AN ORAL HEALTH EDUCATION PROGRAM Oral... · 2019-08-19 · Page 2 of 20 BACKGROUND Newly arrived refugees and asylum seekers often have a high prevalence of dental disease, poor oral

AUTHORS: LIDIJA SESTAKOVA PETER LIST DR STEPHANIE FLETCHER-LARTEY DR MITCHELL SMITH

EVALUATION OF THE “SHARE THE SAME SMILE”

AN ORAL HEALTH EDUCATION PROGRAM

FINAL REPORT 2019

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Table of Contents

BACKGROUND ......................................................................................................................... 2

Intervention ....................................................................................................................... 3

METHODOLOGY ...................................................................................................................... 4

Study design...................................................................................................................... 4

Participant selection .......................................................................................................... 5

Data analysis methodology ................................................................................................ 6

RESULTS .................................................................................................................................. 7

1. Study implementation ................................................................................................. 7

2. Participant demographics ........................................................................................... 7

3. Participant dental knowledge ...................................................................................... 9

3.1 – Best drink choice for keeping your teeth healthy? ........................................................ 9

3.2 – Best drink choice for children under 6 months old? .................................................... 10

3.3 – Best food to avoid? .......................................................................................................... 10

3.4 – How often should you brush your teeth? ...................................................................... 10

3.5 – How often should you visit a dentist? ............................................................................ 10

3.6 – Who can access free public dental services? .............................................................. 11

3.7 – How to access dental care at a public dental clinic? .................................................. 11

3.8 – Feedback on session information or how to improve the sessions? ........................ 11

4. General and Dental Health Status ............................................................................ 13

4.1 – General Health status of study participants ................................................................. 13

Pre-Test Results ..................................................................................................................... 13

Follow-up Results ................................................................................................................... 13

4.2 – Dental Health status ......................................................................................................... 14

Pre-Test Results ..................................................................................................................... 14

Follow-up Results ................................................................................................................... 14

4.3 – Visiting the dentist ............................................................................................................ 15

4.4 – Acute dental issues .......................................................................................................... 16

DISCUSSION ........................................................................................................................... 18

REFERENCES ........................................................................................................................ 20

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BACKGROUND Newly arrived refugees and asylum seekers often have a high prevalence of dental disease, poor oral health and significant oral health needs.1,2 Poor nutrition, poor hygiene, lack of dental care and an absence of fluoridated water in both camps and their country of origin may all contribute to poor oral health.3 In addition during resettlement, newly arrived refugees and asylum seekers face competing demands which will often take priority over health issues and seeking health care.3 An additional settlement challenge for refugees is negotiating Australia’s complex health system. Understanding Australia’s universal Medicare system, its eligibility criteria, the complexity around access to public dental services, and the cost of private dental care, are all contributing barriers in addressing their oral health. Barriers due to language and settlement issues are rarely distinguished and are instead merged with factors for other disadvantaged populations of Australia. Language barriers significantly impact access to oral health care for people from refugee background.4, 5 Service providers may lack insight to these challenges, including that newly arrived refugees lack confidence in knowing their entitlements and appropriate use of government-issued concession cards in order to access public oral health services. It has been reported that people who are socially disadvantaged or on a low income have lower levels of health literacy (including relating to oral health)6. Health literacy enables people to understand basic health information and act in their own interest.7 There is a need to continue to educate newly arrived refugees on their rights as health care consumers, on how to navigate the public health system, while promoting the importance of oral health care, and empowering them with knowledge to maintain their own oral health. It is important that this occurs soon after arrival in Australia. The Australian National Oral Health Plan 2015-2024 “Healthy Mouths Healthy Lives” identifies refugees as a priority population who are socially disadvantaged.8 The “Oral Health 2020: A Strategic Framework for Dental Health in NSW”9 does not explicitly identify refugees as a priority group. Priority populations for oral health in NSW are largely identified by a range of social determinants of health. These include low income, low education levels, social isolation and accessible health services. Adults who are socially disadvantaged or on low incomes have more than double the rate of poor oral health than those on higher incomes10. In addition to the above social determinants, refugees have to manage a range of additional challenges including settlement priorities. These competing settlement priorities may delay addressing both their general and oral health, which may lead to deterioration in health status. Furthermore, for refugee families and people from culturally and linguistically diverse backgrounds, other compounding factors affecting oral health include communication, transport difficulties and inconsistent use of interpreters.11 Further, health screening and medical checks may even be perceived as yet another ‘test’ which they need to ‘pass’ in order to stay in Australia12. The NSW Refugee Health Plan 2011 - 2016 contained specific actions and strategies defining refugee oral health as a priority. Strategies were identified to focus on improving refugee access and provide information and promotion of oral health services. The need to develop refugee-specific dental clinics that are localised to health districts with a significant refugee population was also recommended. The extent of implementation of recommendations within this plan is currently being evaluated at state level.

