Original Paper Received: January 14, 2013 Accepted after revision: April 25, 2013 Published online: July 29, 2014
Caries Res 2014;48:575–583 DOI: 10.1159/000351680
Oral Health Disparities of Children among Southeast Asian Immigrant Women in Arranged Transnational Marriages in Taiwan Y.C. Lin a Y.Y. Yen b C.S. Chang c C.C. Ting a P.H. Chen a C.C. Chen b W.D. Peng d F.L. Chen e C.Y. Hu f H.L. Huang b
a
School of Dentistry, College of Dental Medicine, b Department of Oral Hygiene, College of Dental Medicine, Global Center of Excellence for Oral Health Research and Development, d Department of Medical Sociology and Social Work, College of Humanities and Social Science, Kaohsiung Medical University, Kaohsiung, e Department of Public Health, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan; f School of Public Health, Louisiana State University Health Sciences Center, New Orleans, La., USA c
Key Words Enamel caries · Epidemiology · Oral hygiene · Public dental health · Tooth brushing
Abstract This study assessed the oral health disparities and oral health care needs of children whose parents are Southeast Asian immigrant women in arranged transnational marriages. We used the baseline data of the Lay Health Advisor Approach to Promote Oral Health Program (LHA-POHP) to explore the disparities in oral health between immigrant and native children, and the factors associated with their oral health. A cross-sectional community-based study was conducted to collect data from mothers and their preschool children in Southern Taiwan in 2011. A total of 590 (440 natives, 150 immigrants) children aged 4–6 years and their mothers completed the questionnaire and oral examination. Multiple regression models were used to analyze the association between children’s oral health and their related factors. The caries index was 6.05 in immigrant children and 3.88 in native children (p < 0.001). The caries prevalence of maxillary anterior teeth in the labial surfaces was higher among immigrants, ranging from 14.7 to 22%. The factor associated with children’s caries index was maternal tooth brushing fre-
© 2014 S. Karger AG, Basel 0008–6568/14/0486–0575$39.50/0 E-Mail [email protected] www.karger.com/cre
quency (adjusted odds ratio [aOR] = 8.95, 95% confidence interval [CI] 1.95–41.05). When the mothers did not direct children to brush teeth after eating sweets, their children were more likely to have decayed teeth (aOR = 3.54, 95% CI 1.04–12.03). Children’s filled teeth were related to their dental regular check-ups (aOR = 2.28, 95% CI 1.26–4.10). Disparities in oral health among immigrant and native children were observed. The findings suggest that culturally adequate oral health promotion intervention programs should be implemented for immigrants. © 2014 S. Karger AG, Basel
Recently, Taiwan has been faced with the migration of large numbers of women from Southeast Asian countries. These women are colloquially called ‘foreign brides’ or ‘alien brides’ because their marriages were arranged by marriage brokers. The importation of Southeast Asian brides began in 1987 in rural areas of Taiwan. This form of arranged transnational marriages has created a special phenomenon of ‘marriage trades’ that is popular among the lower middle classes. Arranged intermarriage is one type of cross-border migration flow of women. The majority are from Vietnam and Indonesia. The aggregate number of Southeast Asian wives was estimated at more Dr. Hsiao-Ling Huang, PhD Department of Oral Hygiene, College of Dental Medicine Kaohsiung Medical University 100, Shih-Chuan 1st Road, Kaohsiung, 80708 (Taiwan) E-Mail hhuang @ kmu.edu.tw
than 466,000 in 2012, or approximately one third of Taiwanese marriages [Ministry of the Interior, 2012]. By 2011, 1 in 10 children was born to a foreign spouse. This particular group of immigrant women is highly susceptible and vulnerable to health problems because of language barriers, cultural conflicts, social and interpersonal isolation and a lack of support systems. This segregation has gradually led to inferior medical care for these women and their children [Lin and Hsiao, 2007]. Compared to native mothers, immigrant mothers have difficulty accessing the health care system [Yang and Wang, 2003]. Therefore, health inequalities among immigrant mothers and children and their native counterparts exist [Mendoza, 2009]. Dental caries affects general health and quality of life in preschool children [Sheiham, 2006; Wong et al., 2011]. With growing transnational marriages in Taiwan, health disparities have been demonstrated in maternal and child health. Previous studies conducted in Europe and the United States noted the worsening dental status of immigrant children [Maserejian et al., 2008; Chinn et al., 2011]. The risk factors for preschool children with caries experience were associated with parental educational level, parental attention to the child’s tooth brushing habits, parental brushing habits and frequency of sugar intake among parents [Skeie et al., 2006; Finlayson et al., 2007; Wigen and Wang, 2010; Tapias-Ledesma et al., 2011]. Unlike in previous studies investigating immigrants’ oral health, our participants were immigrant women in arranged transnational marriages and their children. This study assesses the oral health disparities and oral health care needs of immigrant children in order to assist in the planning of a cross-culturally appropriate intervention program. The 5-year Lay Health Advisor Approach to Promote Oral Health Program (LHA-POHP), aimed at promoting the oral health of new immigrant children, was first implemented in the Kaohsiung area in 2011. The LHA’s strategies are feasible and effective for promoting health care, especially among disparate immigrant and children populations [Kim et al., 2004; Plescia et al., 2008]. Prior to this study, no oral health promotion programs for mixed marriage preschool children and their mothers were conducted. The aim of the study was to collect baseline data of the LHA-POHP to explore the disparities and factors associated with oral health among immigrant children. Materials and Methods Data were obtained from the baseline data of the LHA-POHP. A community-based survey was conducted to collect baseline data in February 2011. This survey assessed oral health disparities be-
576
Caries Res 2014;48:575–583 DOI: 10.1159/000351680
