The Teeth Tales Showcase: The Finale to an 8 year community-based oral health research study

Written by Research Fellow Dana Young

My role for the most part of the last 4 years has been implementing a child oral health promotion intervention for children from a migrant and refugee background, also known as Teeth Tales. Although the inception of the project began many years before my involvement, I was involved with rolling out the exploratory trial phase of study.

The idea for the Teeth Tales research study arose in 2006 due to community concerns for the oral health of children from a refugee or migrant background residing in the Moreland and Hume local government areas (LGAs) of Melbourne. From this a PhD study(1) exploring the sociocultural influences on oral health was developed and conducted in partnership with Arabic Welfare, Victoria Arabic Social Services and Pakistani Australia Association of Melbourne to discuss these issues with mothers from a Lebanese, Iraqi and Pakistani background. Based on the findings from this initial work the next phase of Teeth Tales was designed and piloted to explore the implementation of a community based child oral health promotion intervention for children from a migrant and refugee background (2). For more background information about the Teeth Tales study visit out website here.

The Teeth Tales study has been an 8 year project led in partnership between Merri Community Health (MCHS) and The University of Melbourne and was culminated through a showcase on the 23rd of October 2014. This half day event involved members of the key partner agencies involved in the project, which alongside MCHS and the University of Melbourne include Dental Health Services Victoria, Moreland City Council, Arabic Welfare, Victorian Arabic Social Services, Pakistani Australia Association of Melbourne, The Centre for Culture, Ethnicity and Health and North Richmond Community Health Service. Key findings from the research were presented and representatives from the partner organisations presented their experiences and learnings associated with being involved in the Teeth Tales study.

Mandy Truong presenting at the Teeth Tales Showcase October 2014

Mandy Truong presenting at the Teeth Tales Showcase October 2014

This research project provided 667 children with a community based dental screening. For many children this was the first time they had seen a dental professional. Twelve percent of these children were referred on for further treatment at a dental clinic. Parents allocated to the intervention group received education from trained peer educators around the Dental Health Services Victoria key oral health messages of ‘Eat Well, Drink Well, Clean Well and Stay Well’. Based on earlier findings the discussion of traditional oral health practices was incorporated into the peer education oral health course. Results indicate the Teeth Tales intervention increased the oral hygiene practices of the participants, which is very important for the prevention of oral health problems.

Outcomes from the Teeth Tales study were applicable for not only the families involved as study participants but also for the multiple partner organisations involved. Working in partnership with established cultural organisations is critical to health promotion initiatives for families with migrant and refugee backgrounds. The Teeth Tales showcase was an exhibit of the wonderfully strong organisational partnerships that have been created and maintained over the life of the project and how involvement in the project has forged links between the local organisations and potential clients in the community. There was unanimous feedback from the partner organisations that this project had provided them with an opportunity to promote additional health and social service support to participants. Data collection sessions, where children received a free dental screening, were seen as an ideal opportunity to provide this information. One organisation arranged for families to attend appointments at the time data collection sessions were being run to alleviate travel demands on the families to their organisation. Findings from the study will also contribute to the updated Dental Health Services Victoria clinical guidelines for dental clinicians and maternal child health nurses.

It has been extremely rewarding working as a researcher involved with this study. I have developed my skills working with culturally diverse communities in a culturally appropriate manner, undertaken community and stakeholder engagement and liaised between participants and local services; whilst also witnessing the capacity of the cultural partner organisations grow to promote preventative health messages and to be able to aid migrant families to navigate the community health sector. Links have been created between culturally specific social services organisations, community health and the child and family services at local council – which will be of ongoing benefit for newly arrived families trying to access a multitude of services for their family.

For access to resources developed for the Teeth Tales study please visit the relevant organisations websites.