BACKGROUND

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One strategy undertaken by The Centre for Oral Health Strategy NSW (COHS), in partnership with the NSW Refugee Health Service (RHS), was the development of the “Share the Same Smile” - an oral health education program focusing on the effect of lifestyle behaviours, early intervention and prevention, plus better knowledge of and access to public dental services. This program provides oral health information sessions to newly arrived refugees using Bilingual Community Educators (BCEs). The program was based on the provision of specific, culturally appropriate oral health information, delivered at an individual’s level of literacy and by using simple pictorial graphics, as an effective model to improve oral health understanding. The BCEs provide health information for newly arrived refugees in a range of community languages. Languages covered include: Arabic, Assyrian, Burmese, Dari, English, Farsi, Karen, Rohingyan and Tamil. This report will provide evaluation of the extent to which the “Share the Same Smile” program improved oral health knowledge and oral health behaviours among the refugees. In addition, self-reported health information about the oral and general health of newly arrived refugees was collected to allow for comparison of the sample group with the general population and the population eligible for public oral health services.

Intervention: The “Share the Same Smile” oral health program primarily consists of a presentation used by the BCEs to provide oral health information to refugee communities. It aims to provide oral health messages on the importance of maintaining good oral health, preventive advice to achieve this, and information on eligibility and access criteria to free public dental services. The presentation is simple, pictorial and involves participant discussion around the following content:

Importance of a healthy mouth for a healthy body

Tooth decay

Importance of eating well and drinking tap water

Babies and young children’s teeth

Cleaning teeth

Smoking

Seeing a dentist

How to access public dental health clinics.

A supporting factsheet - “Keep Your Mouth Healthy” based on the information of the presentation and translated into eight refugee languages is also provided to participants. 13 In a separate study on the existing oral health promotion material in Australia, this resource was assessed for practical readability. In this study, the oral health fact sheet received the highest readability score out of the 10 oral health resources which were assessed.14

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METHODOLOGY

Study design: An outcome evaluation approach was used to assess whether “Share the Same Smile” resulted in desired outcomes for the participants. These outcomes were defined as:

Improved oral health knowledge of the key oral health messages

Sustained adoption of positive oral health practices

Utilised the information gained to successfully access public dental services.

The evaluation survey used a three-phase evaluation process. Pre and post-test surveys were conducted at the time of the sessions, with a follow up telephone survey six months after the sessions. The questionnaire was developed in collaboration with the Centre for Oral Health Strategy, including several questions from the National Oral Health Survey 2004 – 2006, to enable comparison of the results with the Australian population, as well as additional questions specific to the “Share the Same Smile” educational program. Seven questions were asked across all three surveys to assess changes in the oral health knowledge and attitudes over the study period. The survey used simple English and was translated into the main languages of the participants. The follow-up telephone survey was conducted by the BCEs in the language of the participants. The pre-test survey was used to provide a baseline of the participants’ attitudes and the knowledge of the key oral health messages prior to the session. Demographics questions were included in the pre-test, to allow for testing whether there were any differences within the sample group. These include participant’s age, sex and country of birth, and if they had spent time in a transit country. Participants were also asked questions about their general and oral health. The post-test survey was conducted immediately following the oral health session. It included the same seven knowledge and attitude questions as the pre-test. In addition the post-session survey included questions for the participants, to provide feedback on whether the information was useful and easy to understand or suggestions for improvement. The follow-up telephone survey was conducted six months after the oral health session aimed to identify participants’ sustained knowledge level and any behavioural changes having participated in the oral health sessions. At follow-up participants were also asked whether they had accessed either public or private dental services. They were also asked to self-rate their general and oral health six months after the initial oral health session. BCEs involved in the evaluation data collection were provided with training on evaluation research, including how to appropriately support refugees in completing pre and post surveys, and how to conduct the phone follow-up questionnaire. The importance of accurate and independent recording of responses was emphasised.

