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

A scoping review linking early childhood caries to violence, neglect, internally displaced, migrant and refugee status

BACKGROUND

The aim of the scoping review was to identify and synthesize the available literature concerning the relationship between the status of refugees, migrants, and internally displaced persons (IDPs) and Early Childhood Caries (ECC) as it relates to the United Nation's Sustainable Development Goal 16 (SDG 16).

METHODS

Data regarding the links between the status of refugees, migrants, and internally displaced persons (IDPs) and Early Childhood Caries (ECC), and the associations between ECC and maternal and child exposure to physical and sexual abuse, insecurity, crime, exploitation, torture, and displacement were extracted. The search was carried out in January 2023 across three databases (PubMed, Web of Science, and Scopus). Only publications in English with accessible full texts were included. Descriptive statistics were utilized to summarize the categories of the retrieved papers, and graphical representation was employed for visualization purposes. The relationships between the publications and each of the 10 targets of Sustainable Development Goal 16 (SDG 16) were also assessed.

RESULTS

Forty-five studies were reviewed. Most studies (42.2%) originated from the Americas Regions, while no studies were identified from the Africa Region. A significant portion (46.7%) of the papers focused on abuse, violence, and neglect as risk factors for ECC. Migrants, refugees, and IDPs were the most investigated populations (44.4%). Only one study specifically focused on IDPs and migrants respectively. The prevalence of untreated caries was higher among migrants, refugees, and IDPs compared to the host community, ECC was more prevalent among children who experienced abuse, neglect, or were in protective care. The was no clear direction on the associations between ECC and intimate partner violence, adverse childhood experiences, and wars. In terms of the SDGs, the reviewed publications addressed four targets (SDG16.1, SDG16.2, SDG16.3, and SDG16.5) out of the ten targets outlined in SDG 16.

CONCLUSION

There is available evidence regarding the connections between ECC and war, refugees, migration, violence, and neglect, as outlined in SDG 16. Future studies are needed to investigate how forced movements directly affects ECC status, how disruptions of peace and stability is a risk factor for ECC, and the associations between ECC and other indicators related to SDG 16 targets.

Factors associated with access to dental care among refugees: A systematic review of quantitative studies

OBJECTIVES

To identify, appraise and synthesize the published evidence from quantitative studies on the individual and contextual-level factors determining access to dental care among refugees worldwide.

METHODS

A systematic literature search was conducted until the last week of February 2022 in four electronic databases - MEDLINE, Embase, Web of Science (all databases) and APA PsycINFO - without any restrictions. Quantitative studies published in English language and meeting the a priori eligibility criteria were reviewed and data extracted. Quality assessment was conducted using the National Institutes of Health tool. The identified factors were stratified according to the framework of the Behavioural Model of Health Services Use, and the evidence related to each of these factors was summarized in tables. Narrative synthesis of the findings was conducted.

RESULTS

The search retrieved 6776 unique records, of which 69 were deemed eligible for full-text screening and nine studies were included in the final data analysis and synthesis. The studies were rated to be of 'fair' quality at best. Self-reported previous dental visits was the most commonly used measure of access. Associations between individual-level factors and dental care access were most frequently examined (predisposing [n = 6], need [n = 2] and enabling [n = 1]), while the contextual-level factors were rarely examined (predisposing and enabling [n = 1, each]).

CONCLUSIONS

Individual-level predisposing factors, such as English language proficiency, education, health and dental literacy and acculturation and integration, were shown to be significantly associated with refugees' access. There is limited evidence to determine the effect of individual enabling and need and contextual factors.

Patterns and predictors of public dental service utilisation among refugees in Victoria, Australia: a latent profile and multilevel analysis

BACKGROUND

The purpose of the study was to explore, analyse, and describe the patterns of public dental service utilisation among the refugee populations in Victoria, Australia, and determine their predictors at the individual and contextual levels.

METHODS

Data on the refugees who attended Victorian public dental services between July 2016 to June 2020 was gathered from the Dental Health Program dataset. Latent profile analysis was used to identify discrete groups among the refugee clientele with similar mean utilisation patterns across six indicator variables describing the attributes of dental services received and the site of care provision, over the study period. Multilevel multinomial logistic regression analysis was performed to examine the individual and contextual level correlates of the identified utilisation patterns.