  • The Teeth Tales Peer Education Manual includes class materials for child oral health peer education trainers. You can access it from the Merri Community Health Services Website http://mchs.org.au/research-partnerships/latest-research. For more information, email Maryanne Tadic at maryannet@mchs.org.au
  • The Cultural Competency Organisational Review (CORe) Tool documents will be available via the The Centre for Culture, Ethnicity and Health website soon at ceh.org.au

References:

  1. Riggs E. Addressing child oral health inequalities in refugee and migrant communities. 2010.
  2. Gibbs L, Waters E, de Silva A, Riggs E, Moore L, Armit C, et al. An exploratory trial implementing a community-based child oral health promotion intervention for Australian families from refugee and migrant backgrounds: a protocol paper for Teeth Tales. BMJ open. 2014; 4 (3): e004260.
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Health in Orphanages Project (HOPe)

A few years ago while studying the oral health of school children in Kerala, India, one of the schools I visited was a boarding school for orphaned children. It was obvious from just observing these children and through dental examinations that the health of these orphaned children was a lot worse than children from the non-orphanage schools in my study. While at the time I was doing my masters degree and did not have the liberty to pursue this issue further, I made a mental note that when I had settled down in my career I would re-visit this issue. Fast forward to 2013 (five years since I visited the orphanage in Kerala) and we (my wife and I) have set up the Health in Orphanages Project (HOPe), with support from University researchers and community partners, to explore the health of children residing in orphanages in India.

So what is an orphan – United Nations Children’s Fund (UNICEF) defines an orphan as not only a child who has lost one or both parents but also those who have lost a father but have a surviving mother or have lost their mother but have a surviving father (1, 2). It is estimated that, as of 2010, there were 132 million orphaned children across the globe (about 2% of the world’s population), a shocking number. Of these children, 69 million were located in Asia, 53 million in Sub-Saharan Africa, and 10 million in Latin America and the Caribbean. India alone is home to 32 million orphaned children (~ 2.6% of India’s population or 7.5% of India’s child population). Yet it is quite rare for the local populace in India to encounter these children in their normal lives. The social structure in India has ensured that these children are a hidden and socially stigmatised community.

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Photo of an orphanage from my last trip to India

In spite of such large numbers the available information on the health of children residing in orphanages, particularly in India, is very limited. The available information gave us some insight into the health of these children but again highlighted the need to work with this hidden section of the community that we call the ‘disadvantaged among the disadvantaged’. A parent-child relationship is important for the mental and physical development of the child and the absence of this relationship can be detrimental to their health. Such a separation can negatively impact on various aspects of their development, particularly in relation to their psychosocial, emotional and cognitive skills. The social disadvantage is due to the lack of social and cultural identity that growing up in a family would provide. A joint report by UNICEF, UNAIDS & USAID on orphaned children state that institutional care such as orphanages can be detrimental to the child’s development as they socially isolate the children, discourage autonomy, put the children at risk of losing their family and community identities, and fail to provide any mechanism to support a child’s emotional or mental needs (1). As a result of these issues, orphaned children generally have poor oral health; poor mental health; are malnourished; have low immunity; are prone to medical conditions such as HIV, cardiomyopathy, fetal alcohol syndrome, hepatitis C, otitis media & congenital adrenal hyperplasia; and recurrent episodes of diarrhoea, fever & cough (3, 5-10). These children, particularly girls, are at a high sexual risk which includes having sex at an earlier age, pregnancy and the risk of contracting HIV/AIDS (11-15). Also common among orphaned children are behavioural and cognitive issues such as thought problems, rebellious nature, aggression and being withdrawn (6, 7, 17). A study of children in Romanian orphanages found that due to ‘global neglect’ (when deprivation occurs in more than one domain of child development, such as language, touch and family support) the brain size of orphaned 3-year-olds was significantly smaller when compared to that of a normal child of the same age (16).

So it is quite evident that these children face additional challenges that impact on their health and wellbeing. However, without sufficient country/location specific evidence local program planners and policy makers will not be able to make a case for targeted interventions. We aim to provide this evidence and use the information from this research to determine the future direction of the project. Our first stage will be to explore the health issues affecting children residing in orphanages in the State of Kerala, which is located on the south-west coast of India. At present there are approximately 400 registered orphanages in the State of Kerala alone, with on average 100 children per orphanage (18). We envisage that through HOPe we will be able to provide the evidence needed to progress towards healthier and more socially inclusive environments for these children.

