Role of Acculturation, Social Capital and Oral Health

Literacy on Access to Dental Care among Preschool

Children of Arabic-Speaking Immigrants in Toronto,

Canada

by

Oras Al-Rudainy

A thesis submitted in conformity with the requirements for the degree of Master of Science in Dental Public Health

Graduate Department of Dentistry University of Toronto

© Copyright by Oras Al-Rudainy (2011)

ii

Role of Acculturation, Social Capital and Oral Health Literacy on Access to Dental Care among

Preschool Children of Arabic-Speaking Immigrants in Toronto, Canada

Oras Al-Rudainy

Master of Science in Dental Public Health

Graduate Department of Dentistry

University of Toronto

2011

Abstract

Objectives: To determine access to dental care among preschool children of Arabic-speaking

immigrant families; to investigate the influence of social and cultural factors on access to dental

care; and to measure preschool children‟s oral health as reported by their parents. Methods: This

survey used a semi-structured questionnaire to interview 100 Arabic-speaking parents of children

under the age of 5 who were identified from community centres. Five scales were used to

measure acculturation, social capital, oral health literacy, oral health knowledge, and health

literacy. Results: Only 34% of families had visited the dentist to obtain dental care for their

preschool children. Nineteen-percent of Arabic parents in our sample rated their children‟s oral

health as being fair or poor. None of the scales used in this study had a significant impact on

access to dental care; however, higher scores on these scales tended to be associated with better

access to dental care.

iii

Dedication

This thesis is dedicated to my husband, Emad, and my children Maryam

and Adam; for their love and patience. Without their presence in my life

I could not achieve any success.

To my Mother and Father whose love and support motivated me

throughout my life.

iv

Acknowledgements

Praise and gratitude to ALLAH, almighty, without whose gracious help it would have been

impossible to finish this research.

First and foremost, I offer my deepest gratitude to my supervisor, Dr. Herenia P. Lawrence, who

has supported me with her patience and knowledge. It would be impossible to complete this

thesis without her encouragement and advice.

Next, I would like to thank my Thesis Advisory Committee members: Dr. G. Kulkarni and Dr. T.

Gadalla for their helpful comments and advice. Their insights have added considerably to my

graduate experience.

I am also grateful to Dr. L. Dempster and Dr. D. Otchere; for taking time from their busy

schedule to serve as my internal and external examiners, respectively.

I am grateful to my husband, Emad, whose love, support and understanding have been my

inspiration throughout my study.

Finally, I wish to thank everyone who helped me during the course of my study: my teachers, my

family and friends.

v

Table of Contents

Abstract ................................................................................................................................... ii

Acknowledgements ........................................................................................................................ vi

Chapter One

Introduction ................................................................................................................................... 1

Chapter Two

Literature Review............................................................................................................................ 4

2.1 Immigrants‟ Oral Health ....................................................................................................... 4

2.2 Access to Dental Care ........................................................................................................... 7

2.3 Early Childhood Caries (ECC):............................................................................................. 8

2.3.1 Definition ........................................................................................................................ 8

2.3.2 ECC Risk Factors: .......................................................................................................... 9

2.4 Acculturation: ...................................................................................................................... 10

2.4.1 Definition: ..................................................................................................................... 10

2.4.2 Measuring Acculturation .............................................................................................. 12

2.4.3 Acculturation and Health: ............................................................................................. 13

2.4.4 Acculturation and Oral Health: ..................................................................................... 14

2.5 Social Capital ...................................................................................................................... 16

2.5.1 Definition ...................................................................................................................... 16

2.5.2 Measurement ................................................................................................................ 18

2.5.3 Social Capital and Health ............................................................................................. 19

2.5.4 Social Capital and Oral Health ..................................................................................... 20

2.6 Health Literacy and Oral Health Literacy ........................................................................... 21

2.6.1 Definition ...................................................................................................................... 21

2.6.2 Measuring Health and Oral Health literacy .................................................................. 23

2.6.3 Impact on Health and Oral health ................................................................................. 25

2.7 Summary ............................................................................................................................. 26

2.8 Study Objectives: ................................................................................................................ 28

Chapter Three

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Materials and Methods:................................................................................................................. 29

3.1 Study Design and Target Population: ................................................................................. 29

3.2 Ethical Considerations: ....................................................................................................... 29

3.3 Sample Size Calculation: .................................................................................................... 30

3.4 Enrollment: .......................................................................................................................... 30

3.5 Study Environment:............................................................................................................. 31

3.5.1 Interviews: .................................................................................................................... 31

3.6 Questionnaire: ..................................................................................................................... 32

3.6.1 Calculating the Final Score of the Instruments: ........................................................... 33

3.7 Data Analysis ...................................................................................................................... 35

Chapter Four

Results ................................................................................................................................. 37

4.1 Univariate Results: .............................................................................................................. 37

4.1.1 Sample Characteristics: ................................................................................................ 37

4.1.2 Access to Dental Care: ................................................................................................. 40

4.1.3 Oral Hygiene and Preventive Behaviors: ..................................................................... 42

4.1.4 Parent‟s Knowledge of Oral Health: ............................................................................ 43

4.1.5 Perceived Oral Health: .................................................................................................. 47

4.1.6 OHLI, Oral Health Knowledge, Acculturation, Social Capital and Health Literacy

Scales ............................................................................................................................ 48

4.2 Bivariate Results ................................................................................................................. 52

4.2.1 OHLI, Oral Health Knowledge, Acculturation, Social Capital, Health Literacy ......... 52

4.2.2 Access to Dental Care: ................................................................................................. 55

4.2.3 Perceived Oral Health: .................................................................................................. 58

4.3 Correlations: ........................................................................................................................ 61

4.4 Logistic Regression Analyses ............................................................................................. 66

Chapter Five

Discussion 68

5.1 Study Limitations ............................................................................................................ 78

5.2 Implications and Recommendations for Future Research: ................................................. 79

5.2 Conclusions ......................................................................................................................... 81

vii

References: ................................................................................................................................. 83

List of Tables

Table 1-a: Characteristics of study population – children‟s characteristics ................................. 37

Table 1-b: Characteristics of study population – Caregiver‟s characteristics ............................... 39

Table 2: Child‟s dental care access and utilization ....................................................................... 41

Table 3: Child‟s oral hygiene and other preventive behavior ....................................................... 42

Table 4-a: Parent‟s knowledge of oral health ............................................................................... 43

Table 4-b: Parent‟s knowledge of oral health – oral health knowledge instrument ..................... 44

Table 4-c: Parent‟s knowledge of oral health – ECC ................................................................... 45

Table 4-d: Parent‟s knowledge of oral health – causes of ECC ................................................... 46

Table 5: Children‟s and parent‟s perceived oral health ................................................................ 47

Table 6: Mean scores of OHLI, Oral health knowledge, Acculturation, Social capital and Health

literacy instruments. ................................................................................................. 48

Table 7: Acculturation scale questions and answers for each item .............................................. 49

Table 8: Social capital scale questions and answers for each item ............................................... 51

Table 9-a: Mean scores of OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to parent‟s education ................................................................. 52

Table 9-b: Mean scores of OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to parent‟s age ........................................................................... 53

Table 9-c: Mean scores of OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to the total annual household income ........................................ 54

Table 9-d: Mean scores of OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to the number of years in Canada .............................................. 54

Table 9-e: Mean scores of OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to the frequency of brushing of children‟s teeth........................ 55

Table 10: Access to dental care in relation to selected variables .................................................. 56

viii

Table 11: Mean scores for OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to visiting the dentist. ................................................................ 57

Table 12: Children‟s oral health, as perceived by their parents, in relation to selected variables 59

Table 13: Mean scores for OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to parent-perceived child‟s oral health ...................................... 60

Table 14: Mean scores for OHLI, oral health knowledge, acculturation, social capital and health

literacy in relation to parent‟s self-perceived oral health ........................................ 60

Table 15: Kendall‟s Tau correlation test between the different instruments. ............................... 61

Table 16: Kendall‟s Tau correlation test between the different instruments for children who

visited the dentist ..................................................................................................... 62

Table 17: Kendall‟s Tau correlation test between the different instruments for children who did

not visit the dentist ................................................................................................... 63

Table 18: Kendall‟s Tau correlation test between the different instruments for children whose

perceived oral health is excellent or good ............................................................... 64

Table 19: Kendall‟s Tau correlation test between the different instruments for children whose

perceived oral health is fair or poor ......................................................................... 65

Table 20: Logistic regression analysis .......................................................................................... 67

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List of Figures

Figure 1: Acculturation Continuum ……………………………………………12

Figure 2: Health Literacy Framework ………………………………………….22

x

List of Appendices

Appendix 1: Ethics approval…………………………………………………………….95

Appendix 2: Consent form……………………………………………………………....96

Appendix 3: Recruitment flyer …………………………………………………….……98

Appendix 4: Supporting letter from the Arab Community Center………………....……99

Appendix 5: Questionnaire…. …………………………………………………….…….100

1

Chapter One:

Introduction

International migration, whether as a result of wars or improved international travel opportunities,

is greater than ever before. Over the last half-century, worldwide migration has become a global

issue, and the health-related issues associated with immigrant populations are assuming greater

importance and are increasingly the subject of health services research. In Canada, immigrants

represent 19.8% of the total population (1), and they play an important role in shaping the

Canadian population. The foreign-born population in Canada is rapidly growing; it has increased

by 13.6% between the years 2001 and 2006, compared to 3.3% by the Canadian-born population

during the same period (1). The large number of immigrants makes their health an important

determinant of the population health in general, and oral health in particular; therefore,

immigrants‟ health is vital to policy makers because of its impact on the health care system as

well as in determining the costs and benefits of Canadian immigration policy.

In studying the health of immigrants, a very important question is how immigrants‟ health is

compared to the health of Canadians born in Canada. Immigrants could be healthier than the

general population, due to self-selection – “the fact that only healthy people choose to migrate to

other countries”, or because of the screening tests the immigrants undergo through the process of

immigration to Canada that may exclude those with serious health problems. On the other hand,

immigrants may face economic difficulties, language barriers, acculturation problems and lack of

familiarity with the Canadian health care system and other problems that may leave them in worse

2

health. Studies have shown that immigrants tend to have better health than the Canadian-born

population, with the result that they may underuse the health care system, but this gap tends to

decrease with time and become closer to the general population health (2, 3).

Although little is known about the oral health and access to dental care among immigrants in

Canada, it should be expected that immigrants face more difficulty in utilizing dental services due

to the nature of the “private” dental care system in Canada. Also, immigrants are expected to have

more dental needs than the general population for a variety of reasons. Evidence from other

countries suggests that disparity in oral health status exists between immigrant and non-

immigrants. For example, a study in Germany found that children with migration experience have

less favorable oral health than non-immigrant children who live at the same low socio-economic

level (4). Another study in Italy found that adult immigrants and refugees have higher prevalence

of dental caries and periodontal diseases and less utilization of preventive services compared to

the general population (5). Utilization of dental services may vary even between different

immigrant groups. A study from the United States concluded that Chinese-speaking immigrants

make fewer visits to the dentist compared to Russian-speaking immigrants (6). These studies

collectively suggest that there are different factors that play a vital role in shaping the oral health

of immigrants.

Arabic-speaking immigrants come from 21 Arabic countries that are located in the Middle East

and North Africa. People of Arabic origin constitute 1.3% of the total population of Ontario and

represent 2% of the population of Toronto (7). The Arabic community in Canada is relatively

3

young with 29% of its population under 15 years of age (7). Arabic language was reported as the

mother tongue of 4.7% of immigrants in Canada in the 2006 Census (1).

According to Statistics Canada, Canadians of Arabic origins are usually highly educated and more likely

than the general population to have a post-graduate degree. However, they face difficulty in finding a job

and the unemployment rate is high compared to Canadians in general. Therefore, families of Arabic origin

are more likely to fall in the low income category than the general population (7); in 2000, 40% of Arabic

children were found to live in families considered to have annual income below the Canadian “Low-

Income Cut-Off”.

4

Chapter Two:

Literature Review

2.1 Immigrants’ Oral Health

Little information is available about the oral health status of the Canadian immigrants, which can

be attributed to the lack of information regarding the oral health status of the Canadians in

general. Only a few studies have addressed the relationship between immigration and oral health,

and most of these studies were in Ontario since it is a province with a large percentage of

immigrant population.

