Improving the Oral Health of Young Children of Newcomer Families: A Forum for Community Members, Researchers, and Policy-Makers

According to the most recent Canadian Health Measures Survey (CHMS), 57% of Canadian children experience dental decay.¹ Children of newcomer families have rates of early childhood caries (ECC) between 50% and 98%.^1-5 In particular, Amin and colleagues reported that 63% of preschool children of African immigrant and refugee families newly arrived to the city of Edmonton had a very high rate of ECC.⁶ The poor oral health status of young children of newcomer families is not unique to a particular region of the country. Canadian surveys have found that children from disadvantaged groups, including recent immigrants, have higher rates of caries and lower rates of dental visits than Canadian-born children and tend to seek dental care for treatment reasons primarily.^1,7-9

The symposium on improving oral health of young children from newcomer families was hosted by the school of dentistry at the University of Alberta on October 10 and 11, 2013, in Edmonton. Its aim was to bring together interdisciplinary participants and stakeholders with overlapping interests in improving the overall health of newcomer families to Canada. The symposium brought together an impressive group of 35 researchers and clinicians from across Canada, the Alberta government, Alberta Health Services, and from community organizations that provide support and services to newcomer families in Alberta. The event was supported by the Canadian Institutes of Health Research (CIHR) and the University of Alberta.

The main objectives of the symposium were to improve the oral health of young children from newcomer families through:

• Enhancing nationwide collaborations between researchers, community members and policy makers.
• Reviewing evidence from a systematic review of the literature on the oral health status of immigrant children and the available oral health programs or services for newcomers in North America.
• Proposing changes to existing services and programs offered by local, provincial, and federal governments.
• Defining deliverables and next steps to achieve a broader, multicentre and multidisciplinary research agenda.
• Using the evidence presented at the symposium to inform decision-making around oral health care services for newcomer families.

These objectives were addressed in 3 steps: (1) identifying the needs and expectations of newcomers regarding the oral health of their children as well as existing barriers to optimal oral health, (2) exchanging ideas among the stakeholders to prioritize the issues identified in world café format—a method for hosting large group dialogue—with elaboration of the identified themes in a following panel discussion, and (3) listing important issues for research within each theme with the aim of developing strategies to resolve current and future challenges in world café format.

What are the expectations and needs of newcomers regarding oral health of their children?

Following the welcome and introduction sessions, the symposium began with a presentation by Dr. Robert Schroth from University of Manitoba. The focus of this presentation was on early childhood oral health and current initiatives in Manitoba. He shared data regarding immigrant and refugee parental views of ECC and early childhood oral health in Manitoba, the economic costs of ECC, and what can be done to reduce the burden.

His presentation was followed by a community panel discussion featuring representatives of the Multicultural Health Brokers Coop, Calgary Refugee Health Centre, Catholic Social Services, and Edmonton Multicultural Coalition. Each panelist gave a five-minute talk about one of the following three pre-identified items from the systematic review conducted for the purpose of this symposium: (1) expectations of newcomers regarding oral health care in Canada, (2) newcomers' oral health literacy and (3) adaptive mechanisms used by newcomers.

Most of the discussions following the brief presentations by the three panelists centred on the first topic. The following themes were deliberated:

• Newcomers' expectations and priorities. Refugees have high expectations regarding the comprehensiveness of oral health care; they also expect it to be free and very accessible. They are poorly prepared about what to expect in Canada. Once in Canada, most newcomers have to focus on their urgent needs and pressing concerns related to housing, employment, language barriers, education, and acute health care issues. Preventive health and oral health care is not their priority. Approximately 80% of refugees' earnings are used to cover housing costs, which is very high compared to the Canadian average of 33%. This affects the affordability of preventive oral health care among newcomers.
• Cultural beliefs. Parents' collective experiences with the Canadian dental care system are poor and they are not interested in exposing their children to the system. In general, it is difficult to instill in refugees the importance of preventive health behaviours, including oral health care practices.
• Barriers to dental care uptake (coverage, lack of support from dentists, lack of interpreter). The Interim Federal Health Program provides limited, temporary, taxpayer-funded coverage of health-care benefits to government-sponsored resettled refugees and refugee claimants who are not eligible for provincial or territorial health insurance.