About the author: Bradley Christian is a Research Fellow at the Jack Brockhoff Child Health and Wellbeing Program, working on Teeth Tales – a community based oral health promotion intervention for pre-school children from a refugee and migrant background. Brad is a dentist with specialist training in Dental Public Health whose research interests are around social disadvantage, children and oral health.

 

References

  1. UNAIDS, UNICEF, USAID. Children on the Brink 2004: A joint report of new orphan estimates and a framework for action2004.
  2. UNICEF. Orphans. UNICEF Press Centre; 2012 [cited 2012]; Available from: http://www.unicef.org/media/media_45279.html.
  3. Thielman N, Ostermann J, Whetten K, Whetten R, O’Donnell K, the Positive Outcomes for Orphans (POFO) Research Team. Correlates of Poor Health among Orphans and Abandoned Children in Less Wealthy Countries: The Importance of Caregiver Health. PLoS ONE 7(6) 2012;7(6):e38109.
  4. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-2006 India. Mumbai IIPS2007.
  5. Watts H, Gregson S, Saito S, Lopman B, Beasley M, Monasch R. Poorer health and nutritional outcomes in orphans and vulnerable young children not explained by greater exposure to extreme poverty in Zimbabwe. Tropical Medicine and International Health. 2007;12(5):584-93.
  6. Erol N, Simsek Z, Munir K. Mental health of adolescents reared in institutional care in Turkey: challenges and hope in the twenty-first century. Eur Child Adolesc Psychiatry. [Research Support, N.I.H., Extramural]. 2010 Feb;19(2):113-24.
  7. Hermenau K, Hecker T, Ruf M, Schauer E, Elbert T, Schauer aM, et al. Childhood adversity, mental ill-health and aggressive behavior in an African orphanage: Changes in response to trauma-focused therapy and the implementation of a new instructional system. Child and Adolescent Psychiatry and Mental Health 2011, 5:29. 2011;5(29).
  8. Khare V, Koshy A, Rani P, Srilata S, Kapse SC, Agarwal A. Prevelance of Dental caries and Treatment needs among the orphan children and adolescents of Udaipur district, Rajasthan, India. The Journal of Contemporary Dental Practice. 2012;13(2):182-7.
  9. Lassi ZS, Mahmud S, Syed EU, Janjua NZ. Behavioral problems among children living in orphanage facilities of Karachi, Pakistan: comparison of children in an SOS Village with those in conventional orphanages. Soc Psychiatry Psychiatr Epidemiol 2011;46:787-96.
  10. Johnson DE, Traister M, Iverson S, Dole K, Hostetter MK, Miller LC. HEALTH STATUS OF US ADOPTED CHINESE ORPHANS. .  1996 Abstracts The American Pediatric Society and The Society for Pediatric Research (1996) 39, 135–135; doi:101203/00006450-199604001-008151996.
  11. Birdthistle I, Floyd S, Machingura A, Mudziwapasi N, Gregson S. From affected to infected? Orphanhood and HIV risk among female adolescents in urban Zimbabwe. AIDS 2008;2008:759-66.
  12. Dunbar M, Maternowska M, Kang K, Laver S, Mudekunye-Mahaka I. Findings from SHAZ!: a feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe. J Prev Interv Community 2010;38:147-61.
  13. Gregson S, Nyamukapa C, GP GG, M MW, JJ JL, et al. HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe. AIDS Care. 2005;17.
  14. S SK, Dunbar M, Minnis A, Medlin C, Gerdts C, NS Padian NS (2008) Poverty gi, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci 1136: 101–110. Poverty, gender inequities, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci. 2008;1136:101-10.
  15. Mmari K. Exploring the relationship between caregiving and health: Perceptions among orphaned and non-orphaned adolescents in Tanzania. Journal of Adolescence. 2011;34:301-9.
  16. Perry BD. Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture. Brain and Mind. 2002;3(1):79-100.
  17. Baguma P.  Assessment of psychosocial support programmes for orphans/vulnerable children in Uganda. International Journal of Psychology. 2012;47(1):467-77.
  18. List of charitable institutions.  Thiruvananthapuram: Department of Social Welfare;  [cited 2011]; Available from: http://www.old.kerala.gov.in/dept_socialwelfare/Grant-in-aid.htm.