METHODOLOGY

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Participant selection: The “Share the Same Smile” program evaluation was conducted at scheduled health orientation sessions for newly arrived refugees. Participant recruitment was opportunistic, based on those attending oral health information sessions during the study period. In 2014, RHS BCEs delivered oral health sessions to 1431 participants. It was expected that the survey would take place between September and November 2015, with approximately 200 participants attending the sessions during that period. This number was estimated based on the number of expected arrivals. Participants were eligible for the study if they were 17 years and older. Consideration was also given to a large enough sample size to achieve statistical validity. It was expected that a majority of the participants would consent to participate in the pre and post-survey and approximately 50% would participate in the 6-month follow-up. A previous study evaluating the RHS multi-lingual Oral Health DVD, involving 74 participants found statistically significant findings at follow-up. It was therefore estimated that a sample size of 100 would be sufficient to provide statistical power for this study. The sessions were organised by Settlement Services International (SSI), who were contracted by the Commonwealth’s Department of Social Services (DSS), to provide settlement services to newly arrived refugees in the Sydney Metropolitan region. Due to the make-up of refugee arrivals in NSW at the time of the study, there were only two main cultural groups involved in the evaluation, Iraqi and Syrian, with a small number of refugees from Afghanistan and Iran. The oral health sessions were delivered in Arabic and Dari/Farsi languages. Translated information sheets and consent forms were provided to participants before completion of the pre-session survey. At the session participants were informed that participation in the study was entirely voluntary and would not impact their involvement in either the oral health session or access to dental services. All participants who consented to be involved in the follow-up survey were asked to provide their telephone contact details and contact details for next of kin. Participants were also asked to provide consent for investigators to obtain information on their use of the public dental service in the time between the information session and the follow-up questionnaire. Approval to access this information was also obtained from the data custodian. There has been a delay in obtaining this information from the Centre for Oral Health Strategy NSW and this information is not included in this report. Participants involved in the follow-up survey were provided with a voucher to compensate them for their time.

Ethical approval was provided by the SWSLHD Research Ethics Committee (LNR/15/LPOOL/388).

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Data analysis methodology Survey data was analysed using Microsoft Excel and SPSS©V.25. Data analysis included: (a) proportion of participants able to answer knowledge questions correctly and the difference between these proportions in the pre and post-surveys; and (b) proportion of participants at follow-up who had sustained oral health knowledge, and positive oral health attitudes and practices. Simple descriptive statistics were used. The Chi squared test was carried out for three sets of comparison between the proportion of correct responses for each question between (i) pre and post-test survey, (ii) pre-test and follow-up and (iii) post-test and follow-up. The differences were considered significant if P <0.05.

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RESULTS

1. Study implementation: The evaluation planned for September to November 2015 was delayed due to the late arrival of the refugee intake as a result of additional security checks being required at the time by the Australian Government. This resulted in the oral health survey being extended over a nine month period between October 2015 and July 2016. Follow-up was conducted six months after the oral health session, from April 2016 to January 2017.

2. Participant demographics: A total of 241 participants were recruited into the study; however due to missing data and loss to follow-up, 237 participants completed the pre-test, 234 (98.7% of those) post-tests, and 220 (92.8%) completed the follow-up survey. Of those that completed all 3 phases of the study, 48.1% were male. The average age of participants was 39 years. The majority of participants were originally from Iraq (57.8%) and Syria (37.1%), with a small number from Afghanistan and Iran (5.1% combined). Due to the small cell sizes, participants from Afghanistan and Iran were excluded from the calculations. While waiting for their visa status to be determined, almost all participants (97.9%) had spent time in transit countries, with an average length of stay of 2.5 years (+/- 1.6 years). The most common transit countries were Lebanon (63% of participants), Jordan (14%) and Turkey (8.1%). Table 1: Distribution of participants who completed each study phase by country of birth

Country of Birth (N= 237) Pre-test (n, %) Post-test (n, %) Follow-up-test (n, %)

Iraq 137 (57.8%) 137 (58.5%) 130 (59.1%)

Syria 88 (37.1%) 86 (36.8%) 82 (37.3%)

Afghanistan 10 (4.2%) 9 (3.8%) 7 (3.2)

Iran 2 (0.8%) 2 (0.9%) 1 (0.5%)

Total at each stage 237 (100%) 234/237 (98.7%) 220/237 (92.8%)

RESULTS

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Table 2A: Distribution of participants by sex and age group

Gender (N= 235) * 15-34yrs n (%) 35-54yrs n (%) >=55yrs n (%) Total Gender

Males 41 (36.3) 58 (51.3) 14 (12.4) 113 (48.1)

Females 50 (41.0) 60 (49.2) 12 (9.8) 122 (51.9)

Table 2B: Distribution of participants by age and country of birth (row percentages)

Country of Birth (N= 235) 15-34yrs n (%) 35-54yrs n (%) >=55yrs n (%) Total COB

Iraq 48 (38.1) 64 (50.8) 14 (11.1) 126 (100.0)

Syria 24 (27.6) 51 (58.6) 12 (13.8) 87 (100.0)

Afghanistan 8 (88.9) 1 (11.1) 0 (0.0) 9 (100.0)

Iran 1(33.3) 2 (66.7) 0 (0.0) 3 (100.0)

Total per age group 81 118 26 225 (100.0)

*Two participants did not include their age.

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3. Participant dental knowledge: Table 3: Dental knowledge for participants from Syria and Iraq

Question (Correct response)

Frequency of responses (n, %)

Pre-test (n=225)

Post-test (n=223)

Follow-up (n=212)

Pre-test vs.

post-test†

Post-test vs. follow-up‡

Which of the following is the best drink for keeping your teeth healthy?