Use of the Interim Federal Health Program includes the following shortcomings: (1) Interim Health Fund (IHF) coverage up to a maximum of one year is good, but is underused by the clients as they are overwhelmed with many immediate issues, (2) IHF coverage is rarely accepted by dentists and for those who do accept it, there are no interpreters to facilitate communications between the patient and dental office, (3) coverage is very limited, so many refugees are disappointed when they visit a Canadian dentist, and (4) many newcomers view dentists as schemers out to make money.

• Available resources. Health benefit programs administered by the Alberta Health include dental care for low-income Albertans. However, utilization of dental services among the recipients of Alberta health benefit programs is undersubscribed for young children.

At the Resettlement Centre in Calgary, refugees undergo a health exam and an oral health care exam by a dentist while an interpreter is present. There is a link between the Resettlement Centre, the interpreter, and the dental office so refugees will get the care they require in a language they understand. This program could be considered as a promising practice model.

The panel and workshop participants made the following recommendations:

• Government and private sponsorship programs should inform newcomers that they should address dental issues in their home country, before they arrive in Canada, as these services may be more accessible and affordable there. After arrival, IHF coverage should be delayed or extended to more than one year to allow newcomers to take the advantage of it. In addition, dental care providers need to be educated about what is and is not covered by the IHF.
• Trust must be built between newcomers and the dentist, in terms of the necessity of the treatments and the cost, in order to improve the newcomers' views about their dentist's trustworthiness.
• Population health models require a deep understanding of the full immigration process from both social and economic perspectives. Those interested in reaching newcomers to promote oral health should access the social and cultural networks of these groups.

Following the panel discussion, Dr. Amir Azarpazhooh from the University of Toronto presented a systematic review that aimed to assess the oral health status of newcomer children, identify barriers to the optimal utilization of dental services, and determine the types and effectiveness of intervention programs available to immigrant populations in North America.¹⁰ The systematic review makes the following recommendations: (1) Improving parents' literacy in one of the official languages through language classes can be helpful to reduce the effect of language barriers. Moreover, bilingual oral care providers who can speak both official languages, as well as the home language of the child, may enhance the effectiveness of interventional and educational programs. (2) Enhancing parents' understanding about the importance of routine preventive care can be achieved through community-wide educational programs. (3) Free comprehensive dental care can be considered as the most time efficient way to eliminate caries in children who are in urgent need of care. (4) There is a need to involve both provincial and federal governments in the decision-making process as well as other health care professionals and community workers.

Dr. Maryam Amin and her research team from the University of Alberta then presented the outcomes of a community-based participatory research project,"Understanding the oral health status and needs of children of immigrants and refugees in Edmonton, Alberta." The study was conducted in four phases:

• In phase I, they explored the feasibility of conducting community-based participatory research that would eventually result in an oral health promotion program tailored to the needs of each community. Focus groups shed light on what community health workers knew about dental needs and barriers to dental services within the communities they serve.
• In phase II, the trained community workers facilitated focus groups with newcomer parents from different communities. The study revealed visible differences among the participating communities and confirmed the necessity of customizing preventive strategies to meet the needs of each community.¹¹
• Phase III aimed to identify barriers and explain them using a comprehensive behavioural view of ECC prevention in which individual and contextual factors, and the dynamic between them, are considered.⁶ It was concluded that children of newcomers are at high risk for developing severe dental decay because of low parental awareness and lack of regular dental visits.
• For phase IV, the impact of a knowledge translation workshop was evaluated using a pre- and a post-intervention questionnaire.¹²

The study concluded that a one-time, hands-on training of immigrant parents could be effective in changing their knowledge about, and attitudes toward, preventive dental care and their intention to take action in a foreseeable future.¹²

What are the priorities for pediatric oral health care of immigrant and refugee children?

The panel discussion and presentations enabled participants to appreciate the noticeable gaps between the newcomers' dental care needs and available resources. A world café was then conducted to provide an open and creative series of conversations on the question "What are the priorities for pediatric oral health care in immigrant and refugee children?" The aim was to synergize the collective knowledge and wisdom in the group by sharing ideas and insights and gaining a deeper understanding of the proposed question. The priorities suggested by the participants and their ranking are listed in Table 1.

