the phone for three hours talking to someone who doesn’t speak your language.’ (Refugee Health Nurse)

‘We find it hard to get the message across, you do everything you can, you try to get the message across but two years later you find the next child [in the family] is going to the dental hospital to have a general anesthetic to have teeth out then you realise that the message didn’t come across.’ (Dental Professional)

Community Solutions• Community involvement essential• Communication: patient, health professional, health service• Settings for oral health promotion

– Community gatherings– Primary schools– Early childhood settings– Adult education sites– Dental practice

• Organisational and systems change

‘The school, the dental [services], the family, they work together, they must work together about this’’ (Assyrian Chaldean FG)

‘We have to think creatively now what we can do’ (Refugee Health Nurse)

Intervention Considerations and Further Research

Other broader factors that need to be considered in the intervention and these communities more broadly:

– Racism & discrimination – services & community

– Social Inclusion/exclusion

– Maternal isolation and depression

– Parenting: lack of extended family support, role of father/husband

– Religion and spirituality

Community Intervention

Peer education-support model:• Increase parental knowledge, awareness and skills in

a culturally appropriate manner• Build upon social networks and supports by

facilitating links to community programs and services• Facilitate access to dental services

Reorient services to become culturally competent • All organisational levels• Review community health and social services for

cultural competence • Strengths based approach• Identify areas for improvement

For further information:Elisha Riggs eriggs@unimelb.edu.au