(Tap water)

115 (51.1 %)

209 (93.7%)

194 91.5%

<0.001*** 0.915

Which of the following is the best drink to give a child younger than 6 months old?

(Breast milk)

218 (96.9%)

220 (98.7%)

212 (100.0%)

0.092 NR

Which of the following foods is best to avoid?

(Ice cream)

208 (92.9%)

222 (99.6%)

211 (99.5%)

0.773 0.945

How often should you brush your teeth? (Twice daily)

210 (93.3%)

215 (96.4%)

208 (98.1)%

<0.001*** 0.014

How often should you visit a dentist? (Once a year)

164 (72.9%)

207 (92.8%)

194 (91.5%)

<0.001*** 0.001

Who is able to use the free public dental service?

(Children under 18 and adults with a Health Care Card)

129 (58.1%)

161 (72.5%)

187 (88.6%)

<0.001*** <0.064***

How should you access dental care at a public dental clinic?

(Call the public dental clinic to make an appointment)

161 (72.5%)

216 (96.9%)

205 (97.2%)

<0.0.091***

0.646

† Pp-value for the Fisher's Exact Test; NR = Not calculated/ Reported

The findings revealed significant improvements in knowledge at post-test and knowledge retention at follow-up survey.

3.1 – Best drink choice for keeping your teeth healthy?

Participants were asked to select the ‘Best drink choice for keeping your teeth healthy’ from the following options: Bottled Water, Tap Water, Fruit Juice, and Don’t know. At pre-test, just over half of the participants (51.1%) correctly responded with ‘Tap Water’ being the best drink for healthy water. However, 36.0% of participants responded that ‘Bottled Water’ is the best drink. This is mainly as a result of the experience refugees have of using bottled water as a safe option when they were in their country of origin or transit country, and continuing such a presumption when in Australia. In Australia, tap water is not only safe to drink, but is also fluoridated, which assists with tooth protection. At post-test, which was conducted immediately after the session, participants demonstrated a significant increase in knowledge. Compared to 51.1% of correct responses at pre-test, correct responses increased significantly to 93.7% at post-test (Χ2=11.562, p<0.001) and remained steady at 91.5% at follow-up (Χ2=.011, p>0.915).

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3.2 – Best drink choice for children under 6 months old? The participants were asked to select the ‘Best drink choice for children under 6 months old’ from the following options: Fruit Juice, Water, Breast Milk, and Don’t Know. At pre-test, the majority of the participants (96.9%) correctly responded with ‘Breast Milk’ being the correct answer. Breastfeeding is widely practiced in many refugee communities. Only 1.3% participants responded with ‘fruit juice’ at pre-test, however no participants selected this response at post-test and follow-up. As knowledge was high at pre-test, there was only very minor improvement over time, with correct responses increasing from 96.9% at pre-test to 98.7% at post-test and 100% at follow-up.

3.3 – Best food to avoid? The participants were asked to select the ‘Best food to avoid’ from the following options: Fruit, Vegetables, Ice Cream, and Plain Yoghurt. At pre-test, knowledge was high, with 92.9% of participants correctly responding with ‘Ice Cream’. Correct responses increased significantly to 99.6% at post-test (Χ2=0.083, p<0.773), and remained constant at 99.5% at follow-up (Χ2=0.005, p<0.945).

3.4 – How often should you brush your teeth? The participants were asked ‘How often should you brush your teeth’ from the following options: Once a Day, Twice a Day, A Few Times a Week, and Don’t Know. At pre-test, knowledge was high, with 93.3% of participants correctly responding with ‘Twice a Day’. There was a small but significant increase to 96.4% at post-test (Χ2=24.766, p=0.001), and a further increase to 98.1% at follow-up (Χ2=10.29, p<0.001). The increase in correct responses between post-test and follow-up was also significant (Χ2=6.012, p=0.014).

3.5 – How often should you visit a dentist? The participants were asked ‘How often should you visit a dentist’ from the following options: Once a Year, Once Every Three Years, Only When You Have a Toothache, and Don’t Know. At pre-test, a substantial proportion of participants correctly responded with ‘Once a Year’ to visit a dentist at (72.9%). However, 19.6% of participants believed that they should ‘only go when you have a toothache’. The number of those who responded that they should ‘only go when you have a toothache’ was reduced significantly to 6.3% at post-test and 8% at follow-up. The proportion of those who reported the correct response increased significantly at post-test to 92.8% (Χ2=10.71, p<0.001), and at follow-up to 91.5% (Χ2=11.54, p<0.001).