RESULTS

Six distinct profiles of public dental service utilisation were identified among the study population (n = 25,542). The largest group comprised refugees predominantly using restorative services under general course of care (38.10%), followed by extraction services under emergency course of care (23.50%). Only a small proportion were estimated as having a higher mean utilisation of preventive services under general course of care (9.10%). Multilevel analysis revealed that the following variables had a significant association with refugee utilisation pattern: at the individual-level - demographic and ethnic attributes including age, gender, region of birth, preferred language for communication, use of language interpreter services, and type of eligibility card; at the contextual-level - characteristics of refugees' neighbourhood of residence including urbanicity, socioeconomic disadvantage, delivery of Refugee Health Program at the community health centres, and spatial accessibility to public dental services via driving and public transit modes of travel.

CONCLUSIONS

The study represents a significant step towards the development of an evidence-based knowledge around public dental service utilisation among Victorian refugees. Overall, the study findings reiterate the critical need for targeted strategies to promote the importance of routine dental visits, oral disease prevention, and timely intervention among refugee groups.

Health Care Use and System Costs Among Pediatric Refugees in Canada

BACKGROUND

Resettled refugees land in Canada through 3 sponsorship models with similar health insurance and financial supports but differences in how resettlement is facilitated. We examined whether health system utilization, costs, and aggregate 1-year morbidity differed by resettlement model.

METHODS

Population-based matched cohort study in Ontario, 2008 to 2018, including pediatric (0-17 years) resettled refugees and matched Ontario-born peers and categorized refugees by resettlement model: (1) private sponsorship (PSRs), (2) Blended Visa Office-Referred program (BVORs), and (3) government-assisted refugee (GAR). Primary outcomes were health system utilization and costs in year 1 in Canada. Multivariable logistic regression was used to test the associations between sponsorship model and major illnesses.

RESULTS

We included 23 287 resettled refugees (13 360 GARs, 1544 BVORs, 8383 PSRs) and 93 148 matched Ontario-born. Primary care visits were highest among GARs and lowest in PSRs (median visits [interquartile range], GARs 4[2-6]; BVORs 3[2-5]; PSRs 3[2-5]; P <.001). Emergency department visits and hospitalizations were more common among GARs and BVORs versus PSRs (emergency department: GARs 19.2%; BVORs 23.4%; PSRs 13.8%; hospitalizations: GARs 2.5%; BVORs 3.2%; PSRs 1.1%, P <.001). Mean 1-year health system costs were highest among GARs (mean [standard deviation] $1278 [$7475]) and lowest among PSRs ($555 [$2799]; Ontario-born $851 [9226]). Compared with PSRs, GARs (adjusted odds ratio 1.63, 95% confidence interval 1.47-1.81) and BVORs (adjusted odds ratio 1.52, 95% confidence interval 1.26-1.84) were more likely to have major illnesses.

CONCLUSIONS

Health care use and morbidity of PSRs suggests they are healthier and less costly than GARs and BVOR model refugees. Despite a greater intensity of health care utilization than Ontario-born, overall excess demand on the health system for all resettled refugee children is low.

The effect of unhealthy dietary habits on the incidence of dental caries and overweight/obesity among Egyptian school children (A cross-sectional study)

Background

Obesity and dental caries are public health problems in Egypt. Factors such as unhealthy diet, poor oral hygiene, and physical inactivity can play a major role in both problems. This study was carried out to illuminate the mutual unhealthy dietary risk factors associated with the incidence of both health conditions.

Methods

Between 1 October 2020 and 1 July 2021, 369 Egyptian children (5-10 years) were examined. Dental status was assessed using decayed, missing/extracted, and filled tooth indices (dmft, deft, and DMFT) for deciduous, mixed, and permanent dentitions, respectively. Moreover, the lifestyle, food habits, and body mass index (BMI) were recorded.

