The inclusion of children with disabilities in oral health research: A systematic review

Ethnographic perspectives of mothers and professionals on including children with disabilities in oral health in the Kingdom of Saudi Arabia

BACKGROUND

Children with disabilities generally face poorer oral health outcomes compared with their non-disabled peers due to a range of factors including inadequate oral hygiene, infrequent dental visits and systemic barriers in accessing care.

AIM

This ethnographic study explored the perspectives of caregivers and professionals to identify the ways that children with disabilities are included in oral health.

DESIGN

A purposive sample of 10 caregivers, all mothers with disabled children aged 9-15 years, five healthcare providers and five educators in Saudi Arabia, participated. Data collection used participant observation and semi-structured in-depth interviews. Data were analysed using reflexive thematic analysis.

RESULTS

The findings suggest that mothers lacked a supportive environment to develop their skills and knowledge about oral health care, preventing them from including their children in oral health. Inaccessible services added to the exclusion of both mothers and children. Some dental professionals exhibited poor communication skills and discriminatory attitudes towards the children and problematising mothers. Educators tended to discuss disabled children in terms of inability, displaying a deficit approach to impairment.

CONCLUSIONS

The evidence suggests the exclusion of mothers from oral health. This has an impact on how they enable their children. Recommendations include adopting a social model of disability in dental education and policies in Saudi Arabia to address inequalities. Provision of support, education and focusing on societal barriers moves towards inclusion rather than conceptualising disability as an individual problem.

Inequalities in the use of dental services by people with and without disabilities in Brazil: a National Health Survey

OBJECTIVES

The present cross-sectional study aimed to evaluate if social, racial, and gender inequalities disproportionally affect the use of dental services by people with and without disabilities in Brazil in the year 2013.

MATERIALS AND METHODS

The study used data from the 2013 National Health Survey and the dependent variable was the use of dental services. The outcome was stratified by gender, race, and social variables. Descriptive analysis was represented by absolute and relative frequencies. Two inequality measures were used to investigate the inequalities: the Slope Index of Inequalities (SII) and the Concentration Index of Inequalities (CIX). The SII expresses the absolute difference and the CIX identifies the relative inequality.

RESULTS

Of 145,580 adults evaluated, 7.7% reported disability. The proportion of adults without disabilities who used dental services in the last 12 months was higher (45.2%; 95%CI 44.2-46.1) than adults with disabilities (33.9%; 95%CI 32.0-35.9). There was an absolute difference of 40% points (SII 0.40; CI95% (0.36-0.45) in the use of dental services between poorer and richer people with disabilities. Absolute and relative inequalities were identified in the use of dental services, considering the education of the head of the family and family income, with similar results for people with and without disabilities. High inequality is observed concerning race. Racial minorities (Black, Brown, Yellow, and Indigenous) without disabilities presented a higher use of dental services in the last 12 months than racial minorities with disabilities.

CONCLUSIONS

Our findings demonstrate that social and racial inequities negatively affect individuals with and without disabilities.

CLINICAL RELEVANCE

Inequalities exist in the use of oral health services for people with and without disabilities.

Shining a spotlight on the inclusion of disabled participants in clinical trials: a mixed methods study

BACKGROUND

It is crucial to include a wide range of the population in clinical trials for the outcome to be applicable in real-world settings. Existing literature indicates that under-served groups, including disabled people, have been excluded from participating in clinical trials without justification. Exclusion from clinical trials exacerbates disparities in healthcare and diminishes the benefits for excluded populations. Therefore, this study was conducted to investigate potential obstacles that prevent disabled people from participating in clinical trials in the United Kingdom (UK).

METHODS

The study was carried out through an explanatory sequential mixed methods design. The Imperial Clinical Trials Unit devised and implemented an online questionnaire-based survey (with open/closed-ended questions) and an online focus group discussion. The target population were disabled people, family members/carers of disabled people and staff involved in clinical trials, whereupon the sample was recruited by convenience sampling methods via posters and emails through various networks. The Qualtrics XM survey system was used as the host platform for the online survey, and Microsoft Teams was used for an online focus group discussion. The focus group discussion was conducted to gain a deeper understanding of the themes identified from the survey responses. We analysed responses to the survey via descriptive analysis and used thematic analysis to synthesise the free-text answers from the survey and focus group discussion.

RESULTS

We received 45 responses to the survey questionnaire and 5 disabled people took part in a focus group discussion. Our findings highlighted the differences between the perspectives of researchers and those "being researched" and different types of barriers experienced by disabled people: opportunity barriers (inadequate recruitment strategy and ambiguous eligibility criteria), awareness barriers (perception of disability) and acceptance/refusal barriers (available support and adjustment, and sharing of trial results).