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3.6 – Who can access free public dental services? The participants were asked ‘Who can access free public dental services’ from the following options: Children under 18 years old only, Adults with a Health Care Card only, Children under 18 years old and adults with a Health Care Card, and Don’t Know. At pre-test, just over half of participants (58.1%) correctly identified eligibility for free public dental services as children under 18 years old and adults with a Health Care Card. Of all dental knowledge questions, this question at pre-test demonstrated one of the highest proportions of incorrect responses. At pre-test 41.9% of participants selected the wrong answer or didn’t know. Knowledge increased significantly at post-test. Compared to 58.1% at pre-test, correct responses increased to 71.5% at post-test (Χ2=35.05, p<0.001), and 88.6% at follow-up (Χ2=3.44, p<0.064). Notably, one of the largest improvements of dental knowledge between post-test and follow-up was demonstrated with who was eligible to access free public dental services. While understanding Australia’s dental system was most difficult aspect for the newly arrived refugees, this result demonstrates that explanations of the eligibility criteria are grasped after the presentation.

3.7 – How to access dental care at a public dental clinic? Participants were asked to select ‘How to access dental care at a public clinic’ from the following options: Call the public dental clinic to make an appointment, Go to a dental clinic and wait, Go to a doctor or hospital, and Don’t Know. At pre-test, a substantial proportion of participants correctly responded that to access care at a public dental clinic, you ‘call a public dental clinic to make an appointment’ (72.5%). The remaining participants 27.5% selected the wrong answers or didn’t know. The number of participants that gave a correct responses increased to 96.9% at post-test (Χ2=2.86, p<0.091), and 97.2% at follow-up (Χ2=0.21, p>0.05).

3.8 – Feedback on session information or how to improve the sessions? At the post-session participants were asked to provide feedback about the oral health information, or to indicate options for session improvement. There was overwhelmingly positive feedback on the beneficial nature of the oral health information for the participants. Examples of the comments:

- “The session was so useful and very informative” - “I wish other people who are not newly arrived refugees and don’t have Centrelink card

to benefit from this program” - “Good 10 out of 10” - “I have no comments but would like to present to you my thanks and appreciation for

all the hard work you provide for our health and our children’s health” - “We’ve learnt many things, we understand now, we are very happy. Thank you for

coming.”

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- “ I learnt many new healthy practices, before I was doing them wrongly such as brushing

teeth”

The participant’s comments on improving session were:

- “Can you tell us if we didn’t have health care card, we need some places to be cheaper

than private dentist” - “It would be better to keep the children in childcare before coming to the session”

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4. General and Dental Health Status The questions regarding dental and general health were to document the overall health of newly arrived refugee participants, and evaluate whether the information gained was successfully utilised to access public dental services. Results for these questions have been provided with comparisons to NSW Population data from the NSW Population Health Survey and the National Survey of Adult Oral Health 2004-06. Comparisons have also been made to Government Health Card Holders, the group of the adult population who are eligible for public dental services in NSW. This population group is generally comprised of people from low socioeconomic backgrounds and/or experiencing disadvantage. As has been discussed earlier in this report, recently arrived refugees experience similar disadvantage to this group, as well as additional disadvantages.

4.1 – General Health status of study participants

Table 4: Self-rated General Health Status of study participants

Participants

NSW Population* Pre-Test Follow Up

General Health

Excellent/Very Good/Good

53.6 68.3 80.0

Fair/Poor/Don’t Know 46.4 31.7 19.9

* Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW Ministry of

Health. Available at: www.healthstats.nsw.gov.au. Accessed (15 September 2017).

Pre-Test Results During the pre-test survey participants reported worse self-reported general health than the NSW population. Participants reported having fair/poor self-rated general health levels at over two times than rate of than the NSW population, at 46.4% compared to 19.9%. There was a significant association between age and self-reported general health. Younger people reported better health compared with older people (X2 = 24.65; P<0.001). This trend was maintained at follow-up but with increasingly more younger persons reporting good health and more older persons reporting poor health (X2 =29.24; P <0.001). Significantly more people in the 35-54 years age group reported having good health vs poor health at follow-up (X2 = 10.38; P<0.001).

Follow-up Results These figures have improved at the follow-up, with participants’ general health showing a 14.7% increase towards being excellent/very good (68.3% compared to the pre-test 53.6%). These improvements may reflect the impacts of access to health services for recently arrived refugees through on arrival health assessments provided by GPs, the NSW Refugee Health Service and other services.

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4.2 – Dental Health status

Table 5: Self-rated Dental Health Status

Participants NSW Population*

Pre-Test Follow Up Government Health

Card Holders All

Dental Health

Excellent/Very Good/Good

40.4% 37.5% - -

Fair/Poor/Don’t Know

59.6% 62.5% 29.6 16.9

*National Survey of Adult Oral Health 2004-06: New South Wales, AIHW, Dental Statistics and research Unit, 2008. The recorded results have been also compared above (Table 5) with NSW population data, in particular the population eligible for public dental services, from the National Survey of Adult Oral Health 2004-06 and Health Status NSW. Public dental services for adults in NSW are only available to holders of Government Health Care Cards, Pensioner Concession Cards or Commonwealth Seniors Cards. This population group is generally comprised of people from low socioeconomic backgrounds and/or experiencing disadvantage.