Results

A total of 342 (93.7%) of the included subjects suffered from caries, and only 27(7.3%) were caries-free. Based on BMI percentiles, 247 (66.9%) of the youngsters were overweight/obese, while 122 (33.1%) had normal weight. The mean dmft was 6.9 (±4.6), deft 4.2 (±3.3), and DMFT 0.1 (±1.7). In the primary dentition, a significant positive correlation was detected between dmft and BMI, legumes, sweetened milk and juice, soft drinks, and desserts, while a significant negative correlation was detected between dmft/deft, meat/poultry/fish, fresh fruits, and vegetables. A significant positive correlation was detected between deft and BMI, sweetened milk and juice, ice cream, candies, and crackers. In the permanent dentition, a significant positive correlation was detected between age, soft drinks, sweetened juice, desserts, and DMFT, while a significant negative correlation was detected with fresh fruits and vegetables. BMI was significantly negatively correlated with a healthy lifestyle, meat/poultry/fish consumption, and fresh fruits and vegetables while positively correlated with legumes, ice cream, soft drinks, granulated sugars, desserts, fast food, and caffeinated drinks.

Conclusion

Overweight/obesity was positively correlated with primary dentition dental caries. Desserts (sweetened snacks) and soft drinks could be the common risk factors associated with high caries and overweight/obesity incidence among Egyptian school children; conversely, consumption of fruits and vegetables could hinder both health conditions. Moreover, sweetened juices were associated with primary and permanent dental caries.

Relationship between dental caries, oral hygiene and malocclusion among Syrian refugee children and adolescents: a cross-sectional study

BACKGROUND

Little is known about the oral disease burden in refugee children and associated risk factors. This cross-sectional study aimed to explore the oral hygiene status and prevalence of caries, and to investigate their association with malocclusion characteristics in a child refugee population.

METHODS

606 Syrian refugee children and adolescents aged 7-19 years, registered as refugees in Jordan and residing in Zaatari camp, were recruited to the study. Oral hygiene and caries status were recorded using DMFT (mean of decayed, missing, and filled permanent teeth) and OHI-S (Simplified Oral Hygiene Index) according to WHO criteria. Oral health results were then cross tabulated with previously reported malocclusion traits for the same study sample (crowding, spacing, contact point deflection and IOTN) to detect any associations. Statistical analysis was conducted using chi-square test, independent sample t-test, one-way ANOVA, Welch test and Post Hoc testing (Gabriel and Games-Howell).

RESULTS

Overall DMFT and OHI-S were 4.32 and 1.33 respectively with no difference between males and females. Around 40% of the sample showed ≥ 5 DMFT score. 96.1% of the sample either do not brush or brush occasionally: females showed better oral hygiene practices (P = 0.002). No significant differences in DMFT scores were noted for gender or age, other than the 7-9.9 year old group having significantly higher mean DMFT scores than all other age groups (P < 0.01);the mean of OHI-S was not significantly different between different age groups (P = 0.927). Subjects with malocclusion, specifically crowding, contact point deflection and IOTN grades 3, 4 and 5 had higher scores in both arches for OHI-S and DMFT than subjects without malocclusion traits, although this was not statistically significant for DMFT scores. Overall, patients with generalized spacing had a significantly lower OHI-S score than those without spacing (P = 0.021). Significant correlations were found between parameters of intra-arch and inter-arch relationships and oral health indices (DMFT and OHI-S).

CONCLUSION

Malocclusion may increase the risk of caries and periodontal disease; the magnitude of this risk is amplified in populations with poor oral health and limited access to oral healthcare services, highlighting the need for preventive and curative oral health programs.

Eritrean Refugees' and Asylum-Seekers' Attitude towards and Access to Oral Healthcare in Heidelberg, Germany: A Qualitative Study

Oral health concerns in Eritrean refugees have been an overlooked subject. This qualitative study explored the access of Eritrean refugees and asylum-seekers (ERNRAS) to oral health care services in Heidelberg, Germany, as well as their perceptions and attitudes towards oral health care. It involved 25 participants. We employed online semi-structured interviews (n = 15) and focus group discussions (n = 2). The data was recorded, transcribed, and analysed, using thematic analysis. The study found out that most of the participants have a relatively realistic perception and understanding of oral health. However, they have poor dental care practices, whilst a few have certain misconceptions of the conventional oral hygiene tools. Along with the majority's concerns regarding psychosocial attributes of poor oral health, some participants are routinely consuming Berbere (a traditional spice-blended pepper) to prevent bad breath. Structural or supply-side barriers to oral healthcare services included: communication hurdles; difficulty in identifying and navigating the German health system; gaps in transculturally, professionally, and communicationally competent oral health professionals; cost of dental treatment; entitlement issues (asylum-seekers); and appointment mechanisms. Individual or demand-side barriers comprised: lack of self-sufficiency; issue related to dental care beliefs, trust, and expectation from dentists; negligence and lack of adherence to dental treatment follow-up; and fear or apprehension of dental treatment. To address the oral health burdens of ERNRAS, it is advised to consider oral health education, language-specific, inclusive, and culturally and professionally appropriate healthcare services.

