Facilitators and barriers to asylum seeker and refugee oral health care access: a qualitative systematic review

After removing duplicates, the search yielded 1,477 titles; however, only 13 met the inclusion criteria (Fig. 1).

Fig. 1
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PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only

Included studies

All 13 included studies were published between 2009 and 2021. In total, 417 participants were included. All studies presented qualitative data and used interviews, focus groups or both. Four studies occurred in Canada,12,13,14,15 five in Australia,16,17,18,19,20 one in Germany,21 one in Turkey,22 one in the UK23 and one in the USA.24 The studies occurred across various settings, including community centres, mobile dental clinics and online. Three studies included only female ASRs, two of which explored parental perceptions of their children’s OH,16,22with the other exploring pregnant women’s access to OHC.20 One paper utilised mixed methods, but only the qualitative data were extracted (see online Supplementary Information).22

Methodological quality of included studies

The 13 studies included in this review were of good methodological quality, with 10/13 scoring at least 9/10.10 All papers had appropriate aims, methodology and research design. The full quality appraisal table can be found in the online Supplementary Information.

Thematic analysis

From the included papers, five themes (three barriers and two facilitators) emerged. These were composed of eight barrier sub-themes and four facilitator subthemes (see Figure 2). Many of the findings were unequivocal, while others occasionally acted as both barriers and facilitators, depending on the individual’s experience. Quotations supporting each sub-theme can be found in the online Supplementary Information.

Fig. 2
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Barriers and facilitators to OHC for ARS: identified themes

Barrier 1: accessing effective OHC provision is difficult for ASRs

The direct and indirect costs of accessing dental health care and maintaining good OH acted as a barrier (Theme 1.1). ASRs expressed an inability to pay for care and treatment,12,20,21 often resulting in reduced or no care.13 This was reinforced by insufficient governmental finance schemes13 and health insurance.15,19 Many ASRs were willing to or had sought overseas dental care, often in their country of origin. Paying for the flight and the care transnationally was perceived to be cheaper, and people favoured health care professionals they already know and speak the same language as.13,15,20

Indirect monetary costs of care were also a barrier in seeking OHC. These included an inability to afford OH tools (for example, toothbrushes)17,22 transport costs (often public), time off work, child carers21 and fresh food (versus sugary alternatives).16

ASRs found that dental practices had poor availability (Theme 1.2). Dental practices often ran at capacity17 with long waiting times, which lead to non-attendance.13,15,19,20ASRs described appointment-making as excessively difficult and bureaucratic20 and transportation to and from appointments insufficient or non-existent.19 Appointments were often during working hours and inflexible.21

OH providers and the institutions that support them were viewed as unhelpful and sometimes inadequate (Theme 1.3). ASRs complained of unfair treatment due to their background or refugee status21 and poor communication between themselves and service providers. Training for staff concerning how to treat ASRs effectively, kindly, and how to present their rights to care and funding where applicable, was often lacking.17,20 This resulted in mixed messages regarding ASRs’ care, entitlements and eligibility, with ASRs having little say in their care.16,20,21

Barrier 2: cultural changes and acculturation affect OH and inhibit effective care

This barrier demonstrates how OHC practices and cultural beliefs from home countries can clash with the norms and values of the new hosting culture (Theme 2.1). Considering previous trauma and other resettlement priorities, such as housing, food and education, caring for one’s teeth was often not a priority for ASRs until they felt safe and settled.17,18,21

Toothbrushing and other OH practices may be unfamiliar for ASRs and their children.16 Parents may not see OHC as necessary for their children and this merging and imparting of ‘Western’ culture can feel threatening, creating a mismatch of practices and values in individuals and families.19

Language differences and insufficiencies exacerbated the adverse effects of cultural assimilation (Theme 2.2). A lack of translators and interpreters was frequently reported.13,17 This communication challenge was described throughout the OHC journey: understanding the ask,15 form completion,13 informed consent and post-treatment follow-up needs.21 Follow-up needs communication can lead to dentists misunderstanding the issue, which can lead to incorrect treatments and misinformation.21 This leads to feelings of being misunderstood and humiliated by OHC providers.15

Barrier 3: ASR behaviours, perceptions and knowledge modulate OHC

Individuals having their own behaviours, practices, beliefs, perceptions and knowledge of OH and OHC acted as barriers to care. This does not force blame onto ASRs, rather it acknowledges the importance of understanding the factors that may negatively impact their health. That is that ASRs may unknowingly put themselves at increased need of OHC through changes in behaviours, that is, that OHC access is directly related to OHC need.