Pre-Test Results During the pre-test survey prior to the oral health sessions, participants had worse self-reported dental health than the NSW population. Participants reported having fair to poor dental health at a rate 3.5 times more than the NSW population (59.6% compared to 16.9%). Participant’s self-rated dental health was even lower than NSW population subgroups with the worst self-rating of dental health, including people from low socioeconomic areas (29.6%) and public dental service users (42.2%). Further, their self-rated dental health was worse than National data for the Aboriginal and Torres Strait Islander population, where 25.1% reported their dental health as being fair to poor15. There was a significant association between age and self-reported dental health. Younger people reported better dental health than older people (X2 = 15.77; P<0.001). This trend were maintained at follow-up (X2 =10.11; P <0.006). Significantly more participants in the 35-54 years (X2 = 7.11; P<0.008) age group reported having good oral health compared with older refugees; significantly more persons in the >55yrs and older age group reportedly having poorer oral health at follow-up compared with pre-test (X2 = 5.50; P<0.019). There were no gender related differences.

Follow-up Results The follow-up results showed participants’ self-reported dental health status decreasing by a marginal 2.9%. These results are concerning, however further investigation in this area would be required to determine the cause of this decline. Prolonged waiting times to access the public dental services may be a contributing factor to this outcome.

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4.3 – Visiting the dentist Table 6: Last reported dentist visit.

Frequency of responses (n, %) p-value

Pre-Test Follow Up Pre-test vs. follow-up

Less than 12 months ago 132

58.6% 129 61%

0. 276

12 months to 5 years 29

12.9% 33

15.8%

5 years ago, or more 26

11.6% 3

1.4%

More than 10 years ago/Never 38

16.9% 46

21.8%

TOTAL 225 211

At pre-test, 58.6% of participants reported that they had visited a dentist in the last 12 months. This did not change significantly at follow-up. Table 7: Usual reason for dentist visit.

Frequency of responses (n, %) p-value

Pre-Test Follow Up Pre-test vs. follow-up

Check-up 57

25.6% 103

48.8% 0.845***

Dental problems (e.g. toothache)

168 74.4%

108 51.2%

TOTAL 225 211

The proportion of participants reporting that their usual reason for visiting a dentist for a check-up increased significantly from 25.6% at pre-test, to 48.8% at follow-up (Χ2=0.038, p<0.0.845). While still disproportionate, the follow up result compared more favourably with National data, which shows that 56.8% of the Australian population visits the dentist for a check-up14.

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4.4 – Acute dental issues Table 8: Tooth pain or discomfort in the last 6 months.

Frequency of responses (n, %) p-value

Pre-Test Follow Up Pre-test vs. follow-up

Very often/Often 60

26.7% 53

25.0% <0.006***

Sometimes 120

53.3% 79

37.3%

Never/Don’t know 45

20.0% 80

37.7%

TOTAL 225 212

The participants were asked in their pre-test and follow up survey to report whether they experienced any tooth pain or discomfort within the last 6 months. The results showed that tooth pain or discomfort decreased significantly from pre-test to follow up, with 26.7% of participants reporting pain very often or often and 53.3% sometimes, at the pre-test. This combined result of 80% decreased to 62.3% at follow up (Χ2=7.50, p<0.006). While there were some differences in questions between this study and the National Survey of Adult Oral Health 2004-06, it appears that participants had higher rates of experiencing dental pain. Amongst the NSW population, 16.2% reported having experienced a toothache in the previous 12 months. This rate was higher for government card holders (at 22.6%), and for people whose last dental visit was to a public dental service (42.6%). Table 9: Avoiding certain foods due to tooth or gum pain in the last 6 months

Frequency of responses (n, %) p-value

Pre-Test Follow Up Pre-test vs. follow-up

Very often/Often 71

31.6% 75

35.3% <0.001***

Sometimes 97

43.1% 79

37.3%

Never/Don’t know 57

25.3% 58

27.4%

TOTAL 225 212

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The participants were asked in their pre-test and follow up survey to report whether they had avoided certain foods due to tooth or gum pain in the last 6 months. There was no significant change in the proportion of participants reporting avoiding foods (Χ2=5.34, p=0.254). This indicates a lack of improvement in oral health in a way that would significantly have improved participants quality of life following the intervention. Age was significantly associated with avoiding certain foods due to tooth or gum pain. Significantly younger participants, those that are less than 35 years of age, were avoiding foods at both pre-test (Χ2=14.84, p=0.005), but this difference was not significant at follow-up (Χ2=4.31, p=0.366). While there was a difference in the time period covered by the questions use in the National Survey, almost 4 times the number of study participants reported having avoided eating some foods due to dental problems than the NSW population (19.7% avoided foods). Table 10: Avoiding dentist due to the cost in the last 6 months