In 1998, Locker and colleagues compared oral health status and treatment needs of immigrant

adolescents aged 13–14 years old and their Canadian-born counterparts in North York, Ontario

(8). The results suggested that immigrant adolescents have poorer oral hygiene and higher

treatment needs compared to the Canadian-born. For example, dental decay was found in 15.1%

of the immigrant adolescents but in only 3.8% of the non-immigrants. However, immigrants made

fewer visits to the dentist despite their higher dental needs. Moreover, when length of residence in

Canada was taken into account, there was a significant association between the time since

immigration and oral health. Recent immigrants seem to have less favorable oral health and have

used dental services less than immigrants who have been in Canada for six years or more. This

trend can be explained in many ways. Recent immigrants could be more likely to face financial

problems, to have difficulties in employment, and therefore face difficulties in affording dental

treatment; while those who have been in the country for a longer time could have higher socio-

5

economic status that makes them more capable of affording dental treatment. Another reason for

this phenomenon could be the adoption of a more preventive behavior as a result of acculturation

and blending into the host community that increase with increasing exposure to the host

community culture.

Another study (9) looked at a specific group of Portuguese-speaking immigrants to determine

access to dental care among those immigrants and the factors that may influence oral health of

young children. This study showed that 35% of the sample children did have early childhood

caries with a mean dmft (decayed, missing and filled primary teeth) score of 3.8; however, the

study did not include non-immigrant children to compare the oral health status between the two

groups. The study also found that access to dental care is a challenge for those immigrants, with

77% of children with early childhood caries never having visited a dentist. In fact, the strongest

predictor for caries in these immigrants‟ children was found to be lack of dental insurance.

Immigrant children were also found to have higher unmet dental needs than non-immigrant

children (10). In a small local survey in Ontario, 69.8% of recently immigrated children had acute

dental disease compared to only 7.9% of Windsor-Essex County resident children. Another

survey in North York indicated that the mother‟s length of residency in Canada is a strong

predictor for future decay (11). The odds for developing new dental lesion in newcomer‟s

children were 3.4 times greater than children whose mothers were born in Canada or lived in

Canada for more than 20 years. This finding was also seen in Norway (12), indicating that oral

health of immigrants follows a certain pattern regardless of the migration country or the type of

dental care system.

6

Presently, there are no published studies on the oral health status of Arabic-speaking immigrants

in Canada. However, studies of the oral health status of Arabic populations in their respective

countries have shown that dental caries is still highly prevalent, especially among children. For

example, a study in Saudi Arabia in 2001 found that 27% of 5-year-old children in their study

sample had early childhood caries (ECC), which is a rampant form of dental caries that usually

affects the primary teeth of children aged 2 to 5 years old (13). Another study in Jordan (2002)

found that only 52% of preschool children in Amman were caries-free (14). In addition, not only

is the prevalence of caries in preschool children high in these countries, but the severity is also a

serious issue. A study in Lebanon in 2002 found that the mean decayed, missing and filled

permanent teeth (DMFT) score for 6-year-old children was 2.03, and for 12-year-old children was

5.72 (15). Another study in the United Arab Emirates estimated the average decayed, missing and

filled surface (dmfs) score in a sample of preschool children to be 10.2 (16).

Children of Arabic immigrant families were found to have worse oral health than children of non-

immigrant families in Denmark (17, 18). In these studies, Arabic preschool and school children

had higher caries prevalence and mean dmfs/DMFS values compared to Danish children. Arabic

preschool children had significantly high prevalence of early childhood caries in anterior teeth; 7-

year-old children of Arabic background had a high mean dmfs/DMFS score of 11.5, which was

higher than other immigrant groups (17). This same trend was seen in the second study (18) that

looked at the effect of maternal ethnicity on children‟s oral health. Immigrant children whose

mother is from Arabic countries (Morocco, Iraq and Lebanon) seem to have worse caries

experience than children with Danish mothers and immigrant children from different

backgrounds. These studies emphasize the importance of ethnic background on oral health;

7

although all children living in Denmark have access to free public dental services, disparities still

exist between immigrants and non-immigrants.

2.2 Access to Dental Care

In Canada, the dental care system is mainly private with a small share for public programs that are

directed towards high risk groups, such as children and social assistant recipients (19). Usually

the dental services are paid for either through an employment-based insurance or by out-of-pocket

money. Thus, for newcomers, financial difficulties could be a serious issue as they are trying to

settle down in a new country and start a new life. Evidence from other countries has shown that

immigrants tend to underutilize dental services for various reasons (20, 21). The case is not

different in Canada: Brodeur et al (22) in a survey of women living in Québec (n= 5,795) found

that recent immigrant women use preventive dental services less than long-term immigrants or

non-immigrant women. The study also suggests that this difference cannot be explained by

economic difficulty alone. Barriers to obtaining dental care for immigrants may not be financial

only; it could be a cultural barrier. In 2007, Lai and Hui (23) found that 52.1% of the elder

Chinese immigrants in Québec did not visit the dentist in the past year. In this study, those who

lived in Québec were less likely to visit the dentist than those living in British Columbia; this is

likely due to the limited number of Chinese-speaking dentists in Province of Québec. It has been

found that cultural beliefs and perception of oral health among Chinese immigrants may also

contribute to underutilization of dental care (24). Finally, immigration status was found to be a

predisposing factor for visiting the dentist only when suffering from dental pain among the

working poor (25).

8

On the other hand, analysis of the data from the Canadian National Population Health Survey

(NPHS) of 1996–97 revealed that foreign-born Canadians utilize the dental services more than

native-born Canadians (26). The study also found that immigrants tended to visit the dentist to

obtain treatment such as restorations or extractions, while native-born Canadians visited the

dentist for prevention and examination only. Most importantly, the study showed that having

dental insurance is associated with greater use of dental services among immigrants. However,

75.5% of the immigrant population taking part in this survey had been in Canada for 10 years or

longer; therefore, it is difficult to interpret these results for recent immigrants.

2.3 Early Childhood Caries (ECC)

2.3.1 Definition

Early childhood caries (ECC) is considered the most prevalent chronic disease in children (27).

According to the American Academy of Pediatric Dentistry, ECC is defined as “the presence of

one or more decayed (noncavitated or cavitated), missing (due to caries) or filled tooth surface in

any primary tooth in a child aged up to 71 months (28)”. In Toronto, the overall prevalence of

ECC among preschool children is approximately 4.7% (29).

Early childhood caries is a severe disease with different impacts on the child‟s oral and general

health. It results in pain and difficulty eating and drinking, and interferes with sleeping affecting

the quality of life for young children (30). It also adversely affects growth and development.

Dental caries at early age may affect the permanent dentition and is considered a good predictor

for dental caries in the future (31).

9

ECC treatment is considered costly since it is extensive and usually is carried out under general

anesthesia (GA) in a hospital setting; the mean cost of such treatment could be as high as $1500

per admission (32). Unfortunately, children may have to wait for a long time before this type of

treatment becomes available. In fact, a recent Canadian study found that the highest percentage of

pediatric surgeries completed past target were in dentistry; only 55% of dental surgeries under

GA were completed in time (33).

2.3.2 ECC Risk Factors

Many risk factors have been associated with ECC. High levels of Streptococcus mutans, poor oral

hygiene, putting a child to sleep with a bottle and a high sugary diet are the strongest predictors of

early childhood caries (34, 35).

ECC is highly prevalent among disadvantaged groups including low income families (36),

immigrants (37) and Indigenous populations (38). Socio-economic status plays an important role

in developing dental caries at an early age. A study in Manitoba, Canada, looked at the prevalence

and risk factors of ECC among preschool children visiting public dental clinics (36). In this study,

low monthly family income, low level of parental education, irregular dental visits, and family

structure were found to be strong risk indicators among the study population. These same factors

were identified as risk factors for ECC in a longitudinal study in Norway (39). A recent study of

the risk indicators of ECC among children in Toronto revealed that parent‟s depression, family

income and the language spoken at home are significant risk indicators for ECC that need to be

confirmed in longitudinal studies in this population (29).

10

Since young children spend a lot of time with their mother and it is usually the mother who takes

care of the child‟s mouth, the mother‟s level of education, knowledge of oral health and fatalistic

health beliefs are other important risk indicators/factors (40; 41). Finlayson et al (41) have found

that the mother‟s adopting a fatalistic belief increased the likelihood of ECC, while good oral

health knowledge had a protective effect. Another study indicated that children are more likely to

have ECC if their parents do not believe that oral health problems can affect their children‟s

general health (42).

2.4 Acculturation

2.4.1 Definition

Acculturation has been proposed as an important determinant of immigrants‟ health. Researchers

have studied the effect of acculturation on general health since the 1960s. Its impact on oral

health, however, was not investigated till the 1980s, gaining more interest since then.

Acculturation can be defined from different perspectives; an early sociological view presented

acculturation as “a process of accommodation with eventual (and irreversible) assimilation into

the dominant culture group” (43). From an anthropologic point of view, acculturation is a process

that “comprehends those phenomena which result when groups of individuals having different

cultures come into continuous first-hand contact, with subsequent changes in the original cultural

patterns of either or both groups” (44).

11

According to Berry (45), acculturation is the result of the interaction between two main processes:

maintenance of the original culture and development of a relationship with the new culture. Berry

also suggested four strategies of acculturation:

Integration: in which people maintain attitudes and behaviors from their original culture,

and manage to adopt attitudes and behaviors from the new culture.

Assimilation: when people entirely adopt the attitudes and behaviors of the new culture.

Separation: when people entirely reject the new culture and turn completely to the original

culture.

Marginalization: when the individual does not identify with either the culture of origin or

the new culture.

These definitions assume that acculturation results in changes in both interacting cultures;

however, some investigators have defined acculturation as the changes in immigrants‟ values,

behavior or culture without considering changes in the new culture (46).

Acculturation could be influenced by the social environment, time, gender, age at immigration,

physical characteristics, duration and reason for immigration (47, 48). McDermot-Levy (48)

suggests that immigrants may adopt different acculturation strategies in their public or private

life. As shown in Figure 1, acculturation can occur on a range (acculturation continuum) from

separation to integration to assimilation and can vary with time depending on several factors.

12

Figure 1: Acculturation continuum (48)

2.4.2 Measuring Acculturation

Since acculturation is a multidimensional process (47), proxy measures have been used to assess

it. Such measures include language proficiency and preference, length of residence, ethnic

identification, place of birth and social affiliation (49). In the dental literature, these measures

have been used alone (8, 9, 23, 50), or in combination forming an acculturation scale (4, 20, 54,

57, 58).

Acculturation scales are of three types (49):

Unidimensional scale: this scale measures changes in one culture only, thus

considering acculturation as a linear continuum where people are either

13

acculturated or not. Such a scale usually measures language preference, time living

in the host culture and traditions.

Bidimensional scales measure changes in both original and host cultures

individually and produces two scores for each culture. This type of scale measures

changes in attitudes, beliefs and behaviors.

Multidimensional scales evaluate different dimensions of acculturation such as

changes in values and ethnic interactions.

There is no single scale for measuring acculturation; different studies have used various types of

scales to measure different concepts of acculturation.

2.4.3 Acculturation and Health

Acculturation can change the cultural norms and behaviors of immigrants influencing their ability

to seek care and use preventive services, hence affecting health outcomes. Many studies have

found a relationship between acculturation and immigrants‟ health; for example, Lara et al. (51)

reviewed the literature about the effect of acculturation on Latinos‟ health in USA. The review

found that acculturation of children and adults can have both positive and negative health

outcomes. Some of the studies included in this review found that acculturated immigrants had

poorer health behaviors and poorer nutritional intake, while less acculturated individuals reported

better access to health services and less perceived poor health. Other studies produced mixed

results which can be attributed to the differences in measures used to assess acculturation as well

as the inadequacy of the theoretical construct of acculturation itself among the different studies

14

(51). The relationship between acculturation and health is complicated and depends on the

particular health outcome measured; for example, one study found that lack of acculturation is

associated with increased risk for diabetes among Arab-Americans living in the United States

(52), while another study (53) concluded that acculturation is associated with worse self-reported

health for Arab-Americans.

2.4.4 Acculturation and Oral Health

Few studies have investigated the effect of acculturation on the oral health of immigrants and

have yielded contradictory results. In a cross-sectional analysis, Ismail and Szpunar (54)

compared the prevalence of caries and periodontal diseases and use of preventive services among

high-acculturated and low-acculturated Mexican-Americans in the United States; the results

indicated that those with low acculturation had a higher mean DMFT score, as well as higher

prevalence of gingivitis than those with high acculturation. Low acculturation was also found to

be associated with a lower frequency of visiting the dentist as compared to the highly acculturated

Mexican-Americans even after adjusting for education and income (20, 50). Spolsky et al. (55)

described the dental caries experience of a Hispanic sample from Los Angeles. They concluded

that caries experience was significantly related to acculturation. Those who were highly

acculturated had a better dental status when compared to those who were less acculturated.