Numerous behaviours and traditions that ASRs practise affected their OH (Theme 3.1). OHC was not routinely prioritised15 and there was poor attendance at routine check-ups, perhaps due to differing ‘cultural perceptions of time’.15,21

Drinks consumed by ASRs varied. Some perceived the tap water in their host country to be dirty’, which led to people consuming soft drinks and juices regularly.16,17 Other ASRs filtered their tap water or added cordial to improve the taste,17 with little understanding of fluoridation.16

An increase in sugar in everyday foods and an increased availability of sugary sweets was cited as problematic.24 Low-sugar foods were harder to access and high-sugar foods were perceived as tastier and more nutritious.16,21 Mothers also often struggled not to give their children sugary foods during the weaning process. This included giving children juices or sugar mixed with water as alternatives to formula.17

Smoking, drug use and hazardous behaviours that impact the teeth were also a barrier to good OH. Smoking ‘chelam’ and sucking ‘naswar’ were referenced as traditional tobacco agents that affect the teeth.18 Other behaviours included ‘breaking nuts’ with their teeth and chewing ‘khat leaves’,24 which are bitter and so often drank with sweetened tea.24 The stress of fleeing their home country often leads to chronically dry mouths and the conflict, persecution or torture that may have occurred previously can leave ASRs with severely damaged and missing teeth.18

Further, multiple traditional cleaning sticks from plants were referenced, including ‘aday’ and ‘miswak’.16,17,18,24 These trusted tools were used regularly for prayer ablution and ASRs had cultural attachments to them. ASRs even froze or imported these plants so they can be used for longer.21 Other substances used for OHC included bicarbonate soda, sage and carnation flowers.16 ‘Takhak’, aspirin, saltwater, antiseptics, cloves, ‘derum’ bark, the spice blend ‘berbere’ and garlic were also used to treat pain or bad breath.13,18,21,24

Poor understanding of determinants of OH acted as a barrier to preventative OHC (Theme 3.2). ASRs lacked knowledge on the causes of oral diseases and sometimes had false beliefs on the causes of poor OH.12 This was intertwined with poor education on OH.18 Mothers had a knowledge gap concerning their children’s OH and the causes of caries.16,20 Further, a lack of understanding of OH terminology caused confusion.16,20 ASRs tended to seek information from family members, information which may not be reliable and can lead to further confusion.14,15

This lack of education was exacerbated by low rates of help-seeking.19 For example, help-seeking for oral caries only appeared to occur when there was a problem12 or pain,14,18,19 the latter of which was consistently the main driver for dental consultations. This lack of routine care may suggest insufficient preventative dental behaviours, meaning problems were discovered when it was already too late.

ASRs had negative and incongruous beliefs and perceptions surrounding OHC (Theme 3.3), often manifesting as fear. Many ASRs avoided seeking dental care and treatment due to fear, past experiences of pain,21 or lingering pain after a procedure.24 Fears also extended to their safety during dental care, especially in pregnant people20 and for some in whom it was triggering of prior dental torture.17

Associated with this fear was a lack of trust in the system, the motivations of dentists and the efficacy of local methods and tools.21 There was a sense of loss in their locus of control over their own and their children’s OHC.14,16

Facilitator 1: positive drivers for individuals seeking and achieving good OH

This theme explored the factors that drive effective help-seeking.

Understanding the importance of OH was a prominent facilitator (Theme 4.1), enabling help-seeking and good OH practice.13 An appreciation of OH and its association with general health, knowledge of the causes of poor OH, what good OH is and how to maintain it were all beneficial.12,16,21

Teaching of OH practices and its importance in schools, in addition to a greater knowledge of English language, often resulted in younger ASRs having better OH and more effective OH practices.19 Promotion and education of OH were also effective through GP surgeries and community centres.14 Although pain was often caused by caries, it can increase engagement with OHC as ASRs acknowledged the issue, sought help, and changed their behaviour post-treatment.19

Social influence in the form of conforming to peers, acculturation and faith-related influence all facilitated good OH (Theme 4.2). ASRs may conform to ‘Western’ beauty standards and seek care for themselves or their children in order to have straight, white and healthy teeth.21 There was a desire to be attractive17 and a belief that conforming to these physical standards increased employment prospects.12 Maintaining good OH also occurred through faith-based promotion, for example, Islam encourages teeth cleaning before every prayer.19

Facilitator 2: effective, accessible services and institutions lead to thriving OH.

This theme acknowledged the positive effect that care providers, communities and government schemes had on ASRs OHC when they work effectively.

Health care providers can be important facilitators for ASRs accessing OHC (Theme 5.1). Supplying helpful information on finding clinics, transportation, providing information in the ASRs’ first language/providing interpreters and making appointments accessible greatly increased care satisfaction and high-quality, personalised care.15,17 Compassionate, kind and informative staff also increased care quality, calming ASRs’ fears concerning OH, thus increasing their trust in the care provided.15 This contributed to positive perceptions of dentists and care providers21 and positive experiences encouraged individuals to bring other ASRs to seek care at that practice.21 Educating midwives and doctors on ASRs’ OHC access was also important.15,16

Wider support was a powerful facilitator for accessing effective care (Theme 5.2). Community members supported one another, shared information and acted as interpreters during dental consultations.19 Health professionals also translated and distributed information on OH and how to access care.20 Organisations collaborating to share information made it easier for ASRs to access care.17 Financial support from governments enabled some access to OHC for ASRs, which may otherwise be inaccessible.15

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