CONCLUSION

Our findings support perspectives drawn from the Ford Framework regarding the need to consider all barriers, not just up to the point of enrolment into trials but also beyond the point of inclusion in clinical trials. We support calls for the introduction of legislation on including disabled people in clinical trials, implementation of industry/community-wide participatory approaches and the development of guidelines, a combined public-private approach.

Oral health inequalities and disability: Closing the gap

The social determinants of health impact disproportionately on disabled people creating a cumulative risk of unequal oral health outcomes, compounded by impairment. Problems in early life, education and employment, poor social status and support, social exclusion, poverty and stress characterize the life course of many disabled people. Ableism and exclusion combine to ensure that disabled voices are rarely heard, ignorance and indifference lead to prejudice in policy-making and enforcement and negative media attitudes fuelled by political austerity lead to stigmatization. Yet, the health disparities experienced by disabled people are still perceived as being uniquely caused by a medical condition or impaired body function, excluding disabled people from the inequalities discourse. In parallel, the influence of medical conditions within other marginalized groups are minimized (e.g. mental health), leading to the underestimation of the impact of disability on oral health generally. The common ground between all groups subject to oral health inequalities can be conceptualized using the WHO International Classification of Functioning. Outcomes for all might be improved by emphasizing this common ground; by considering disability as a primary variable, such as gender or age; by identifying disabled people within existing inequalities research; and by explicitly including disabled people in future research.

Oral health experiences and perceptions of children with disabilities in the Kingdom of Saudi Arabia

BACKGROUND

The clinical focus on oral health means there is a scarcity of evidence from the perspectives of children with disabilities because of the continuing exclusion of their views from oral health research. This study takes a rights-based approach, aiming to give disabled children a voice by exploring their oral health perspectives and experiences. In order to do this, innovative and inclusive methods are needed.

AIM

The aim was to include the voices of children with disabilities by representing their perspectives and experiences of oral health.

DESIGN

An ethnographic study employed a purposive sample of 10 children between the ages of 9 and 15 years with a range of intellectual disabilities and physical impairments attending special centres in Riyadh, Saudi Arabia. All children in the sample were female. Pluralistic methods enabled the inclusion of children in the research. Thematic analysis was used to analyse the data.

RESULTS

The study describes different inclusive methods to enable children's voices on oral health. Main themes were children's knowledge, and their oral health practices and experiences of visiting dental clinics. Children also described the physical barriers they experienced and their positive and negative feelings about oral health.

CONCLUSIONS

The study highlights that including children with disabilities in oral health research is possible, but that researchers need to be creative and be able to work in tandem with children. One goal for dental research is to include all children as active participants, working with them as collaborators. This would help transform services and reduce children's oral health inequalities.

Management of dental caries lesions in patients with disabilities: Update of a systematic review

The aim of this systematic review was to update an existing review on the management of dental caries lesions in patients with disabilities so as to provide an up-to-date summary of the evidence. Randomized clinical trials and cohort studies related to preventive and restorative programmes for dental caries among people requiring special care, published in English, Spanish, Portuguese, French and German languages from February 1st 2011 to April 1st 2022, were retrieved from three databases ("updated review"). From the 1,105 titles identified using the search topic "Caries AND Disability", 17 papers informed in the analyses: 6 referring to caries preventive strategies and 11 related to restorative care strategies. Most of these studies targeted children and adults with intellectual/physical disability, although preventive and therapeutic strategies were also reported for frail older adults and onchohematological patients. Fluorides in tablets, gels or varnishes forms and the use of xylitol as a sugar substitute were reported as effective approach to prevent the onset of caries in high-risk groups. Minimally intervention treatment options such as the Hall technique, the ART approach and the use of SDF for arresting caries, were deemed suitable and effective strategies for treating existing lesions in-office. In conclusion, in the past decade (2011-2022) an increased number of articles reported strategies to prevent and manage caries among people requiring special care. Although an array of preventive and therapeutic strategies for dental caries exists, more and better-quality clinical evidence is needed to offer guidance to inform policy and practice for special care dentistry.

Inclusion of children with disabilities in qualitative health research: A scoping review

Background

Children with disabilities have the right to participate in health research so their priorities, needs, and experiences are included. Health research based primarily on adult report risks misrepresenting children with disabilities and their needs, and contributes to exclusion and a lack of diversity in the experiences being captured. Prioritizing the participation of children with disabilities enhances the relevance, meaningfulness, and impact of research.

Methods

A scoping review was conducted to critically examine the participation of children with disabilities in qualitative health research. The electronic databases PubMed, PsychInfo, Embase, and Google Scholar were searched. Inclusion criteria included qualitative health studies conducted with children with disabilities, published between 2007 and 2020, and written in English. Articles were screened by two reviewers and the synthesis of data was performed using numeric and content analysis.