On the other hand, some studies found no relation between acculturation and the use of preventive

dental services (56). All of the previous studies were about Hispanic immigrants only, but Cruz

and colleagues (57) studied the association between immigration and acculturation attributes in

15

different immigrant groups living in New York City. The acculturation attributes included were

age at immigration, length of stay and the preferred language. In addition to that, the participants

had an oral examination and answered a questionnaire about access to dental care, utilization of

dental care services, oral health practices, self-perceived oral health, self-perceived need for oral

health care, immigration status, knowledge regarding oral health, and attitudes regarding oral

health. The results showed a significant association between the country of birth and the level of

oral disease even after controlling for socio-economic status among the different groups of

immigrants. These results indicate the influence of the cultural background of immigrants on their

oral health. Immigrants carry with them their traditions, culture, and dietary practices that, in

conjunction with their exposure to environmental and socio-political factors may influence oral

health. This study also found that the length of stay in the United States had a positive effect on

the oral health, which is another indication of the effect of acculturation on changing immigrants‟

behavior towards more use of preventive services.

The level of acculturation influences immigrants‟ oral health in a variety of ways. Mariño and

colleagues (58) suggest two types of acculturation: behavioral and psychological. In their study

among Vietnamese living in Melbourne, Australia, behavioral acculturation was associated with

the language preference and was found to be a significant predictor only for dental caries status,

while psychological acculturation, as measured by cultural and social beliefs, was related to oral

health knowledge and the use of preventive services.

16

2.5 Social Capital

2.5.1 Definition

While starting a new life in a new country, social networking is an important part of immigrants‟

settlement process. Moore et al. (59) encouraged the development of research that views networks

as social contexts which influence the behavior and practices of individuals. Social capital is

defined as an investment in relationships that facilitates the exchange of resources. This definition

was „„etymologically derived from the terms social, referring to interpersonal relationships, and

capital, referring to assets that accrue through investment‟‟ (60). There are many definitions for

social capital (61, 62, 63); most of them, however, agree that social capital has three elements:

social networks, norms of reciprocity and trust (64).

Social network is seen as the structural component of social capital (65), and, in turn, can be

divided into two types (66):

Horizontal networks: these improve society by bringing equivalent status and power, thus

maintaining equal social capital in the society through ties with family, friends, neighbors and

colleagues.

Vertical networks: these include hierarchical relationships with people in power in the society,

such as religious organizations and political parties. Such ties may lead to unequal social capital;

17

however, Woolcook (67) argues that such vertical dimension of social capital, which he called

“linking social capital”, is important to increase involvement in the local community.

Norms of reciprocity usually refers to social support (64). There are four main types of social

support: emotional, instrumental, informational support and social companionship (68).

Emotional support, as its name indicates, includes moral support from family and friends in terms

of caring, empathy and love. Instrumental support is any practical support, such as money,

providing transportation method or any labor help. Informational support is providing the

guidance and information to help in solving problems. Finally, social companionship means

whether a person spends time socializing with others.

The last concept of social capital is trust, which is simply the capacity to trust other people in the

society (61). This trust could also be institutional, that is, trust in the formal system, such as

political or judicial systems. Both norms of reciprocity and trust can be enhanced through social

interaction and are seen as a cognitive dimension of social capital because they define the quality

of social bonds.

Social capital can further be classified into bonding social capital and bridging social capital.

Bonding social capital refers to strong relationships between individuals who know each other

and are socially similar, such as between family members and friends. Bridging social capital

comprises less strong relations that are formed between people who are different in their socio-

demographic characteristics such as education or ethnic group (69)

18

2.5.2 Measurement

Social capital can be assessed on two levels: individual level and community level. There are

several indicators used for this purpose, the most commonly used, especially in health research, is

membership in voluntary organizations and general social trust (64). Putnam (70) included these

two measures in addition to measures of engagement of public affairs, measures of community

voluntarism, and measures of informal sociability in his Social Capital Index. However, Moore et

al. (59) suggest that the best way to assess social capital is by using a social networks approach so

that the effect of both quality and quantity of social relations can be assessed. Moore et al. believe

that social relations play an important role in determining individuals‟ and community public

health.

There is no standard scale to measure social capital; researchers have used the different concepts

of social capital to measure it. For example, Pattussi et al. developed a scale to measure

neighborhood social capital; in this scale five dimensions were assessed: social trust, social

control, which is the degree to which neighbors would intervene to protect children from harmful

behaviors, empowerment, neighborhood security, and finally political efficacy (71). Others (72)

measured vertical and horizontal social capital by assessing memberships in various types of

organizations, unions and clubs. In a recent study, Nakhaie and Arnold (73) used different

indicators to capture the various dimensions of social capital; these measures include voluntarism,

norms of reciprocity, social support, social networks, household size and participation in a sport

team.

19

2.5.3 Social Capital and Health

Recently, there has been increased interest in the importance of social capital and its influence on

the health behaviors and practices of individuals. Evidence has shown that social capital is

positively related to health status. Studies have shown positive influence of high social capital on

mental health (74), lower level of mortality rates (75), and self-rated health (76).

Several studies from Canada looked at the link between social capital and health. Veenstra (77–

80) conducted several studies in Saskatchewan, British Columbia and Hamilton, Ontario, to find a

positive effect of different forms of social capital on self-rated health and mortality rates. Another

Canadian study (73) analyzed data from the 1996-2000 National Population Health Survey

(NPHS) to determine the effect of various social measures on the general health of the Canadian

population. This study concluded that social capital can affect changes in health. Moreover,

results suggested that marital status, contact with family, and attendance at religious services all

affect health positively.

Social networking may help new immigrants in navigating the health care system and therefore it

can affect the rate of health service utilization. In 2005, Deri (81) studied the effect of social

networking on health care utilization among immigrants in Canada. Analyzing data from the

National Population Health Survey, Canadian Census and Canadian Medical Directory, Deri

found that utilization of the health care system is affected by social networking; those who are

living in a neighborhood with many people speaking the same language have higher rates of

health care use. Deri also concluded that health care utilization is increased by increasing the

20

number of physicians speaking the same language as the immigrants in the area. However, we

cannot expect the same for dental care utilization because health care is universal and in this case

the economic factor is not of concern for the new immigrants.

2.5.4 Social Capital and Oral Health

Research on oral health and social capital is not as extensive as in the case of general health; only

a few studies have investigated the possible influence of social capital on oral or dental health. In

Brazil, Pattussi et al. (82) investigated the effect of community empowerment on the dental caries

status of 14- and 15-year-old students and found a negative association between community

empowerment and high DMFT rates. The same researchers found in another study (71) that in

Brazilian communities with high social capital there was less prevalence of traumatic dental

injuries among adolescents.

Community social context was found to have a beneficial effect on dental caries experience

among three-year-old children in Japan (72). In this study, social cohesion, measured by the

number of community centres per 100,000 residents, was significantly associated with the dmft

Index.

Social capital could affect dental care utilization among immigrants. Nahouraii and colleagues

(83) looked at the effect of four different types of social support, namely informational support,

influence of family and friends, material aid and emotional aid, on dental care utilization among

Latino women and their children in the USA. The results showed that instrumental aid, which

21

represents the dental care information provided to mothers in hospitals for example, has no effect

on dental care utilization, while the support from families and friends, such as helping in booking

dental appointments and accompanying mothers to these appointments, has a significant

association with visiting a dentist. The findings of this study suggest the influence of family on

dental services use; currently, public health interventions concentrate on information

dissemination which has, according to this study, little effect on parents‟ dental behavior. This

aspect of social support was also seen among elder Chinese immigrants in the USA (6); frequent

contacts with friends were significantly associated with increased dental visits.

2.6 Health Literacy and Oral Health Literacy

2.6.1 Definition

Health literacy is defined as the “degree to which individuals have the capacity to obtain,

process, and understand basic health information and services needed to make appropriate health

decisions (84)”. Besides the language barrier, new immigrants may face difficulty in navigating

the already-complicated health care system. Health literacy is not only associated with the ability

to read or write the English language, but is also affected by education, culture and the context of

the situation. Oral health literacy, on the other hand, is defined as “the degree to which

individuals have the capacity to obtain, process and understand basic health information and

services needed to make appropriate oral health decisions” (85). The ability to understand health

information and obtain services is vital for personal health management; therefore, health literacy

is recognized as an important determinant of health (86).

22

A committee formed by the Institution of Medicine in the U.S. to understand health literacy and

its impact on health outcomes have developed a health literacy framework (Figure 2). This

framework identifies three major areas that may play important roles in shaping individuals‟

health literacy: culture and society, the health system, and the education system. Interventions

should be directed towards these three areas to improve health literacy (87).

Figure 2: Health Literacy Framework (87)

Nutbeam (89) believes health literacy should be defined on three different levels:

Basic functional literacy includes reading and writing skills in addition to knowledge

about health conditions and health care systems;

23

Communicative /interactive literacy is the ability to understand health information from

different forms of communication;

Critical literacy requires higher levels of cognitive and social skills to help in making

informed decisions by critically analyzing information.

These levels should not be seen as hierarchical because individuals may have a variety of skills

within each type of literacy. However, they can be used to improve health literacy through

targeted health promotion activities (89).

2.6.2 Measuring Health and Oral Health literacy

The first two measures of health literacy developed focus on an individual‟s ability to read and on

word recognition. The Rapid Estimate of Adult Literacy in Medicine (REALM) test was

developed by Davis et al. in 1991; this tool assesses word recognition and pronunciation skills

(90). The second instrument, Test of Functional Health Literacy in Adults (TOFHLA), was

developed in 1995 and it measures reading comprehension and numeracy skills (91). Other

instruments use screening questions to assess a patient‟s ability to read and write the necessary

information in a medical setting; an example of such a scale is the health literacy scale developed

by Chew at al. (92), which is a short questionnaire used to identify patients with inadequate health

literacy. These instruments have been validated and are used widely in the medical literature;

however, they are limited to measuring individuals‟ ability to read and write while health literacy

itself goes beyond that (93).

24

To measure oral health literacy, researchers developed modified versions of the REALM: Rapid

Estimate of Adult Literacy in Dentistry (REALD) (94, 95). There are two versions of this tool

(REALD-30 and REALD-99) depending on the number of words used in the instrument.

Atchison et al. (96) created a new instrument based also on REALM; this new instrument

(REALM-D) combines both medical and dental terms into a single 84-item scale to screen for

oral health literacy and was found to be a valid and reliable measure when tested on a diverse

sample of dental clinics patients in the USA.

Other instruments used in the dental literature are based on the TOFHLA (97); for example, the

Test of Functional Health Literacy in Dentistry (TOFHLiD) assesses comprehension and

numeracy skills for dental patients. These instruments have the same limitations as their original

versions: they focus only on word recognition and numeracy skills. More recently, another

instrument was developed by Sabbahi et al. (98) to determine the oral health literacy of adults:

Oral Health Literacy Instrument (OHLI). In addition to comprehension and numeracy skills,

OHLI also measures oral health knowledge in an attempt to capture another dimension of health

literacy.

With the increasing interest in health literacy in the last 25 years, it has become clear that health

literacy is a multidimensional concept, which further complicates the development of a single

scale to measure all dimensions of health literacy. Frisch et al. (99) suggest that other domains of

literacy should be incorporated into health literacy to develop an extensive scale inclusive of

different dimensions such as functional, critical, attitude, awareness and procedural knowledge.

To date, such an instrument does not exist but the research is ongoing.

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2.6.3 Impact on Health and Oral health

Health literacy is considered low in North America, but Canadians were found to have higher

health literacy than the USA population. However, almost 60% of Canadians have a low level of

health literacy that may negatively influence health outcomes (100). Health literacy was found to

be lower among the elderly, those with low level of education, and among immigrants and ethnic

minorities (87).

Low levels of health literacy have been associated with increased risk of hospitalization and

emergency care use (101); lower utilization of preventive services (102); inability to follow

prescriptions appropriately (103); and poor management of chronic diseases such as diabetes

(104) and asthma (105). There is also increasing evidence that health literacy may explain

disparities in health outcomes among different ethnic groups; such a relation has been found in

many studies with different health outcomes (106). With limited language proficiency and

cultural barriers, immigrants are more likely to have inadequate health literacy, affecting their

utilization of health services (107). In a recent qualitative study from Canada, recent immigrants

reported that differences in language and culture were the main reasons for lacking effective

communication with health care providers and for not understanding health information (108).

Caregiver‟s level of health literacy can impact their young children‟s health (109, 110). Children

with chronic diseases, such as asthma and diabetes, are more likely to have severe asthma and

worse glycaemic control, to use emergency care, and to be hospitalized when their parents have

low level of health literacy.