How to address the identified gaps and who will need to be involved in evoking the change?

Day 2 of the workshop was dedicated to matching key research questions and research strengths of the participants followed by a prioritization discussion. The second panel discussion was then formed by three researchers; each was given 15 minutes to create a common understanding of high-ranked themes/priorities and to develop strategies to tackle current and future challenges:

• Influencing existing policy. This theme highlights the diversity between provinces regarding immigrants and refugees, their health, and coverage. Three items were mentioned under this theme: (1) a mismatch exists between policies in use of dental services, (2) available resources should be optimized to improve utilization of dental services, and (3) for any reforms to oral health benefits for newcomers to be effective, the process should involve settlement agencies, oral health professionals, and other stakeholders.
• Socioeconomic conditions. Items discussed under this theme included: (1) The equity context means to close the gaps of disparities between populations within Canada. The "Ottawa Charter" could be considered as a roadmap to follow for executing change within the system. (2) There is a difference between mitigating or eliminating strategies as research goals. In mitigation, infrastructure such as food banks have been developed. Conversely, eliminating something entails the loss of the existing infrastructure, which is not in anyone's interest. (3) The focus for any effort should be on affecting change in the long-term rather in the short-term due to the difficult challenge of changing human behavior. Changed human behaviour in the short-term is often not sustainable in the long-term. Thus, real and sustainable change can only be measured in the long-term.
• Lack of collaboration across health care sectors: Items listed for this theme were as follows:

(1) The lack of joint learning opportunities between medical and dental students persists into the professional arena. Dental professionals should initiate a best practice educational model on oral health to integrate oral care, supports and services into the educational programs of all health care professionals. (2) Oral health care providers need to adopt a collaborative relationship with community health services to provide services (e.g., interpreters, visual aids, and culturally relevant education) to diverse cultural groups.

The researcher panel discussion was following by a world café aiming at identifying research questions within each theme discussed by the academic panelists. Research questions formulated by the participants are presented in Table 2.

Conclusion

We defined deliverables and next steps to achieve a broader, multicentre, and multidisciplinary research agenda to reach our aim. This workshop served as a catalyst to evoke the changes necessary to overcome identified barriers to oral health care among newcomer families, particularly parental behaviours and beliefs about oral health care for young children. In addition, it proposed changes to existing services and programs for newcomer families offered by stakeholders (government, health care system, and community-based) and identified priorities.

Following the workshop, there were scheduled teleconferences with collaborators to maintain momentum, hone strategies, identify and apply to funding opportunities, and establish contact with newly invited participants who may be filling expertise gaps. There is ample opportunity for the continued exchange of ideas as the research agenda is constantly improved upon.

THE AUTHORS

THE AUTHORS

	Dr. Amin is associate professor and head, division of pediatric dentistry, University of Alberta, Edmonton, Alberta, Canada.
	Dr. Elyasi is an MSc student, division of pediatric dentistry, University of Alberta, Edmonton, Alberta, Canada.
	Dr. Schroth is associate professor, department of preventive dental science, faculty of dentistry, and department of pediatrics and child health, faculty of medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
	Dr. Azarpazhooh is assistant professor, disciplines of dental public health and endodontics, faculty of dentistry, and institute of Health Policy, Management and evaluation, faculty of medicine, University of Toronto, Toronto, Ontario, Canada.
	Dr. Compton is professor and director, dental hygiene program, University of Alberta, Edmonton, Alberta, Canada.
	Dr. Keenan, is associate professor, department of family medicine, director of community engaged research, division of community engagement, faculty of medicine & dentistry, University of Alberta, Edmonton, Alberta, Canada.
	Dr. Wolfe is practice program director & instructor, school of public health, University of Alberta, Edmonton, Alberta, Canada.

Correspondence to:   Dr. Maryam Amin, Division of Pediatric Dentistry, University of Alberta, 5-513 Edmonton Clinic Health Academy, 11405 - 87 Avenue NW, 5^th Floor, Edmonton, AB, T6G 1C9. Email: maryam.amin@ualberta.ca

This work was supported by the Canadian Institutes of Health Research (CIHR) grant FRN: 126751.