Research with culturally and linguistically diverse communities

Encouraging people to participate in research can be a tough gig. We are usually asking people to volunteer their time just for a small piece of information, which is sometimes only relevant and generalisable if large numbers provide this same, small piece of information. As researchers we know the enormous value that gathering this information can have to inform change at the policy, practice and the community level. But the general population sometimes does not place the same value on research or understand how important the research and outcomes can be. So, how do we encourage people to participate in research? And in particular, how do we encourage those from culturally and linguistically diverse backgrounds, where research may not be a common concept or practice.

I am currently working on a large scale child oral health research project entitled ‘Teeth Tales’, being conducted in partnership with government and community agencies  and Australian families from refugee and migrant backgrounds. Oral health is included in the Victorian Health and Wellbeing Plan 2011 – 2015 as a priority area for preventative health, as it is one of the most preventable diseases, particularly for children. Tooth decay is Victoria’s most prevalent health problem, with more than half of all children and almost all adults affected (1). Initial qualitative research was conducted with mothers from Lebanese, Iraqi and Pakistani backgrounds exploring oral health practices, beliefs and service needs. We learnt about many cultural differences and the real interest these communities have to learn more about keeping their children’s teeth healthy. From this earlier research, a community-based trial was developed to include an oral health education program for parents delivered by a trained educator from the same cultural background. This peer educator is able to talk about traditional beliefs and practices and introduce parents to the key Dental Health Services Victoria oral health messages of ‘Eat Well, Drink Well, Clean Well and Stay Well’. The program also included a site visit to local dental and family services. In addition to this education program, local services underwent a review of their practices to improve their competence in dealing with culturally diverse communities.

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Photo from:  http://www.dshs.state.tx.us/dental/promo_oh.shtm

For this trial we recruited Lebanese, Iraqi and Pakistani families in metropolitan Melbourne with children aged 1 – 4 years. We wanted to make sure that the research was as useful and relevant to families as possible so we sought the advice and expertise of relevant cultural organisations. They provided guidance on the cultural practices and beliefs of the target cultural groups, and the cultural appropriateness of our research methodology. They also helped us to recruit families, conduct the trial, interpret the findings and they provided language assistance. If it wasn’t for these partnerships we may have been lucky to recruit 10 families rather than the over 500 families who ended up participating! The advice and support of these cultural partners is invaluable when trying to recruit families with a refugee or migrant background, some of whom may be unfamiliar with research conduct, health promotion and the Australian health system.

In order to evaluate the success of the program we needed to check children’s teeth before and after the trial, as well as ask parents to complete a questionnaire. The free dental screenings for the children proved to be a key incentive for parents to register for the study. Oral health is one of the most contentious current health issues in Australia as access to fast, affordable dental care is often not available. The private dental system is run as a business and many walk out of the service with an expensive bill. The public dental system has huge waiting lists and strict eligibility for access. We found that many parents were not aware that children and refugee and asylum seekers in Victoria are considered a priority group for public dental services access. So when our study offered a free dental screening for children many families jumped at the opportunity!

The strategies outlined above helped us to successfully recruit over 500 families into our study. Engaging culturally and linguistically diverse groups in research can be difficult, but is very important, particularly for health services that need to respond to the evolving health needs of refugee and migrant and groups.

To read more about the ‘Teeth Tales’ study please visit:  http://mccaugheycentre.unimelb.edu.au/research/current/intergenerational_health/teeth_tales

Blog by Dana Young

Research Fellow, Child Public Health

The University of Melbourne

e: dana.young@unimelb.edu.au

References

  1. NACOH. 2004, Healthy mouths healthy lives: Australia’s National Oral Health Plan 2004-2013. Adelaide, National Advisory Committee on Oral Health, Australian Health Ministers’ Advisory Council.