26

Health literacy can also impact oral health. Adults with inadequate oral health literacy have

poorer oral health knowledge, tend to have fewer dental visits, and are more likely to report poor

or fair oral health (111). Oral health literacy varies between racial groups; those from ethnic

minorities tend to have inadequate literacy levels that may impact their oral health (112, 113).

Children of parents with low literacy have poor reported oral health (114, 115) and are less likely

to have sealants on their permanent teeth (116). Using REALD-30, Miller and colleagues (114)

examined the association between caregiver‟s literacy and preschool children‟s oral health. This

study evaluated clinical oral health status and oral health behaviour of children, caregiver‟s oral

health knowledge and children‟s oral health as perceived by their caregiver. There was a

significant association between caregiver‟s oral health literacy and children‟s oral health as

determined by both clinical examination and caregiver‟s perception. Oral health knowledge and

behaviour was not found to be affected by literacy; however, another study concluded that low

levels of oral health literacy were associated with poor knowledge and behaviour among low-

income mothers (115). This variation between the two studies could be the result of the different

characteristics of their study populations, especially the level of education.

2.7 Summary

Canada is a country that accepts thousands of immigrants every year, yet little is known about the

health or oral health of those newcomers. Recently, the interest in immigrants‟ health is

increasing and more research is being conducted in this field. However, studies regarding

27

immigrants‟ oral health in Canada are sparse. The few studies available now indicate that the oral

health status of the Canadian immigrants is worse than that of the general Canadian population.

Coming from countries with high rates of dental caries, children of Arabic-speaking families are

expected to have high rates of early childhood caries. Cultural, social and economic factors play

an important role in leading to this result. New immigrants face many challenges and changes in

their cultural and social environment that may affect their oral health, in addition to facing

financial challenges that might limit their access to care.

Dental caries is not the result of individual behaviors alone, but there are other broader factors

that contribute to the development of this disease. The social determinants of oral health are now

well-established and understanding the influence of these factors on immigrants‟ oral health is

essential in order to improve the oral health of new Canadians. Factors such as acculturation,

social capital and health literacy are gaining more interest as important determinants of oral

health. The literature provides strong evidence that these factors shape oral health status

especially among ethnic minorities and immigrant groups. However, such studies about the

Arabic-speaking immigrants are not currently available.

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2.8 Study Objectives:

The objectives of this research were:

1- To determine access to dental care among preschool children (aged 5 years and younger)

of Arabic-speaking immigrant families residing in Toronto, ON, Canada;

2- To measure the oral health of these preschool children as perceived by their parents;

3- To evaluate the effect of acculturation, social capital, and oral health literacy on access to

dental care for preschool children of Arabic-speaking immigrants residing in Toronto, ON,

Canada.

29

Chapter Three

Materials and Methods:

3.1 Study Design and Target Population

This study was a descriptive, cross-sectional survey. The targeted population consisted of Arabic-

speaking immigrant families with at least one child aged 71 months or younger; when the family

had more than one child in this age group, only the youngest child participated in the study.

Participants were parents, preferably mothers (as mothers usually have better knowledge of their

children‟s oral health and oral health behaviour) of young children. Almost 170 families were

approached, of these, 100 parents agreed to participate in this study and they were interviewed

and answered a questionnaire.

3.2 Ethical Considerations

Ethics approval for the study was obtained from the University of Toronto Research Ethics Board

(REB) (Appendix 1). Prior to participation, potential participants were asked to read and sign a

consent form (Appendix 2) that included a brief description of the study and the benefits and risks

of involvement. Participants had the right to withdraw from the study at any time and they were

provided with contact numbers of the primary investigator for any further inquiries.

30

3.3 Sample Size Calculation

A targeted non-probability snowball sampling strategy was used since there is no sampling frame

for the Arabic-speaking immigrants in Toronto. In this technique, participants who were

successfully recruited were asked to name friends or relatives who might be eligible for this study

and be interested in participating. This method is usually successful in reaching minorities and

hard-to-reach populations.

Based on a previous study (9), we estimated that approximately 34.5% of immigrant parents

would have used dental care services for their young children. Since no national dental care

access data were found for preschool aged children, we assumed that 20% more (54.5%) of the

Canadian population has used dental services for their preschool children. This was an

underestimation given that the most recent Canadian Health Measure Survey (CHMS) (117)

reported that 91% of school children had visited the dentist in the previous year. Using these

proportions, the minimum sample size required was approximately 100 complete responses. With

this sample size, the study has a power of 80% to yield a statistically significant result. The

criterion for significance (alpha) was set at 0.05 (2-tailed).

3.4 Enrollment

To recruit participants, flyers (Appendix 3) were distributed in the Arab Community Centre of

Toronto (ACCT), which is a non-profit, non-political, non-religious organization that aims to help

all newcomers to Canada, especially Arabs, and to provide information and assistance to

31

guarantee the success of individuals and families in Canada. The centre is located in Toronto, yet

immigrants from different parts of the GTA visit the centre for the multiple services it provides.

The ACCT agreed to help in this research by providing support and encouraging community

members to engage in this study (see Appendix 4 for letter of support). In addition to that, flyers

were circulated in some Arabic stores and in Arabic-speaking family physicians‟ and

paediatricians‟ offices. Arabic-speaking families were also approached in the malls and shopping

centres by the primary investigator and were given the flyers and asked to participate in the study.

3.5 Study Environment

The interviews were conducted at the ACCT centre and in the shopping malls where recruitment

was carried out. In addition, the investigator visited 20 private homes to conduct the interviews.

3.5.1 Interviews

Upon agreeing to participate, the child‟s primary caregiver was asked to read and sign the consent

form (Appendix 2). The caregiver was then interviewed by the primary investigator, who was

fluent in Arabic, and asked to answer a semi-structured questionnaire (Appendix 5). The

interviews were carried out in a quiet place and each interview took approximately 30 minutes to

complete. Participants answered the questionnaire either in Arabic or English based on their

preference. After finishing the interview, each participant received $20 as a token of appreciation

for their time and effort.

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3.6 Questionnaire

The questionnaire was adapted from different instruments that have been tested in previous

studies. The English-language questionnaire was translated by the principal investigator to the

Arabic language and then translated back to English to check for the accuracy of the translation.

The questionnaire was pilot tested with members of the Arabic-speaking community before being

used in the study. In total, it consisted of 32 multiple-choice questions comprising ten different

sections that covered the following areas: child‟s background, child‟s dental care utilization,

child‟s oral health and other preventive behaviour, parent‟s knowledge of oral health, parent‟s

oral health perception, parent‟s background and demographic information.

In addition, the following five instruments were used:

1- Acculturation scale: this is an eight-item instrument to measure acculturation that was

developed and tested using an Arabic-speaking sample in Australia and found to be valid and

reliable (118).

2- Social capital scale: this instrument was adapted from a scale that was developed in Egypt for

families of children with special health care needs. It was tested in the Arabic language and found

to be valid and reliable (119).

3- Oral Health Literacy Instrument for parents of young children: this instrument was adapted

from the Oral Health Literacy Instrument (OHLI) for adults, which was developed by Sabbahi et

al. (98). The instrument contains comprehension and numeracy sections and an oral health

knowledge component. In this research, only the numeracy part of this oral health literacy

33

instrument was used for Arabic-speaking parents with preschool-aged children. Participants were

shown appointment and instruction cards in addition to bottles with prescriptions on them. They

were asked to read the cards and labels carefully before they were asked the questions by the

primary investigator. The instrument was given only in English, because the aim of the study was

to assess the ability of parents to understand the medical and dental instructions given to them in

Anglophone Canada. All other instruments were conducted either in Arabic or English based on

participants‟ preference.

4- Parent/primary caregiver’s knowledge of child oral health was measured by a 14-item scale

developed by Lawrence et al. (2004) and validated among a sample of Canadian Aboriginal

parents/caregivers of young children (120).

5- The Health Literacy instrument was a short scale consisting of four screening questions that

was found to be effective in detecting inadequate health literacy among patients (92).

3.6.1 Calculating the Final Score of the Instruments

1- Oral Health Knowledge instrument (120):

For each item of this 14-item scale, a score of (1) was given to the correct answer; and a score of

(0) was given to the item answered incorrectly. For the answer of “Don‟t know” a value of (98)

was given; this value was considered as missing in the analyses. The final score was calculated by

summing the scores of the 14 items used. Higher scores meant better oral health knowledge.

34

2- Acculturation Scale (118):

Each item of this 8-item instrument was recorded using a Likert scale with 5 response options,

except item number 8, which had 4 Likert response options. Therefore, we weighted item number

8 by multiplying the response by 1.25 (5/4); then the final score that measures acculturation was

calculated by summing all the scores for each participant. Higher values meant higher levels of

acculturation.

3- OHLI (98):

This scale has 14 items. For each item a value of (1) was given to the correct responses and (0) to

the incorrect responses. The total raw value for the scale was a simple sum of correct responses.

The raw scores were then multiplied by 3.571 (50/14) to create a weighted total score for

numeracy ranging from 0 to 50, with higher scores reflecting higher oral health literacy.

4- Health literacy (92):

This scale has 4 items. For “confident with forms” and “follow the instruction” the categories

were “not at all”, “a little”, “somewhat”, “quite”, and “extremely”. For “problems learning” and

“help reading,” response categories were “always”, “often”, “sometimes”, “occasionally”, or

“never”. To create the summative scale, responses were assigned a number from 1 to 5. For

“confident with forms” and “follow the instruction” 1 was assigned for a Likert response of

“extremely,” and 5 for “not at all”. For “problems learning” and “help reading” number

assignments were reversed. Scores ranged from 4–20 with higher scores reflecting worse self-

reported health literacy (HL).

35

5- Social Capital Scale (119):

The Arabic version of the Social Capital Scale, originally developed by Looman in 2006, has 14

items measuring four different areas: Engagement for the Common Good, Sense of Belonging,

System Connection, and Family Role in Community. Respondents were asked to read each

statement and place an (X) in the column that best represented how well the statement described

their family and the community they lived in. Items were scored from 1(strongly disagree) to 5

(strongly agree). Items number 5, 6 and 7 measuring Sense of Belonging were reverse-scored.

The final score was calculated by summing the scores of all the items. Scores could range from 14

to 70, with higher scores meaning higher social capital.

3.7 Data Analysis

The dependant variables or primary outcomes for analyses were: access to dental care and

children‟s oral health as perceived by their parents. The independent variables were: parents‟,

children‟s and families‟ socio-demographic characteristics, parents‟ knowledge about child oral

health and preventive oral health behaviours, parents‟ perceived oral health, acculturation, social

capital, health literacy, and oral health literacy.

Statistical analyses were performed using non-parametric tests because some of scales presented a

skewed distribution. These tests included the Chi-squared test, the Mann-Whitney U test, and

Kendall-Tau Correlation to measure the association between the dependant and independent

variables assessed in this research. Logistic regression analysis was also used to determine the

factors that affect access to dental care among Arabic-speaking immigrants with young children.

36

Qualitative data were analyzed using descriptive statistics (frequencies). All statistical analyses

were carried out using SPSS® version 19. All the tests were two-tailed and interpreted at the 5%

significance level.

37

Chapter Four

Results

4.1 Univariate Results

4.1.1 Sample Characteristics

One hundred questionnaires were completed in this study; no questionnaires were excluded as all

of them were fully completed by one of the parents. Table 1-a shows the characteristics of the

children who participated in this study. More than half (58%) of children were females. The

majority (77%) were born in Canada. The mean age of the children was 3.16 years old with most

of the participating children (58%) between 2 and 3 years of age.

Table 1-a: Characteristics of study population – children’s characteristics

Percent Number

Gender of child

Male 42 42

Female 58 58

Place of birth for child

Canada 77 77

Outside Canada 23 23

Age of child (years)

0–1 19 19

2–3 58 58

4–5 23 23

Mean (SD) 3.16 (0.11)

38

Ninety-six percent of caregivers who participated in this survey were mothers; and most of them

were between 25 and 34 years of age (Table 4-b). The study population was highly educated; 64%

of parents had completed university, and only 17 (17%) had finished education at the High School

level. The majority (85%) of families had at least one other child in addition to those included in

the study, with a mean number being almost two other children per family.

When asked about total annual household income, 30% refused to answer or indicated they didn‟t

know. Less than half (44%) of families were of low income with a total annual income of less

than $50,000; only 8% of families earned $100,000 per year or more.

In order to study the effect of acculturation on oral health, participants were asked how many

years their families had spent in Canada. Almost half (47%) of the immigrant families included in

this study had been in Canada for less than five years (Table 1-b).