A Scoping Review of the Health of African Immigrant and Refugee Children

Migration is a growing phenomenon around the world, including within the African continent. Many migrants, especially African children, face challenges related to health and social inclusion and can face increased health risks. A systematic scoping review of available literature on the health of African migrant children across the globe was conducted to offer insight into these health risks. The review was conducted over a 15-month period from January 2019 to April 2020, yielding 6602 articles once duplicates were removed. This search included electronic databases, reference lists of articles reviewed, and searches of libraries of relevant organisations. A total of 187 studies met the inclusion criteria, of which 159 were quantitative, 22 were qualitative, and 6 used mixed methods. The findings reveal decreased health in this population in areas of nutrition, infectious diseases, mental health, birth outcomes, sexual and reproductive health, physical and developmental health, parasitic infections, oral health, respiratory health, preventative health, endocrine disorders, health care services, and haematological conditions. The findings offer insights into factors influencing the health of African immigrant and refugee children. Further studies, especially qualitative studies, are needed to determine barriers to service access after migration and to investigate other underexplored and overlooked health concerns of African migrant children, including pneumonia and child maltreatment.

Research ethics and refugee health: a review of reported considerations and applications in published refugee health literature, 2015-2018

Introduction

Public health investigations, including research, in refugee populations are necessary to inform evidence-based interventions and care. The unique challenges refugees face (displacement, limited political protections, economic hardship) can make them especially vulnerable to harm, burden, or undue influence. Acute survival needs, fear of stigma or persecution, and history of trauma may present challenges to ensuring meaningful informed consent and establishing trust. We examined the recently published literature to understand the application of ethics principles in investigations involving refugees.

Methods

We conducted a preliminary review of refugee health literature (research and non-research data collections) published from 2015 through 2018 available in PubMed. Article inclusion criteria were: participants were refugees, topic was health-related, and methods used primary data collection. Information regarding type of investigation, methods, and reported ethics considerations was abstracted.

Results

We examined 288 articles. Results indicated 33% of investigations were conducted before resettlement, during the displacement period (68% of these were in refugee camps). Common topics included mental health (48%) and healthcare access (8%). The majority (87%) of investigations obtained consent. Incentives were provided less frequently (23%). Most authors discussed the ways in which community stakeholders were engaged (91%), yet few noted whether refugee representatives had an opportunity to review investigational protocols (8%). Cultural considerations were generally limited to gender and religious norms, and 13% mentioned providing some form of post-investigation support.

Conclusions

Our analysis is a preliminary assessment of the application of ethics principles reported within the recently published refugee health literature. From this analysis, we have proposed a list of best practices, which include stakeholder engagement, respect for cultural norms, and post-study support. Investigations conducted among refugees require additional diligence to ensure respect for and welfare of the participants. Development of a refugee-specific ethics framework with ethics and refugee health experts that addresses the need for stakeholder involvement, appropriate incentive use, protocol review, and considerations of cultural practices may help guide future investigations in this population.

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

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

Health Considerations for Immigrant and Refugee Children

Immigrant and refugee children are at increased risk for physical, developmental, and behavioral health challenges. This article provides an overview of physical, developmental, and behavioral health considerations for immigrant and refugee children within an ecological framework that highlights family, community, and sociocultural influences. Experiences and exposures relevant to immigrant and refugee children are discussed. Clinical pearls are provided for topics of chronic disease, nutrition, infectious disease, developmental screening, and mental health assessment. Interdisciplinary and community partnerships are emphasized as a means to decrease barriers to care and facilitate family navigation of complex social, educational, and health care systems.

The prevalence of dental caries among Egyptian children and adolescences and its association with age, socioeconomic status, dietary habits and other risk factors. A cross-sectional study

Background: Dental caries is a chronic, multifactorial disease, with limited data available for the Egyptian population. The aim of this study is to assess the prevalence of dental caries among Egyptian children and adolescents in correlation with age, gender, body mass index, socioeconomic status, parental education, biological risk factors and dietary habits.