Frequency of responses (n, %) p-value

Pre-Test Follow Up Pre-test vs. follow-up

Yes 125

55.6% 92

43.4% 0.013**

No 100

44.4% 120

56.6%

TOTAL 225 212

The participants were asked in their pre-test and follow up survey to report whether they had avoided going to the dentist within the last 6 months due to the associated costs. The proportion of participants reporting avoiding the dentist due to cost significantly decreased, from 55.6% at pre-test, to 43.4% at follow-up (Χ2=6.16, p=0.013). The improvement may reflect increased awareness of the free public dental services that are offered. The study results indicate a discrepancy in the avoiding dental care due to cost between newly arrived refugees (43.4% avoided care) and the NSW population (29.8% avoided care). However, a significant proportion of participants (78.9%) indicated that they were planning a dentist visit after follow up, with 97.6% planning to go to a public dental service. This is indicative of participants increased knowledge following the intervention. When asked at follow-up who paid for their last dental service, half (49.5%) reported individual payments and the other half reported government assistance (50.5%). In comparison amongst the NSW population 92.3% of people reported having paid for their last dental visit, while 67.4% of government health card holders reported paying.

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DISCUSSIONS

Results from the ‘Share the Same Smile’ oral health program survey indicate positive outcomes in terms of participants’ increased oral health knowledge by attending this education program. It is noted that this cohort of participants held a sufficient degree of oral health awareness in some areas prior to the education program. In this respect, it should be noted that oral health services in both Iraq and Syria prior to those conflicts was of high standard, however knowledge and education about oral health care and water fluoridation was lacking. Of particular importance was the need for local information about accessing oral health services, eligibility, and rights to an interpreter. Prior knowledge was high in areas of breastfeeding, foods to avoid and frequency of tooth brushing. Similarly correct responses of ‘how often should you brush your teeth’ were given. However, caution would need to be taken in removing these sections of the oral health presentation, due to their importance for both oral and general health. In areas where correct responses were less common in the pre-test survey, knowledge and its retention were noticeably increased. Overwhelmingly, tap water was recognised as the best drink of choice at post and follow-up responses, compared to pre-test where bottled water was considered best by 36% of respondents. This may be reflective of the refugee experience where bottled water is considered safes in refugee camps and/or in areas of conflict. This significant improvement in knowledge demonstrates the value of the education program in orienting refugees to the importance of drinking tap water and the benefits of fluoridation on their oral health. Additional aspects of increased knowledge were reflected in several other key areas of the survey. These include ‘how often should you visit a dentist’ showing an increased correct response from 73% at pre-test to over 90% at post and follow-up. The study indicates that on arrival, almost half of refugees would not know how to access Australia’s public oral health services. However, participants demonstrated increased understanding of Australia’s public oral health services post education session with a further bolstering of knowledge to over 88% on follow-up. Another aspect of improvement in knowledge was demonstrated by correctly indicating the need to make an appointment when asked ‘how to access dental care at a public dental clinic’. Knowledge increased from 73% at pre-test, to over 97% at post-test and follow-up. Although this may be basic information for local residents, it highlights the different experiences participants had in their countries of origin in accessing oral health services, where they may have presented to clinics without having to make an appointment. Rudimentary as this seems, it is essential for successful settlement in general, and for accessing dental care. Unfortunately, actual access could not be corroborated for this report due to delays in obtaining this information from the Centre for Oral Health Strategy NSW. Participants were also asked questions to determine self-rated overall general and dental health as part of the ‘Share the Same Smile’ education program. It is worth noting the importance of gathering this valuable information as participants attending had been in Australia less than 4 weeks. It appears that the general health levels amongst participants who responded that they had excellent/very good health increased from around 50% at pre-test to 68% at follow-up. On-arrival health checks by both General Practitioners (GPs) and the RHS Refugee Health Nurse Program (RHNP) are likely to have contributed to this increased perception of good health.