39

Table 1-b: Characteristics of study population – Caregiver’s characteristics

Relation to child Percent Number

Mother 96 96

Father 4 4

Parent’s age

Younger than 25 5 5

Between 25 and 34 58 58

Between 35 and 44 37 37

Parent’s education

Less than high school 3 3

Completed high school 17 17

Completed college 11 11

Completed university 64 64

Completed Post graduate study 4 4

Still in college 1 1

Have other children

Yes 85 85

No 15 15

Number of other children

Mean (SD) 1.89 (0.951)

Years in Canada

Less than 5 years 47 47

Between 5-10 years 28 28

10 years and more 25 25

Total household income

Less than $10,000 3 3

$10,000 to less than $20,000 6 6

$20,000 to less than $30,000 13 13

$30,000 to less than $40,000 15 15

$40,000 to less than $50,000 10 10

$50,000 to less than $60,000 5 5

$60,000 to less than $70,000 4 4

$70,000 to less than $80,000 6 6

$80,000 to less than $100,000 4 4

$100,000 or more 4 4

Refuse to answer or don‟t know 30 30

40

4.1.2 Access to Dental Care

The main outcome of this survey was access to dental care. This was assessed by asking parents if

their child had visited a dentist in Canada before. Also, questions about dental care utilization and

reasons for visiting and not visiting the dentist were asked. Table 2 illustrates the children‟s

dental history. Only 34% reported their children were seen by a dentist, mainly for regular check-

ups (14) or because of dental problems such as cavities (7), followed by problems related to teeth

or gingival appearance (6), or dental pain (1). Most of the children visited the dentist in the first

four years of age.

Of those who visited the dentist, only five children had early childhood caries and two children

needed fillings on such teeth. Parents also stated the method of payment for their children‟s dental

visits; equally 47% were paid by employment-based insurance and public dental programs.

Sixty-six percent of children had not visited a dentist before; the main reason for that was because

parents did not know there was a need to see the dentist. Eight parents (12%) thought it was “too

early” or their child was “too young” to have a dental visit; other three families indicated they

were following their dentist advice to start dental visits later. Only two (3%) families stated it was

“too expensive” to go to the dentist.

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Table 2: Child’s dental care access and utilization

Child visited the dentist (n=100) Percent

Yes 34

No 66

Reasons for not visiting the

dentist(n=66) Percent (n)

Too busy to see dentist 4.5 (3)

No need or didn‟t know child needed to

go to dentist 71 (47)

The child is too young or too early 12.1 (8)

Dentist recommendation 4.5 (3)

Child fears the dentist 3 (2)

Too expensive 3 (2)

Couldn‟t find a nearby paediatric dentist 1.5 (1)

Age of child at first dental visit (n=34) Percent (n)

Before age of one 5.9 (2)

Age 1 to 2 41.2 (14)

Age 3 to 4 44.1 (15)

Age 5 or more 8.8 (3)

Reasons for visiting the dentist (n=34) Percent (n)

Regular check up 41.2 (14)

Toothache/ dental pain 2.9 (1)

Cavities/ rotten teeth 20.6 (7)

Concern about appearance of teeth/gum 17.6 (6)

Trauma/accident/injury 5.9 (2)

Other 11.8 (4)

The child has ECC (n=34) Percent (n)

Yes 14.7 (5)

No 85.3 (29)

The child has filled or missed anterior

tooth (n=34)

Yes 5.9 (2)

No 94.1 (32)

Method of payment* (n=34) Percent (n)

Insurance from work 47.1 (16)

Government assistance 47.1 (16)

Out-of-pocket 20.6 (7)

* Responses were not mutually exclusive.

42

4.1.3 Oral Hygiene and Preventive Behaviors

Table 3 shows the results for the parents‟ oral health care practices for their children. Most

children (76%) brushed or had their teeth brushed at least once a day, usually using a toothbrush

(95.7%) and a fluoridated toothpaste (93.6%); however, 8 parents indicated their children did not

brush teeth at all.

Forty-nine percent of parents started cleaning their children‟s teeth during their first year of life,

29 children during the second year, and 17 when they were three years old.

Table 3: Child’s oral hygiene and other preventive behavior

Tooth brushing frequency of child’s teeth Percentage (N)

Never 8 (8)

A few times per month 2 (2)

Once a week 3 (3)

A few times per week 11 (11)

Once a day 48 (48)

Two or more times per day 28 (28)

How teeth are cleaned

Using a toothbrush 95.7 (88)

Using a washcloth/tender gauze/sponge 5.4 (5)

Using a dental floss 9.8 (9)

Other (miswak) 1 (1)

Toothpaste used

Fluoridated 93.6(76)

Non-fluoridated 6.4 (7)

No toothpaste used 9.8 (9) of those who brushed

Age of child when brushing of teeth started

(months)

0-12 48.9 (45)

13-24 31.5 (29)

25-36 18.5 (17)

More than 36 1 (1)

43

4.1.4 Parent’s Knowledge of Oral Health

To explore how much parents knew about oral health and the effect of such knowledge on their

children‟s oral health and access to dental care, the oral health knowledge instrument (119) was

used in addition to two questions about the ideal age of child to start dental visits and to start

drinking directly from a cup. The parents were also asked about Early Childhood Caries and how

much they knew about ECC and its causes in two open-ended questions. Tables 4-a, b, c and d

show the answers of parents to these questions.

Forty-three percent of parents thought children should start drinking from a cup when they were

one-year old or older, only 27% parents believed drinking from a cup must start as early as 6

months old. Parents gave different answers to the best age when their child should first go to the

dentist; 27% thought such a visit should start at 2 years of age, while another 24% thought the

best time for the first dental visit was by the child‟s first birthday. Eighteen percent of parents

believed their child should only go to the dentist for pain or dental problems.

Table 4-a: Parent’s knowledge of oral health

Age of child to start drinking from a cup Percent (N)

6-9 months 27 (27)

10-12 months 30 (30)

After one year 43 (43)

Age of child to start dental visits Percent (N)

As soon as first tooth appears 4 (4)

By first birthday 24 (24)

By 2 years 27 (27)

By 3 years 12 (12)

After 3 years 14 (14)

Only after dental pain occurs 18 (18)

Other (when child is old enough to understand) 1 (1)

44

Table 4-b shows the percent of correct answers to each item of the oral health knowledge

instrument used in this survey. The majority of parents believed baby teeth are important, that

frequent sugar intake is bad for the teeth and that the child should not be put in bed with a nursing

bottle. It is worth noting that the statements with the least number of correct responses were about

the benefits of fluoridated toothpaste and the disadvantages of frequent feeding of milk.

Table 4-b: Parent’s knowledge of oral health – oral health knowledge instrument

Statement Percent of correct responses (N)

Baby teeth are important, even though they fall out. 96 (96)

Problems with baby teeth will affect adult teeth. 67 (67)

Tooth decay (rotten teeth) could affect my child's health. 90 (90)

A baby‟s mouth should be cleaned before the first baby

tooth is in the mouth. 42 (42)

Brushing my child's teeth with fluoride toothpaste will help

prevent tooth decay. 35 (35)

Baby teeth are developed before the baby is born. 44 (44)

My diet during pregnancy will affect my baby‟s teeth. 87 (87)

It‟s a good idea to give my baby a bottle to comfort him/her

while teething. 47 (47)

Frequently feeding my child sweetened liquids, such as pop

and fruit juice/drink, is bad for his/her teeth. 92 (92)

Frequently feeding my child milk or formula is bad for

his/her teeth. 30 (30)

As my baby gets older and can hold a bottle easily, he/she

can have a bottle whenever he/she wants. 73 (73)

It‟s OK to let my child nurse in bed with me all night. 81 (81)

It‟s OK to put my child to bed with a bottle. 92 (92)

Bottle-feeding after my child is 1-year-old is bad for his/her

teeth. 43 (43)

45

The majority of parents have heard or known about the term “early childhood caries”; only

fourteen participants did not know anything about this type of caries (Table 4-c). Some of the

families in our sample had experienced ECC with their own children; some others only heard

about it from friends or neighbors. Several themes were recognized in the parents‟ answers; these

themes reflected a good knowledge of early childhood caries etiology. Parents also identified the

main risk factors for ECC such as frequent bottle feeding, frequently eating sweets and sugary

food, poor oral hygiene, and not visiting the dentist regularly (Table 4-d). It is interesting to note

that some parents considered negligence as a risk factor for ECC. Many parents also believed

ECC has a genetic factor and is caused as a result of weak teeth or weak nourishment.

Table 4-c: Parent’s knowledge of oral health – ECC

Theme Parent’s answer

Milk

“Caries result from formula milk and not

brushing teeth before sleeping”.

Feeding at night

“it's caries caused by feeding at night,

especially if the mother adds sugar to milk, or

feeding is frequently”

Had this experience

“It is a hard experience for children at young

age, my eldest daughter had this problem, it is

difficult to prevent children from having

sweets, and I had this experience before”.

Bottle feeding during the night

” it results from frequent feeding at night and

before bedtime; therefore, I always give her

water after finishing feeding”.

Heard about it

“Yes, I heard about it but it didn't happen to

my children”

“I heard from my neiboughrs, their children

had caries from baby bottles and they had

fillings under GA”

Do not know 14 responses

46

Table 4-d: Parent’s knowledge of oral health – causes of ECC

Causes

Genetics

Too much sweets and sugar

Bad oral hygiene

Weak teeth, low vitamins and systemic diseases

Eating less healthy food

Antibiotics at young age or medicines during pregnancy

Special bacteria

Frequent bottle feeding at night

Parents‟ negligence

Not visiting the dentist regularly

47

4.1.5 Perceived Oral Health

Parents were asked to rate their children‟s oral health in addition to their own oral health (Table

5). Forty-two percent of parents thought that their children‟s oral health was good, compared to

39% who believed it was excellent. When asked about their own oral health, 49% of parents rated

it as being good; only 7% thought their oral health was excellent. All parents stated that oral

health is as important as general health.

Table 5: Children’s and parent’s perceived oral health

Child’s oral health as

perceived by their parents Percent (N)

Excellent 39 (39)

Good 42 (42)

Fair 18 (18)

Poor 1 (1)

Parent’s perceived oral health

Excellent 7 (7)

Good 49 (49)

Fair 38 (38)

Poor 6 (6)

48

4.1.6 OHLI, Oral Health Knowledge, Acculturation, Social Capital and

Health Literacy Scales

Table 6 illustrates the mean scores and the possible ranges for all the instruments used in this

survey. The mean scores for all the instruments appear to be in the middle range, except for the

acculturation score which is considered to be low, indicating a low acculturation level in our

study sample.

Table 6: Mean scores of OHLI, Oral health knowledge, Acculturation, Social capital and

Health literacy instruments.

Measure N Possible Range Mean (SE)

OHLI(99)

100 0-50 39.0 (0.79)

Oral health knowledge(120)

100 0-14 9.19 (0.20)

Acculturation(118)

100 8.25-40 16.76 (0.42)

Social capital(119)

100 14-70 54.48 (0.52)

Health literacy(93)

100 3-15** 8.13 (0.26)

** Higher scores indicate low health literacy. For the other instruments higher scores mean better outcomes.

49

Table 7 shows the answers to each question of the acculturation scale. Although 55% of parents

favored both English and Arabic equally, less than half of families spoke only Arabic at home.

Forty percent of parents identified themselves as both Canadian and Arabic. At the same time,

thirty-six percent preferred to be identified as Arabic only. Most of participants agreed that Arabic

traditions are very important to them.

Table 7: Acculturation scale questions and answers for each item

Item Only

Arabic

Mostly

Arabic

English and

Arabic

Mostly

English

Only

English

What language do you normally

speak at home? 45% 30% 25% 0% 0%

What language do you normally

speak with your friends? 29% 24% 43% 4% 0%

What language do you prefer? 24% 16% 55% 4% 1%

What language do you read better? 23% 20% 51% 4% 2%

What language do you write better? 27% 29% 37% 4% 3%

In what language do you usually

think? 46% 24% 24% 3% 3%

How would you describe yourself?

Only

Arabic

Mostly

Arabic

Canadian and

Arabic equally

Mostly

Canadian

Only

Canadian

36% 23% 40% 1% 0%

How important is it to you to

honour/follow Arabic traditions? Very

important

Somewhat

important

Not very

important

Not at all

important

71% 27% 2% 0%

50

The answers to each item of the Social Capital scale are shown in Table 8. The mean score was

(54.48 ± 0.52), which indicates high social capital for our study sample. Interestingly enough, a

large percentage of parents (60%) felt that their children were not appreciated by health care

workers. When asked about their religiosity, almost half of participants reported going to a place

of worship. Responses to item (f): “Our child hardly spends time with people outside our family”

were highly variable; 42% agreed to this statement, 31% disagreed with it, and 17% were neutral to

it.