Results

A total of 62 studies met inclusion criteria. Rationales for including children with disabilities included child-focused, medical model of disability, and disability rights rationales. Participation of children with disabilities in qualitative health research was limited, with the majority of studies conducting research on rather than in partnership with or by children. Findings emphasize that children with disabilities are not participating in the design and implementation of health research.

Conclusion

Further effort should be made by health researchers to incorporate children with a broad range of impairments drawing on theory and methodology from disability and childhood studies and collaborating with people who have expertise in these areas. Furthermore, an array of multi-method inclusive, accessible, adaptable, and non-ableist methods should be available to enable different ways of expression.

Parental psychosocial factors, unmet dental needs and preventive dental care in children and adolescents with special health care needs: A stress process model

Background

Children and adolescents with special health care needs (SHCN) have higher unmet dental needs, but the potential mechanisms by which parental factors can influence dental care use have not been determined. Parenting a child with SHCN can present special demands that affect parents’ well-being and, in turn, their caregiving. Hence, the study's overall aim was to apply the stress process model to examine the role of parental psychosocial factors in the association between child SHCN and dental care. Specifically, the study tested hypotheses regarding how (a) children’s SHCN status is associated with child dental care (unmet dental needs and lack of preventive dental visits), both directly and indirectly via parental psychosocial factors (parenting stress, instrumental, and emotional social support) and (b) parental social support buffers the association between parenting stress and child dental care.

Methods

A secondary data analysis of the 2011–2012 US National Survey of Children’s Health was performed for 6- to 11-year-old children (n = 27,874) and 12- to 17-year-old adolescents (n = 31,328). Our age-stratified models estimated associations between child SHCN status and parental psychosocial factors with two child dental care outcomes: parent-reported unmet child dental needs and lack of preventive dental care.

Results

Parents of children with (vs without) SHCN reported higher unmet child dental needs, higher parenting stress, and lower social support (instrumental and emotional). Instrumental, but not emotional, parental support was associated with lower odds of their child unmet dental needs in both age groups. The association between parenting stress and child dental care outcomes was modified by parental social support.

Conclusion

Differences existed in child unmet dental needs based on SHCN status, even after adjusting for parental psychosocial factors. SHCN status was indirectly associated with unmet dental needs via parental instrumental support among adolescents, and parental instrumental support buffered the negative association between parenting stress and both child dental care outcomes. Hence, parental social support was an important determinant of child dental care and partially explained the dental care disparities in adolescents with SHCN.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02314-y.

The involvement matrix as a framework for involving youth with severe communication disabilities in developing health education materials

Introduction

Involving youth with severe communication disabilities in health research is foregrounded in a perspective of rights and participation. Researchers aligned with a participatory and inclusive research agenda recommend that involving youth in health research should be a deliberate and well‐planned process. However, limited examples exist of how researchers can facilitate the involvement of youth with severe communication disabilities in research projects.

Method

The aim of this paper was to describe the application of the Involvement Matrix as a conceptual framework to guide the three phases of a research project with youth with severe communication disabilities.

Results

Six youth aged 19–34 years consented to be involved in the project. All youth had a severe communication disability and used augmentative and alternative communication (AAC) to support their involvement in the research project. The Involvement Matrix provided a structure to delineate four involvement roles in three research phases: In Phase 1, youth were listeners to research information and advisors in the needs analysis. In Phase 2, as advisors and decision‐makers, youth provided their opinions on selecting picture communication symbols for health materials. In Phase 3, as partners, they were copresenters at an online youth forum.

Conclusion

The Involvement Matrix was used to plan and implement the involvement of youth with severe communication disabilities in codeveloping health materials for use during the COVID‐19 pandemic. The Involvement Matrix can be applied together with AAC to enable meaningful involvement of youth in a health research project as listeners, advisors, decision‐makers and partners.

Patient or Public Contribution

This study project was codeveloped with youth with severe communication disabilities who use AAC in South Africa. A person with lived experience was involved as an advisor to the health material development process and in the drafting of the manuscript.

Use of dental services by disability status in Brazil in 2013

OBJECTIVE

To describe the prevalence and factors associated with the use of oral health services in people with and without disabilities in Brazil.

METHODS

A cross-sectional study was used with the secondary data of 60,202 individuals from the Brazilian National Health Survey of 2013. The main exposure variable was 'Disability', and the main outcome was 'Dental service use'. Independent variables were selected using the modified Andersen and Davidson model, according to four groups: exogenous variables, primary determinants of oral health, health behaviours and oral health conditions. The analysis was based on a hierarchical approach stratified by 'disability (yes/no)', with multiple logistic regression incorporating sampling design. Interaction terms between the disability variable and covariates were tested in logistic regression models.

RESULTS

A total of 45.5% of the people without disabilities and 34.1% of those with disabilities visited the dentist in the last year. In the crude model, the nondisabled group used dental services more (OR = 1.61, 95%CI = 1.45-1.79), but the difference was no longer significant (OR = 1.18, 95%CI = 0.93-1.51) when adjusted by the health behaviour and oral health condition blocks. Determinants of dental use were similar among people with and without a disability.

