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
vi
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
ix
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.
25
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.
28
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.
32
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.
41
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
68
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.
70
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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