51

Table 8: Social capital scale questions and answers for each item

Statement Strongly

agree Agree Neutral Disagree

Strongly

disagree

a) We work with families like our own

to help the community understand

our needs

38% 42% 15% 4% 1%

a) We usually ask for help when we

need it

28% 58% 13% 1% 0%

b) We talk to others about ways to

improve the community

42% 39% 16% 2% 1%

c) We do things with our neighbours to

improve the neighbourhood

41% 38% 17% 2% 2%

d) When our family is having a hard

time, the community does not seem

to notice

1% 15% 32% 35% 17%

e) People in the health care system do

not feel our child is important

18% 60% 14% 3% 5%

f) Our child hardly spends time with

people outside our family

10% 32% 17% 29% 12%

g) We participate in activities through a

church or place of worship

13% 35% 36% 15% 1%

h) If we needed help from the school

system, we know how to get it

23% 55% 20% 2% 0%

i) If we wanted to make a change in

our child‟s school we would know

whom to talk to

20% 50% 23% 5% 2%

j) We work with others in the

community to make it a good place

to live

30% 53% 13% 3% 1%

k) The health care system is set up to

work for us

30% 62% 6% 2% 0%

l) Our child‟s health (including oral

health) is important to this

community

62% 33% 4% 1% 0%

m) As parents, we are contributing to

the community‟s well-being

59% 36% 3% 2% 0%

52

4.2 Bivariate Results

4.2.1 OHLI, Oral Health Knowledge, Acculturation, Social Capital, Health

Literacy

Tables 9-a, b, c, d and e show the results of the bivariate analyses carried out to study the effect of

different explanatory variables on the mean scores of all the instruments used. These variables

included: parent‟s level of education, parent‟s age, years in Canada, total annual household

income, frequency of tooth brushing, and the age when teeth cleaning started. Each variable was

dichotomized and p-values were obtained using the Mann-Whitney U test.

Level of parent‟s education seemed to have a strong relation with OHLI scores (Table 9-a).

Parents who have completed University had significantly better oral health literacy (p-value

<0.01). However, both groups had low levels of acculturation and health literacy, and a high level

of social capital. There was no statistical difference between the two groups regarding the

remaining instruments.

Table 9-a: Mean scores of OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to parent’s education

Parent’s education

Completed

college or less

Completed

university p-value

Mean± SE (n) Mean± SE (n)

Mann-Whitney U

test

OHLI 35.82± 1.32 (31) 40.42± 0.93 (69) 0.005

Oral health knowledge 8.77± 0.40 (31) 9.38± 0.24 (69) 0.30

Acculturation 15.53± 0.94 (31) 17.30± 0.43 (69) 0.06

Social capital 54.45± 1.02 (31) 54.49± 0.60 (69) 0.96

Health literacy 8.65 ± 0.45 (31) 7.90 ± 0.31 (69) 0.19

53

OHLI and acculturation had the same strong relation with parent‟s age; those who were 35 years

or older had higher OHLI scores than younger parents (p-value <0.05). On the other hand, parents

younger than 35 years old showed significantly higher acculturation scores (p-value<0.05). Again

there was no significant difference in the mean scores of all the other instruments (Table 9-b).

Table 9-b: Mean scores of OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to parent’s age

Parent’s age

Less than 35

years old

35 years old or

more p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney

U test

OHLI 37.52± 1.06 (37) 41.50± 1.03 (63) 0.02

Oral health knowledge 9.13± 0. 26 (37) 9.30± 0.33 (63) 0.61

Acculturation 17.47± 0.54 (37) 15.53± 0.62 (63) 0.03

Social capital 53.93± 0.70 (37) 55.40± 0.71 (63) 0.23

Health literacy 8.33± 0.32 (37) 7.78± 0.42 (63) 0.25

Interestingly enough, income had no effect on the different scales used in this study, though the

scores were in general higher for families with higher income (Table 9-c). Similar non-significant

results were seen when studying the number of years immigrant families have been in Canada and

its effect on all the tools included in this survey (Table 9-d). Also, parents who brush their

children‟s teeth twice a day had higher OHLI scores than parents who brush their children‟s teeth

less frequently; however, the difference did not reach statistical significance (Table 9-e; p=0.06) .

54

Table 9-c: Mean scores of OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to the total annual household income

Total income

Less than $40,000 $40,000 or more p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney

U test

OHLI 39.48±1.27 (37) 41.99±1.15 (33) 0.14

Oral health knowledge 9.57±0.29 (37) 9.48±0.35 (33) 0.87

Acculturation 16.48±0.72 (37) 17.11±0.60 (33) 0.43

Social capital 54.16±0.96 (37) 55.72±0.88 (33) 0.27

Health literacy 7.84±0.38 (37) 7.67±0.43 (33) 0.73

Table 9-d: Mean scores of OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to the number of years in Canada

Years in Canada

Less than 5

years

More than 5

years p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney U

test

OHLI 39.13± 1.26 (47) 38.88± 0.99 (53) 0.73

Oral health knowledge 9.19± 0.29 (47) 9.19± 0.29 (53) 0.94

Acculturation 16.90± 0.50 (47) 16.62± 0.66 (53) 0.58

Social capital 54.17± 0.79 (47) 54.75± 0.68 (53) 0.32

Health literacy 8.51 ± 0.40 (47) 7.79 ± 0.31 (53) 0.19

55

Table 9-e: Mean scores of OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to the frequency of brushing of children’s teeth

Frequency of brushing teeth

Once a day or

less

Twice a day or

more p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney U

test

OHLI 41.67±1.34 (24) 38.16±0.93 (76) 0.06

Oral health knowledge 9.29±0.44 (24) 9.16±0.24 (76) 0.66

Acculturation 17.10± 0.82 (24) 16.65± 0.49 (76) 0.52

Social capital 54.50±0.72 (24) 54.47±0.64 (76) 0.89

Health literacy 7.88 ±0.49 (24) 8.21± 0.30 (76) 0.65

4.2.2 Access to Dental Care

The Chi-square test was used to study the different factors that may impact access to dental care

among Arabic-speaking immigrants. Table 10 shows the results of this test. Children aged four

years or more were more likely to visit the dentist than younger children (p-value <0.05). Also,

children with fair or poor oral health visited the dentist more than children with excellent or good

oral health but the difference was borderline statistically significant (p-value =0.06). All other

factors included in the analysis did not have a significant effect on access to dental care. However,

it is clear that a female child who was born outside Canada or whose family has been in Canada

for more than 5 years was more likely to have had a dental visit. Also children of older parents

who started brushing the child‟s teeth at two years of age and who brushed her/his teeth at least

twice a day seemed to have visited the dentist, though the difference was not statistically

significant. Worth noting was that parent‟s level of education and household income had no

significant effect on access to dental care.

56

Table 10: Access to dental care in relation to selected variables

N Child visited the dentist

Age of child Percent p-value *

3 years and younger 77 24.7 0.0001

4 years or more 23 65.2

Sex of child

Male 42 28.6 0.33

Female 58 37.9

Child birthplace

Born in Canada 77 32.5 0.55

Born outside Canada 23 39.1

parent’s oral health

Excellent or good 56 33.9

Fair or poor 44 34.1 0.99

Age of child at

starting brushing

teeth

Age one year 45 33.3 0.62

Age two years or more 47 38.3

Frequency of

brushing teeth

Twice a day 76 35.5 0.57

Once a day or less 24 29.2

Children’s oral health

Excellent or good 81 29.6 0.06

Fair or poor 19 52.6

Education of parents

Completed College or

less

31 41.9

0.26 Completed University

or more

69 30.4

Age of parents

Less than 35 63 28.6 0.14

35 or more 37 43.2

Years in Canada

Less than 5 years 47 27.7 0.21

More than 5 years 53 39.6

Household income

Less than $40,000 37 35.1 0.92

$40,000 or more 33 36.4

*Obtained using the Chi-square test.

57

Table 11 describes the difference in the mean scores of the five instruments used in this study

(OHLI, Oral Health Knowledge, Acculturation, Social Capital, and Health Literacy) between

children who visited the dentist and those who had never seen a dentist before. There was no

significant difference in the scores of all the different instruments between the two groups.

Table 11: Mean scores for OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to visiting the dentist.

Child visited the dentist

Yes No p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney U

test

OHLI 39.81± 1.37 (34) 38.58± 0.97 (66) 0.41

Oral health knowledge 9.59± 0.37 (34) 8.98± 0.25 (66) 0.20

Acculturation 16.10± 0.78 (34) 17.10± 0.50 (66) 0.18

Social capital 54.94± 0.76 (34) 54.24± 0.68 (66) 0.58

Health literacy 7.82 ± 0.45 (34) 8.29 ± 0.31 (66) 0.30

58

4.2.3 Perceived Oral Health

To determine the factors that may have an effect on children‟s oral health as perceived by their

parents, different variables were included in the Chi-square analysis as shown in Table 12. As

expected, household income and parent‟s perceived oral health were related to children‟s

perceived oral health; parents with higher income and better perceived oral health tended to rate

their children‟s oral health as excellent or good, although the difference was borderline

statistically significant (p-value ≈0.06).

It seems that parents who start brushing their children‟s teeth earlier in life were more likely to

perceive their children‟s oral health as good or excellent (p-value <0.05). Other variables such as

parent‟s education, age, years in Canada, gender of children, children‟s birth place and frequency

of brushing teeth had no significant effect on perceived oral health of children (Table 12).

Children‟s oral health, as perceived by their parents, was not influenced by any of the continuous

scale measures in our study (Table 13). Nonetheless, Parents with higher levels of oral health

literacy, oral health knowledge, and health literacy, tended to rate their children‟s oral health as

being excellent or good.

Parent‟s perceived oral health, on the other hand, was influenced by both social capital and health

literacy (Table 14). Parents who reported their own oral health as being excellent or good, had

significantly higher scores on social capital and health literacy scales, compared to parents with

fair or poor self-perceived oral health.

59

Table 12: Children’s oral health, as perceived by their parents, in relation to selected

variables

N Child’s oral health* is

excellent or good

Age of child Percent p-value **

3 years and younger 77 81.8 0.70

4 years or more 23 78.3

Sex of child

Male 42 83.3 0.61

Female 58 79.3

Child birthplace

Born in Canada 77 81.8 0.70

Born outside Canada 23 78.3

parent’s oral health

Excellent or good 56 87.5 0.06

Fair or poor 44 72.7

Age of child at starting

brushing teeth

Age one year 45 91.1 0.01

Age two years or more 47 70.2

Frequency of brushing teeth

Twice a day 76 81.6 0.79

Once a day or less 24 79.2

Education of parents

Completed college or less 31 74.2 0.25

Completed university or more 69 84.1

Age of parents

Less than 35 63 79.4 0.59

35 or more 37 83.8

Years in Canada

Less than 5 years 47 80.9 0.97

More than 5 years 53 81.1

Household income

Less than $40,000 37 78.4 0.06

$40,000 or more 33 93.9

*As perceived by their parents

** Obtained from the Chi-square test

60

Table 13: Mean scores for OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to parent-perceived child’s oral health

Child’s perceived oral health

Excellent or good Fair or poor p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney

U test

OHLI 39.68± 0.85 (81) 36.09± 1.99 (19) 0.10

Oral health knowledge 9.31± 0.24 (81) 8.68± 0.38 (19) 0.20

Acculturation 16.93± 0.47 (81) 16.01± 0.96 (19) 0.63

Social capital 54.56± 0.60 (81) 54.16± 1.00 (19) 0.59

Health literacy 7.96 ± 0.28 (81) 8.84 ± 0.66 (19) 0.19

Table 14: Mean scores for OHLI, oral health knowledge, acculturation, social capital and

health literacy in relation to parent’s self-perceived oral health

Parent’s perceived oral health

Excellent or

good

Fair or poor p-value

Mean± SE (n) Mean± SE (n) Mann-Whitney U

test

OHLI 40.12± 1.02 (56) 37.58± 1.23 (44) 0.11

Oral health knowledge 9.39± 0.27 (56) 8.93± 0.32 (44) 0.46

Acculturation 17.33± 0.59 (56) 16.04± 0.58 (44) 0.18

Social capital 55.82± 0.56 (56) 52.77± 0.88 (44) 0.008

Health literacy 7.50 ± 0.29 (56) 8.93 ± 0.42 (44) 0.02

61

4.3 Correlations

Since some of the data were not normally distributed, Kendall‟s Tau non-parametric correlation

test was used to determine any significant correlations between OHLI, Oral Health Knowledge,

Acculturation, Social Capital and Health Literacy. Table 15 shows the results of this test. As

expected, OHLI had a significant, though weak, correlation with health literacy. Health literacy

also correlated significantly with acculturation and oral health knowledge; however, those

correlations were weak. Although the coefficients are negative, they do not indicate inverse

correlations because lower values in the health literacy scale refer to higher literacy. For all the

other scales, higher values indicate improved outcomes. All other correlations were not

statistically significant. It is worth noting that social capital showed a negative, though a weak

borderline significant correlation with health literacy.