CONCLUSIONS

No difference in dental service use according to disability status was found after adjusting for oral health conditions. Although edentulism is more prevalent among disabled people, they do not go to the dentist as regularly as nondisabled people. Health services should actively schedule maintenance visits to ensure that the needs of disabled individuals are fully addressed.

Barriers to and facilitators of communication to care for people with sensory disabilities in primary health care: a multilevel study

OBJECTIVE

Communication barriers are the main obstacle for people with sensory disabilities (visual and hearing) to access health services. This study aims to describe the presence of facilitators of communication of basic health units in Brazil and to verify its associated factors.

METHODS

Cross-sectional multilevel study, of 38,811 health units in 5,543 municipalities between 2012 and 2013, collected in the National Program for Improving Access and Quality in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB). The outcome was defined by grouping facilitators of communication (braille material; hearing resources; visual communication; accessible list of service; professionals to welcome users with sensory disabilities). The two levels were structured, using the variables: level I (contextual): macro region, population size, and GDP per capita; and level II (service): extended professional team (psychologist/social worker); service shifts; welcoming room; publishing of service hours; presence of physical access facilitators. Multilevel Poisson regression with hierarchical modeling was used in both stages.

RESULTS

The presence of facilitators of communication is small in Brazilian health units (32.1%). It is more frequent in the municipalities with a higher GDP (RP = 1.02, 95%CI 0.92 - 1.12) and population size (RP = 1.25, 95%CI 1.02 - 1.52).

CONCLUSION

Welcoming users is the main access facilitator and should be the focus of initiatives to improve health care for disabled persons. Universal access with adequate services, removal of communication barriers and encouragement to properly welcome users must be promoted.

Dental caries experience, care index and restorative index in children with learning disabilities and children without learning disabilities: a systematic review and meta-analysis

Data sources MEDLINE, PubMed, Scopus and Web of Science.Study selection Two reviewers independently selected observational studies which compared caries experience between children with learning disabilities (CLD) and children with no learning disabilities (CNLD). Data extraction and synthesis DMFT/dmft, Care Index (CI) and Restorative Index (RI) data was extracted from each study. Meta analyses were conducted on the overall data and then on the following subgroups: Down's syndrome, autism and mixed learning disabilities. An adapted Newcastle-Ottawa Scale (NOS) was used to assess bias. Results Twenty five comparative cross sectional studies from eighteen countries were included in the review. The standardised mean difference in DMFT between CLD and CNLD was 0.43 (95% CI; 0.91 to 0.05 I² >95%) and for dmft was 0.41 (95% CI; 0.14 to 0.96 I² >95%). The only significant difference revealed by sub group analyses of the three main disability groups was lower caries experience in the permanent dentition of children with Down's syndrome (SMD = 0.73; 95% CI; 1.28 to 0.18). There was a larger difference between mean CI and mean RI for CLD than for CNLD, however, the standard deviations were large and no variance data was provided so meta-analyses could not be completed.Conclusions Overall there was no difference in caries experience between CLD and CNLD. However, sub group analysis showed that children with Down's syndrome had lower levels of caries than CNLD but this may be due to the delayed eruption of the permanent teeth commonly seen with Down's syndrome. There was limited data suggesting that caries in permanent teeth was more commonly treated by extraction in CLD than in CNLD, however, this was based on only eight studies.

Parent perspectives on perceived dental pain and dental caries in Saudi schoolchildren with intellectual disability

AIMS

To assess dental pain among male Saudi schoolchildren with intellectual learning disabilities (ILD) compared with controls and evaluate parents' perceptions of their children's dental pain and dental status.

METHODS AND RESULTS

A mixed-method cross-sectional study of 92 male schoolchildren aged 12-16 years was conducted at schools in Albaha, Saudi Arabia between March and May 2018. Participants were clinically examined for dental caries. Parents' perspectives on their children's dental pain were explored using interviews and a questionnaire. Chi-square, Mann-Whitney, Kendall's tau-b, and t-test analyses were run using SPSS^® version 20.0. Children with and without ILD had a high prevalence of dental caries (77% and 86%, respectively). Participants with ILD had significantly higher Dental Discomfort Questionnaire (DDQ) scores than healthy controls (0.75 ± 0.27 and 0.59 ± 0.11, respectively), and their decayed teeth (DT) scores were higher. Parents' ability to determine the complexity of dental treatment needed was significantly related to oral pain in both groups.

CONCLUSION

Children with ILD had more dental caries and pain than children without disabilities. Future research may use longitudinal studies to examine dental pain and caries in younger children with ILD and assess their parental perspectives. Implementation of oral educational programmes targeting parents of those children may be recommended.