DISCUSSION

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Self-reported perceptions of oral health did not follow the same pattern as above. This could be explained by a lack of timely intervention, despite RHNP assessment of dental problems and referrals to public dental clinics whenever required. Additionally, that proportion of sponsored humanitarian entrants who do not attend RHNP may not benefit from public dental referrals. This may be an indicator to enhance GP knowledge in this area. In NSW, children and those with concession cards can access public dental clinics. These clinics have huge demands on their services, resulting in long waiting lists. As such, it’s possibly not surprising that participants’ self-rated responses as having ‘excellent/very good/good’ dental health status decreased from 40.4% at pre-test to 37.5% at follow-up. Twice as many refugees stated poor oral health more often than NSW Concession Card holders and the overall population. Further, their self-rated dental health was worse than National data for Aboriginal and Torres Strait Islander population. Inability to access dental services are reflected in the survey findings, as only 2.4% of participants were able to visit a dentist in the six-month period between pre-test and follow-up. These figures are of significant concern, and require equitable interventions. Another area of increased knowledge for participants was the importance of regular preventative oral health check-ups. This key preventative message was well understood and retained; however, the predominant barrier is access to an overburdened public oral health system. This study highlighted that despite the participants’ understanding of how to maintain good oral health, access to timely intervention is important. Refugees on arrival, with numerous basic demands on their limited financial resources, are unable to afford private dental care. With inadequate access to public dental services, it is probable that their oral health will deteriorate in time. It is clear that the “Share the Same Smile” education program is a valuable intervention. There is evidence that important information is not only gained, but is retained for at least six months. In terms of access to care, currently in NSW, vouchers are provided to some individuals to access a private dentist, which helps to reduce waiting lists for over-stretched public oral health services. Local Health Districts with high numbers of refugee settlers may also consider setting up refugee-specific dental clinics, equipped with interpreters, for ease of access.

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Acknowledgments:

The NSW Refugee Health Service - Bilingual Community Educators (BCEs): Qais Al Shakarchi, Nahla Toma, Anaam Halabi, Maysoon Shammu and Sajia Faiz provided invaluable assistance in conducting the survey. Monika Wadolowski (UTS) for statistically presenting the survey results.

1 Davidson N, Skull S, Calache H, Murray S and Chalmers J. “Holes a plenty: oral health status a major issue for newly arrived refugees in Australia” Australian Dental Journal 2006; 51(4): 306-311 https://doi.org/10.1111/j.1834-7819.2006.tb00448.x 2 Lamb, C. F. & M. Smith, “Problems refugees face when accessing health services”. NSW Public Health Bulletin 2002; vol 13(7): 161-163 3Davidson N, Skull S, Calache H, Chesters D and Chalmers J. “Equitable access to dental care for an at-risk group: a review of services for Australian refugees”. Australian and New Zealand Journal of

Public Health 2007; 31(1):73-80 https://doi.org/10.1111/j.1753-6405.2007.00014.x 4 Hobbs, C “Talking about teeth: exploring the barriers to accessing oral health services for Horn of Africa community members living in inner west Melbourne. Doutta Galla Community Health; 2010 5 Riggs E, Yelland J, Duell-Piening, Brown S. ”Improving Health Literacy in refugee populations” MedJAust 2016; 204(1):9-10.e1. 10.5694/mja15.01112 6 Adams R, Appelton S, Hill C, Dodd M, Findlay C, Wilson DH. Risks associated with low functional health literacy in an Australian population. Medical Journal of Australia. 2009; 191 (10):530-4. 7 Paasche-Orlow M, Wolf M. The causal pathways linking health literacy to health outcomes. American Journal of Health Behaviour. 2007;3:S19-26 8 Australia’s National Oral Health plan 2015-2024 “Healthy Mouths Healthy Lives” https://www.mah.se/PageFiles/1541119092/Australias-National-Oral-Health-Plan-2015-2024_uploaded-170216.pdf 9 Oral Health 2020: A Strategic Framework for Dental Health in NSW” https://www.health.nsw.gov.au/oralhealth/Publications/progress-on-oral-health-2020.pdf 10 Christopoulos S, Harford J. Oral health and dental care in Australia: key facts and figures 2012. Cat. No. DEN 224. Canberra: Australian Institute of health and Welfare; 2013 11 Nicole P, Al-Hanabali A, King N, Slack-Smith L, Cherian S. Informing a culturally appropriate approach to oral health and dental care for pre-school refugee children: a community participatory study. BMC Oral Health, 2007 12 NSW Refugee Health Plan 2011 - 2016. Policy Directive 2011_014, NSW Ministry of Health https://www1.health.nsw.gov.au/pds/pages/doc.aspx?dn=PD2011_014 13 “Keep Your Mouth Healthy” – Multilingual Oral Health fact sheet – NSW Refugee Health Service: https://www.swslhd.health.nsw.gov.au/refugee/oral_health.html 14 de Silva AM et al. Developing a practical readability tool for assessing written oral health promotion material for people with low literacy. Health Education Journal 2017; 76(7). https://doi.org/10.1177/0017896917715498 15 Harford J and Spencer AJ. Oral Health Perceptions. In: Slade GD, Spencer AJ, Roberts-Thomson KF (Editors). Australia’s dental generations: the National Survey of Adult Oral Health 2004–06. AIHW cat. No. DEN 165. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 34). 2007. pp. 173-195.

REFERENCES