Table 15: Kendall’s Tau correlation test between the different instruments.

N= 100 OHLI Oral health

knowledge Acculturation

Social

capital

Health

literacy

OHLI

Kendall‟s Tau

(p-value)

0.117

(0.123)

0.087

(0.235)

0.087

(0.250)

- 0.262

(0.001)

Oral health knowledge

Kendall‟s Tau

(p-value)

0.006

(0.930)

0.051

(0.489)

- 0.283

(<0.001)

Acculturation

Kendall‟s Tau

(p-value)

- 0.089

(0.212)

- 0.157

(0.030)

Social capital

Kendall‟s Tau

(p-value)

- 0.130

(0.075)

62

The Kendall‟s Tau correlation test was also used after splitting the data into two subgroups:

children who visited the dentist, and those who did not report any dental visit. For children who

visited the dentist, health literacy continued to show a significant correlation with oral health

literacy, oral health knowledge and acculturation (Table 16). Worth noting that among those who

had visited the dentist, health literacy showed a moderate correlation with oral health knowledge.

However, health literacy correlation with both OHLI and acculturation remained weak.

Table 16: Kendall’s Tau correlation test between the different instruments for children who

visited the dentist

N=34 OHLI Oral Health

Knowledge Acculturation Social Capital Health Literacy

OHLI

Kendall‟s Tau

(p-value)

0.047

(0.724)

0.002

(0.988)

- 0.050

(0.705)

- 0.283

(0.034)

Oral health knowledge

Kendall‟s Tau

(p-value)

0.062

(0.629)

- 0.010

(0.940)

- 0.435

(0.001)

Acculturation

Kendall‟s Tau

(p-value)

0.058

(0.643)

- 0.252

(0.049)

Social capital

Kendall‟s Tau

(p-value)

-0.068

(0.598)

63

For children who did not visit the dentist, there was also a highly significant correlation between

OHLI and health literacy (Table 17). Health literacy also showed a significant correlation with

oral health knowledge. Furthermore, acculturation scores had a significant but weak negative

correlation with the social capital scores among those who did not visit a dentist.

Table 17: Kendall’s Tau correlation test between the different instruments for children who

did not visit the dentist

N=66 OHLI Oral Health

Knowledge Acculturation Social Capital Health Literacy

OHLI

Kendall‟s Tau

(p-value)

0.147

(0.118)

0.148

(0.103)

0.114

(0.211)

- 0.247

(0.008)

Oral health knowledge

Kendall‟s Tau

(p-value)

- 0.008

(0.928)

0.095

(0.300)

- 0.203

(0.031)

Acculturation

Kendall‟s Tau

(p-value)

- 0.175

(0.047)

- 0.136

(0.132)

Social capital

Kendall‟s Tau

(p-value)

- 0.148

(0.104)

64

There was a significant correlation between health literacy and both OHLI and oral health

knowledge when parents rated their children‟s oral health as excellent or good (Table 18).

Interestingly enough, there was no significant correlation between all the instruments used in this

study when correlation tests were carried out only for children with fair or poor perceived oral

health (Table 19). However, health literacy had a moderate, though non-significant correlation

with the OHLI and acculturation scales for this subgroup (Table 19).

Table 18: Kendall’s Tau correlation test between the different instruments for children

whose perceived oral health is excellent or good

N=81 OHLI Oral Health

Knowledge Acculturation Social Capital Health Literacy

OHLI

Kendall‟s Tau

(p-value)

0.105

(0.217)

0.071

(0.383)

0.135

(0.100)

- 0.242

(0.004)

Oral Health Knowledge

Kendall‟s Tau

(p-value)

- 0.014

(0.866)

0.079

(0.333)

- 0.296

(<0.001)

Acculturation

Kendall‟s Tau

(p-value)

- 0.117

(0.139

- 0.115

(0.157)

Social Capital

Kendall‟s Tau

(p-value)

- 0.145

(0.076)

65

Table 19: Kendall’s Tau correlation test between the different instruments for children

whose perceived oral health is fair or poor

N=19 OHLI Oral Health

Knowledge Acculturation Social Capital Health Literacy

OHLI

Kendall‟s Tau

(p-value)

0.199

(0.278)

0.075

(0.669)

- 0.208

(0.239)

- 0.320

(0.078)

Oral Health Knowledge

Kendall‟s Tau

(p-value)

0.089

(0.616)

- 0.122

(0.496)

- 0.259

(0.158)

Acculturation

Kendall‟s Tau

(p-value)

0.157

(0.359)

- 0.320

(0.069)

Social Capital

Kendall‟s Tau

(p-value)

- 0.019

(0.915)

66

4.4 Logistic Regression Analysis

The method used for logistic regression analysis was the “Backward Wald” method, i.e.,

backward elimination based on the results of the Wald statistic. All the variables that were

expected to influence access to dental care were included. These variables were: sex of the child,

age of the child, whether the child was born in Canada or not, child‟s oral health as perceived by

their parent, parent‟s self-perceived oral health, parent‟s age and education, years in Canada, total

family annual income; in addition to the five scales used in this study: OHLI, oral health

knowledge, acculturation, social capital and health literacy.

Table 20 shows the final logistic regression model with all the significant variables affecting

access to dental care among preschool-aged children of Arabic-speaking families. Three

independent variables had a significant/borderline significant effect on access to dental care: age

of child (p=0.001); child‟s oral health (p=0.050); and parent‟s oral health knowledge (p=0.055).

67

Table 20: Logistic regression analysis

Variable Adjusted Odds Ratio 95% CI p-value

Age of Child

Aged four years or more vs.

Aged 3 years or under

(reference group)

5.97 (2.01-17.62) 0.001

Child’s oral health as

perceived by their parents

Fair or poor vs. Excellent or

good (reference group) 3.16 (1.00-10.01) 0.050

Oral Health Knowledge scale

(continuous) 1.28 (0.99-1.64) 0.055

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Chapter Five

Discussion

The main goal of this research was to investigate access to dental care among Arabic-speaking

immigrant families with young children, and how this access is influenced by acculturation, oral

health knowledge and literacy, and social capital. We also wanted to evaluate oral health of

Arabic-speaking preschool children as perceived by their parents. We hypothesized that Arabic-

speaking immigrants have difficulty in accessing dental care for their young children, and that this

difficulty is caused by low levels of acculturation, social capital, and oral health knowledge and

literacy.

One hundred families participated in this study: there were more female children (n=58) than

male children (n=42), and 77% of children were born in Canada. In general, our study sample has

similar characteristics to those of the Arabic community in Canada as reported by Statistics

Canada (7) in 2001. In general, the Arabic community in Canada is relatively young and highly

educated but with fairly low total annual household incomes. Almost half of those families are

newcomers to Canada, and have spent less than five years living in Canada.

Our study showed that there is difficulty in accessing dental care for preschool children among

the Arabic-speaking families who participated in this study. Only 34% of children had visited a

dentist before; this rate is similar to findings of Werneck et al. (9) despite the different ethnic

group studied. Unfortunately, although data are available on school children, no data are available

69

regarding access to dental care among preschool children in Canada to allow for comparison. Our

results may indicate that, among this sample, families are not motivated to visit the dentist on a

regular basis unless there is a dental problem. Seventy-one percent of parents did not take their

children to a dental clinic because they did not believe there was a need to do so. Moreover,

another 21% of parents thought their children were too young to see a dentist. This means Arabic-

speaking parents need to be educated about the necessity of regular dental checkups.

Although 55% of parents thought the first dental visit should be by two years of age or less, our

results showed that older children were significantly more likely to visit the dentist than children

aged three years or less. A longitudinal study from Norway investigated change in dental attitudes

and beliefs among parents of young children from different cultural backgrounds and similarly,

the study found that negative dental attitudes were more prevalent among immigrant parents, and

that these negative attitudes persisted and even increased after two years even though parents

were educated about children‟s oral health in public dental clinics (121).

Only five children from this sample population had ECC. This is very close to the ECC

prevalence among preschool children in Toronto which is 4.7% (29). On the other hand, this

contradicts findings of other studies (8, 9) that immigrant children tend to have higher caries rates

than the general population. The low rate we found may not reflect the true prevalence because

only families who visited a dentist answered this question about ECC; the other children could

have had undiagnosed ECC since they were not examined by a dentist.

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Our analyses showed that access to dental care is significantly influenced by a child‟s age and

reported oral health. Older children were more likely to visit the dentist than young children; this

is probably because Arabic-speaking immigrants prefer to take children to the dentist only after

the child develops a dental problem. This may also explain why more children with reported fair

or poor oral health had visited the dentist than children with a reported excellent or good oral

health.

It is interesting to note that income did not show a significant impact on dental visits, although

families with higher annual incomes visited the dentist slightly more than lower income families.

This may be because the income cut-off point was set arbitrarily; therefore, the difference

between the two income categories was not obvious. Further studies are required to investigate

this issue.

Although the difference is not statistically significant, parents with higher education tended to

take their children to the dentist less than parents with lower education. Again, this could be

attributed to the fact that Arabic-speaking immigrants who participated in this study visited the

dentist only when needed; to be sure, our analyses showed that children of highly educated

parents have better oral health, as perceived by their parents. This indicates that parents‟ beliefs

and attitudes towards dental visits are shaped by various factors and not only parents‟ level of

education.

Our results showed that access to dental care was not influenced by any of the five instruments

used in this research. Although families that took their children to the dentist had higher scores on

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OHLI, oral health knowledge, health literacy, and social capital, the difference was not statically

significant. This is probably because the sample was more homogenous than expected, which

could be a disadvantage of the convenience sampling technique used in this study. The

homogeneity in our sample is reflected in the fact that the data distributions for the social capital

and acculturation scales were a little skewed.

In our study, Arabic-speaking parents generally showed low scores on the acculturation scale. As

expected, parents who completed University were more acculturated. This is probably because the

acculturation scale used in this study focuses mainly on the language spoken in daily life;

therefore, immigrants with better education could become more exposed to the host language

even before migration and thus education in this case acts as enabling factor (47). Younger

parents showed significantly higher acculturation than older parents in this study; this result

supports the findings of other studies that associated immigration at younger age with more

acculturation (47, 48). This may indicate that younger parents can adapt easily into the new

culture unlike parents older than 35 years of age.

Acculturation scores were not different between recent immigrants and established immigrants in

this study. It can be argued that this surprising finding is because the study sample itself lacks

variability, especially given that the mean acculturation score for all participants was low

(16.76±0.42 out of a maximum score of 40). Another reason for this result could be that five years

of residency in Canada is a short time to induce acculturation in Arabic-speaking immigrants.

Also, there was no difference in acculturation score between parents who took their children to

the dentist and parents of children who did not visit the dentist. This result was found in another

72

study (56), but contradicts the findings of other studies (57, 58). These contradictory results may

highlight the inability of the measures used to assess acculturation to capture its different aspects.

In our study, we employed a scale of acculturation that mainly focused on language preference. It

has been suggested that in multicultural cities language barrier may have a minimal impact on

dental services use since immigrants can easily find dental care providers and oral health

information in their mother tongue (57).

One of the objectives of the current research was to determine the oral health status of Arabic-

speaking preschool-aged children in Toronto as reported by their parents. Nineteen percent of

parents rated their children‟s oral health as being fair or poor. Unfortunately, we cannot compare

this result with a Canadian sample since there are no national data available about the oral health

status of immigrant preschool children. In addition, the current study used a convenience sample.

When asked to rate their own oral health, 44% of Arabic-speaking parents in our sample thought

their oral health was fair or poor. This is higher than the 17.4 % of Canadian adults aged 20–39

years who reported their oral health as fair or poor in the 2007–2009 CHMS (117). Our analyses

also showed a trend that parent‟s perceived oral health may be associated with children‟s oral

health; this supports the conclusions of other studies that maternal oral health does influence

children‟s oral health and treatment needs (122,123). This finding also suggests that to improve

children‟s oral health, public dental programs need to consider improving parent‟s oral health as

well.

73

Another factor that was found to significantly influence children‟s oral health in the current

research was age of child when starting to brush teeth. Children who started to brush their teeth at

one year of age had better parent-reported oral health than children who started brushing later in

life. This result emphasizes the importance of starting oral hygiene habits early in life. On the

other hand, children‟s oral health was not affected by frequency of daily brushing. One possible

explanation is that parents overestimated their children‟s oral hygiene habits as they tended to

answer such questions according to social norms. Another possible reason could be a recall bias.