Methods: A total number of 369 Egyptian children and adolescents (age ranges from 3-18 years) were examined over the period from 15 ^th November 2017 to 13 ^th January 2018. Socio-demographic data, oral hygiene measures and dietary habits for children were recorded. Dental status was analyzed using decayed, missing and filled tooth index (dmft) for deciduous dentition and (DMFT) index for permanent dentition. For mixed dentition (deft) index was used, d (decayed tooth indicated for filling), e (decayed tooth indicated for extraction) and f (filled tooth).

Results: 74% of the children had dental caries with mean dmft: 3.23±4.07; deft: 4.21±3.21; DMFT: 1.04±1.56. In primary dentition, dmft of the children was positively correlated with age, beans, candies, crackers, chocolates and inversely correlated with gender, socio-economic status (SES), parental education, brushing frequency of the parent, brushing frequency of the parent to the child teeth, brushing frequency of the child and consumption of eggs, fruits/vegetables, milk and milk products. In mixed dentition, deft was positively correlated with candies, crackers, citric juices, while negatively correlated with age, SES, parental education, brushing frequency of the parent to the child, brushing frequency of the child, fruits/vegetables. In permanent dentition, DMFT in children was positively correlated with age and chocolates while not correlated with any of the remaining risk factors.

Conclusion: The present study clarifies the significant risk factors associated with dental caries amongst Egyptian children. This will help in planning strategies to prevent and treat such disease.

Migrant children's health problems, care needs, and inequalities: European primary care paediatricians' perspective

BACKGROUND

Primary care paediatricians' perception of migrant children's health in Europe has not been explored before. Our aim was to examine European paediatricians' knowledge on migrant children's health problems, needs, inequalities, and barriers to access health care.

METHODS

European primary care paediatricians were invited by the European Academy of Paediatrics Research in Ambulatory Setting Network country coordinators to complete a web-based survey concerning health care of migrant children. A descriptive analysis of all variables was performed.

RESULTS

The survey was completed by 492 paediatricians. Sixty-three per cent of the respondents reported that the general health of migrant children is worse than that of nonmigrants, chronic diseases cited by 66% of the respondents as the most frequent health problem. Sixty-six per cent of the paediatricians reported that migrant children have different health needs compared to nonmigrant children, proper oral health care mentioned by 86% of the respondents. Cultural/linguistic factors have been reported as the most frequent barrier (90%).to access health care. However, only 37% of providers have access to professional interpreters and cultural mediators. Fifty-two per cent and 32% do not know whether one or more of the family members are undocumented and whether they are refugees/asylum seekers, respectively. Updated guidelines for care of migrant children are available for only 35% of respondents, and 80% of them have not received specific training on migrant children's care.

CONCLUSIONS

European primary care paediatricians recognize migrant children as a population at risk with more frequent and specific health problems and needs, but they are often unaware of their legal state. Lack of interpreters augments the existing language barriers to access proper care and should be solved. Widespread lack of guidelines and specific providers' training should be addressed to optimize health care delivery to migrant children.

Health of adolescent refugees resettling in high-income countries

Adolescent refugees are a vulnerable population with complex healthcare needs that are distinct from younger and older age groups. Physical health problems are common in this cohort with communicable diseases being the focus of attention followed by an emphasis on nutritional deficiencies and other chronic disorders. Adolescent refugees have also often experienced multiple traumatic stressors and are at a heightened risk of developing mental health problems. Navigating these problems at the time of pubertal development adds further challenges and can exacerbate or lead to the emergence of health risk behaviours. Educational difficulties and acculturation issues further compound these issues. Adolescents who have had experiences in detention or are unaccompanied by parents are particularly at risk. Despite a constantly growing number of adolescent refugees resettling in high-income countries, knowledge regarding their specific healthcare needs is limited. Research data are largely extrapolated from studies conducted within paediatric and adult cohorts. Holistic management of the medical and psychological issues faced by this group is challenging and requires an awareness of the socioeconomic factors that can have an impact on effective healthcare delivery. Legal and ethical issues can further complicate their management and addressing these in a culturally appropriate manner is essential. Early identification and management of the healthcare issues faced by adolescent refugees resettling in high-income countries are key to improving long-term health outcomes and future healthcare burden. This review article aims to increase knowledge and awareness of these issues among paediatricians and other health professionals.