While total household income did not impact children‟s access to dental care, it showed a trend

with children‟s oral health in this study: children from higher income families had better oral

health as reported by their parents. The positive influence of income on oral health is well

documented. A previous study also found that children from families with an annual income of

less than $40,000 were at four times greater risk of having ECC than children of families with

higher income (9). Evidence is strong that income is a very important determinant of oral health;

individuals with higher incomes have been found to have better oral health, and better access to

dental care (124, 125).

Our results showed that parental oral health literacy was not associated with children‟s oral

health. This finding disagrees with other studies (114, 115) that found parent‟s oral health literacy

to be an important factor in determining children‟s oral health. In those two studies parents with

lower oral health literacy scores, as measured by REALD-30, tended to report their children‟s oral

health as being fair or poor. Thus, it is not surprising that, in our sample, parents who reported

their children‟s oral health as being excellent or good tended to have higher OHLI scores. Parents

74

with good general and oral health literacy are expected to have better access to the dental care

system and health information thus positively influencing their children‟s oral health. OHLI might

be useful in identifying children at high risk of developing early childhood caries during planning

for oral health promotion programs.

Parent‟s reported oral health, on the other hand, was not associated with their OHLI score. This

surprising finding disagrees with Vann et al. (115), who reported a significant association

between oral health literacy and caregiver‟s oral health. However, OHLI higher scores were still

associated with better parent‟s oral health but the association was not strong enough to be

statistically significant which could be a drawback of the small sample size. This may also be

because we used only one section of OHLI (the numeracy section) and we modified it to use for

parents of young children.

In this study, general health literacy was significantly associated with caregiver‟s oral health.

Previous studies looked for an association between measures of oral health literacy and oral

health; ours is the first study to find out that oral health is affected by health literacy. Good

general health literacy has been found to have a positive influence on management of health

problems, thus leading to better health outcomes (103-106).

Another factor that was significantly associated with parent‟s oral health in this study was social

capital. Other investigators found that high levels of social capital are associated with better oral

health outcomes (71, 72, 82). We are uncertain why social capital did not impact children‟s oral

health or access to dental care in our study, but this was probably because parent‟s social capital

75

is not a good proxy measure for the impact of social support on children‟s oral health. It has been

concluded that different forms of social support influence dental care utilization differently among

immigrants (83). It may be that social capital also impacts oral health of parents and children in

different ways. Another possible reason is that social capital could be generally high among

Arabic-speaking immigrants in Canada; therefore, we were not able to detect its influence on

children‟s oral health.

We also carried out correlation analyses between the five instruments used in this study. Since

some of the data were skewed we used the non-parametric Kendall‟s -Tau correlation test to

detect any significant correlations. Our analyses showed significant but weak correlations

between health literacy and OHLI, oral health knowledge, and acculturation. Individuals with

higher levels of health literacy tended to have higher levels of oral health literacy, knowledge, and

acculturation. Other studies also found a correlation between health literacy and knowledge of

oral health (116, 99); and between literacy and knowledge of chronic disease (126, 127).

Knowledge itself can be considered as an important part of health literacy, specifically of

interactive literacy, which is the ability to understand health information provided by different

resources (88). Therefore, a significant correlation between the two is completely understandable.

We also expected to see such an association between OHLI and knowledge; however, the non-

parametric test did not reveal a correlation although the parametric test showed a significant

association (data not shown). This could be the result of some outliers in the data that caused this

correlation to disappear.

76

Although the health literacy instrument was administered in the Arabic language, it appears that

English language proficiency is associated with health literacy. We can expect that individuals

who are familiar with the English language can also easily fill out medical forms and understand

any health instructions and information. A recent study among Chinese immigrant women in

Canada found that acculturation is actually a strong predictor of health literacy, and women with

weak English language abilities scored lower on a health literacy scale (128). This important

finding highlights the risks of low literacy in immigrants with limited acculturation and language

capabilities.

One of the surprising findings of this study was the significant negative correlation between social

capital and acculturation. This association appeared only among families who did not visit the

dentist; it may indicate the complexity of both acculturation and socializing processes of

immigrants in their new community. The social capital scale used in this study was developed to

measure four different areas of social capital: engagement for the common good, sense of

belonging, system connections, and family role in community. Looking at the participants‟

responses for each item on this scale, we see that Arabic-speaking immigrants scored low on the

sense of belonging area; however, the final score was a little skewed towards high social capital.

This probably caused the high scores of the social capital scale to correlate negatively with

acculturation. Another possible explanation is that the scale used in this research actually

measured social capital in the Arabic community in Canada; therefore, low acculturated

participants showed a high social capital in their own Arabic community. It is not clear, however,

why such correlation appeared only among those who visited the dentist.

77

One of the interesting findings of our research is that most of the Arabic-speaking parents in our

sample did not know that brushing teeth with fluoridated tooth paste plays an important role in

preventing dental caries. Also, the majority of parents believed that frequent milk feedings are

good for their child‟s teeth; this is probably because parents think milk is high in calcium, which

is necessary for healthy teeth. However, the problem is the addition of sugar to formula that can

lead to ECC with frequent feeding. These two misconceptions need to be addressed in oral health

promotion programs, especially those targeting new immigrant families, since feeding practice

and oral health behaviour are important determinants of early childhood caries among risk groups.

Logistic regression analysis revealed three independent factors that influenced access to care: oral

health knowledge, child‟s oral health, and age of child. Among this study population, the odds for

visiting the dentist among children aged four years or older were approximately six times greater

than the odds among children aged three years or younger. This is probably because in Ontario,

children who enter the school system become eligible for an oral health screening that is carried

out through public health units. Thus, school children with oral health problems are diagnosed

and referred for dental treatment. This also could be the result of parents‟ negative attitudes

towards starting dental visits at early age. A large percentage of parents indicated they did not

take their children to the dentist because they did not know they should do so.

Children with fair or poor oral health were three times more likely to visit the dentist than

children with excellent or good reported oral health. This result emphasizes the interpretation that

Arabic-speaking children are more likely to visit the dentist to obtain restorative treatment as

opposed to preventive dental services. In our study population, the main reason for not taking

78

their children to the dentist was the absence of dental problem. Similarly, Newbold and Patel (26)

found that foreign-born Canadians reported restorative treatment as the main reason for visiting

the dentist; native-born Canadians, on the other hand, visited the dentist for routine examinations

and prevention more often.

The third independent variable that significantly predicted access to care in this study was

parent‟s oral health knowledge. Better oral health knowledge increases the odds of visiting the

dentist. This result was expected since maternal knowledge has been found to influence child‟s

oral health and preventive behaviors (40, 41). Our result highlights the importance of parents‟

knowledge as a significant determinant of children‟s oral health. Community interventions that

focused on improving parental oral health knowledge have also improved dental care utilization

(120, 129). This may also suggest that educational public health programs can improve access to

dental care among recent immigrants. However, such interventions need to consider cultural

factors and should be designed in collaboration with the immigrant communities if possible (12).

5.1 Study Limitations

One limitation of our study is the sampling technique. We used a convenience sample because

there is no sampling frame for the Arabic-speaking immigrants in Toronto. This sampling

technique may result in selection bias; therefore, the results of this study cannot be generalized for

all Arabic-speaking immigrants in Canada although the demographic characteristics of the study

sample were similar to those of Arabic-speaking immigrants in Canada as reported by Statistics

Canada in 2001 (7).

79

Second, our study used a cross-sectional design; therefore, it is difficult to investigate causality

between our variables and the main outcomes. The third limitation is sample size. Our relatively

small sample size probably did not allow for some of the results to attain the level of statistical

significance because of the insufficient power. It should be also kept in mind that perceived oral

health may not reflect the true clinical state of oral health which adds another limitation to our

study results.

Despite pilot-testing all the instruments used in this study, there where occasions were the

wording of some of the scale items had to be explained to participants, which may have led to

measurement errors. This occurred in the social capital scale and oral health knowledge

instrument. For example, there was a misunderstanding whether the word “community” in the

social capital scale referred to the Canadian community or the Arabic community in Canada.

Finally, because the questionnaire was administered during an interview with the researcher,

participants may have answered some of the questions according to what they believe is correct or

socially acceptable, although the researcher emphasized that there is no right or wrong answer.

This could be of concern especially with the social capital and acculturation scale questions.

5.2 Implications and Recommendations for Future Research:

This research highlights the problem of access to dental care among immigrants in Canada.

Although immigrants represent a growing segment of the Canadian population there had been few

studies regarding their oral health and factors that may play a crucial role in determining oral

80

health and dental care utilization among new Canadians. Dental public health programs are

usually directed towards high risk groups; however, immigrants are not covered under such

programs in Canada although they are considered at high risk of developing dental caries.

Findings of this study can be helpful in planning for public dental programs for immigrants. It is

now evident that parental oral health knowledge plays an important role in shaping children‟s oral

health; oral health promotion programs need to be directed towards new immigrants to educate

them about the importance of preventive oral health behaviors, the importance of fluoride in

preventing dental caries, and correct feeding practices to prevent the development of early

childhood caries in young children.

Many immigrants come to this country with no previous knowledge about the Canadian dental

care system or the available public programs; therefore, the first step should be providing

immigrants with necessary information about the dental care system and how to get care when

needed. However, studies have shown that merely providing immigrants with information is not

enough to improve oral health; interventions should utilize the social and cultural context of

immigrants to be more effective. Peer health promoters with the same cultural background may be

helpful in changing oral habits and dental attitudes of immigrants to achieve better oral health.

Social support and structure are also important, yet only a few studies have looked into this area

and its relation with oral health.

Prenatal classes provide the potential for high quality education for mothers-to-be about oral

health of their children, as well as to improve parents‟ oral health knowledge and establish

81

dentally healthy feeding practices. An oral health component can be also integrated into the

medical examination that immigrants are required to undergo before they enter Canada so that

new immigrants can be aware of their children‟s dental problems and can be advised on how to

get help once they are in Canada.

Cultural and social factors may impact oral health differently among different ethnic groups.

Therefore, future research should focus on the different immigrant groups to have a better

understanding of their oral health needs and access to dental care. It is also important to detect

disparities in oral health; future studies are required to compare immigrants‟ oral health with that

of the general population. Research should not only focus on children; it should also be directed

towards adults to highlight other determinants of oral health, namely economic factors and its

influence on immigrants‟ oral health.

5.2 Conclusions

Our study is the first in Canada to investigate access to dental care among preschool children of

Arabic-speaking immigrants in Toronto; and the first to measure acculturation, health literacy and

social capital for Arabic-speaking families in Canada. The main objective of this study was to

assess access to dental care among preschool children of Arabic-speaking immigrant families

residing in Toronto. Our research showed that access to dental care among immigrant children, in

our study sample, is a problem. Only 34% of families who participated in this study had visited

the dentist to obtain dental care for their preschool children.

82

Bivariate analysis showed that only child‟s age influenced access to dental care among our study

population: children aged four years or more were more likely to visit the dentist than younger

children. Logistic regression showed that, in addition to child‟s age, parent-perceived child‟s oral

health, and oral health knowledge had a significant positive influence on access to care for their

preschool-aged children. It seems that Arabic-speaking parents in our sample take their young

children to the dentist only after they develop dental problems.

Another objective of this study was to measure the oral health of those Arabic-speaking preschool

children as reported by their parents. Nineteen percent of Arabic parents rated their children‟s oral

health as being fair or poor. Better reported oral health was associated with brushing the child‟s

teeth at earlier age.

None of the scales used in this study had a significant impact on access to dental care; however,

higher scores on these scales tended to be associated with better access to care. Similarly, no

association was found between the scales we used in our study with children‟s oral health as

perceived by their parents. However, parent‟s self-perceived oral health was significantly affected

by social capital and health literacy. This finding adds to the currently available evidence about

the importance of these two factors in shaping immigrants‟ oral health.

In general, Arabic-speaking parents in our study showed low acculturation but higher levels of

social capital and oral health literacy. The general health literacy scale used in this study showed

significant, although weak, correlations with oral health literacy, oral health knowledge, and

acculturation. Such a scale has the potential to be a useful screening tool to identify immigrant

83

families that could be at higher risk of developing dental caries because of low levels of oral

health literacy, acculturation and social capital.

Our research is an important contribution to the few available Canadian studies that have focused

on immigrants‟ oral health. However, more research is needed to understand the various reasons

behind oral health disparities among immigrants and to develop the necessary interventions that

can effectively help these newcomers to start a better life in their new country.

84

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