tween immigrant and native children and their potential determinants to obtain baseline data and intervening factors. Both oral health examinations and maternal questionnaires were used to assess the oral health status of children and its potential determinants among the mothers. Study Design The data of immigrants were collected from 20 communities selected from a list of 87 Kaohsiung communities, which were based on the high proportion of Vietnamese and Indonesian mothers who received care from the Kaohsiung Health Sector. The native children were selected from kindergarten schools using systematic random sampling. Fifteen schools were randomly selected from a list of kindergartens that was provided by the Education Bureau of Kaohsiung City. All of the schools agreed to participate in the study, and in the winter of 2011, all children aged 4–6 years were invited to participate. Participants A total of 590 (440 native, 150 immigrant) children aged 4–6 years and their mothers completed the questionnaire and oral examination. The response rate for natives and immigrants was 96.1 and 78.5%, respectively. A sample size calculation was established by comparing proportions between the values found in native and immigrant children, with an 80% power and 5% significance, respectively. The sample size was estimated at 422 natives and 89 immigrants. Oral Examination Each child was examined by one well-trained dental hygienist. Calibration courses and training sessions were performed before and during the study, based on the caries index. Intra-rater reliability was found to be 0.92. The examinations were conducted in accordance with the primary dentition caries experience. The instruments of oral examination included an oral health checklist developed by the World Health Organization [World Health Organization, 1997], tongue spatula, flashlight, dental mirror and standard dental explorer. Caries was registered by tooth and tooth surface. Teeth were given a code according to their status: decayed (d), missing (m) or filled (f) tooth (t) and surface (s). The dmft/ dmfs was based on 20 primary teeth and each tooth recorded once. Questionnaire Development The questionnaire was modified from an established and validated questionnaire used in recent studies [Finlayson et al., 2005; Skeie et al., 2006]. The self-administered questionnaire was reviewed by a panel of experts and children’s mothers for assessment of its content and validity. To ensure that the content was understood by our participants, the questionnaire was piloted to 50 mother samples in a kindergarten. Based on the results of the pilot testing, items were revised to enhance clarification and appropriateness. The questionnaire used response formats of closed-ended items, such as dichotomous, ordinal and multiple-level response choices, to assess oral health behavior and its relevant variables. The questionnaire was first developed in Chinese and then translated into Vietnamese and Indonesian by bilingual experts. To ensure translation accuracy, the two versions were translated back into Chinese and then verified for accuracy by senior researchers. In January 2011, a self-reported questionnaire was given to all participating mothers under examination conditions overseen by trained LHA program research staff.
Lin/Yen/Chang/Ting/Chen/Chen/Peng/ Chen/Hu/Huang
Oral Health Indices The oral health measures used to determine dmft in this study included the number of decayed, missing and filled primary teeth. A more detailed index is the dmfs that is calculated per tooth surface. The maximum value for dmfs is 88 for 20 teeth. They are used to estimate the degree to which dentition has been affected by dental caries on the day of examination. The significant caries index (SiC) was determined by adopting the mean dmft of one third of the children with the highest caries values.
Table 1. Characteristics of participants in the native and immigrant groups
Independent Variables Oral health behavior items were included in the analysis. These items were used to reflect the mothers’ and children’s oral health behavior. Participants responded to questions such as ‘Daily frequency of brushing’ and ‘The frequency of sugary beverages consumed per week’. An overview of the items in each behavior variable is shown in online supplementary table 1 (for online suppl. material, see www.karger.com/doi/10.1159/000351680).
Caries Res 2014;48:575–583 DOI: 10.1159/000351680
Oral Health Disparities of Children among Southeast Asian Immigrant Women in Arranged Transnational Marriages in Taiwan Y.C. Lin a Y.Y. Yen b C.S. Chang c C.C. Ting a P.H. Chen a C.C. Chen b W.D. Peng d F.L. Chen e C.Y. Hu f H.L. Huang b
a
School of Dentistry, College of Dental Medicine, b Department of Oral Hygiene, College of Dental Medicine, Global Center of Excellence for Oral Health Research and Development, d Department of Medical Sociology and Social Work, College of Humanities and Social Science, Kaohsiung Medical University, Kaohsiung, e Department of Public Health, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan; f School of Public Health, Louisiana State University Health Sciences Center, New Orleans, La., USA c
Key Words Enamel caries · Epidemiology · Oral hygiene · Public dental health · Tooth brushing
Abstract This study assessed the oral health disparities and oral health care needs of children whose parents are Southeast Asian immigrant women in arranged transnational marriages. We used the baseline data of the Lay Health Advisor Approach to Promote Oral Health Program (LHA-POHP) to explore the disparities in oral health between immigrant and native children, and the factors associated with their oral health. A cross-sectional community-based study was conducted to collect data from mothers and their preschool children in Southern Taiwan in 2011. A total of 590 (440 natives, 150 immigrants) children aged 4–6 years and their mothers completed the questionnaire and oral examination. Multiple regression models were used to analyze the association between children’s oral health and their related factors. The caries index was 6.05 in immigrant children and 3.88 in native children (p < 0.001). The caries prevalence of maxillary anterior teeth in the labial surfaces was higher among immigrants, ranging from 14.7 to 22%. The factor associated with children’s caries index was maternal tooth brushing fre-
© 2014 S. Karger AG, Basel 0008–6568/14/0486–0575$39.50/0 E-Mail [email protected] www.karger.com/cre
quency (adjusted odds ratio [aOR] = 8.95, 95% confidence interval [CI] 1.95–41.05). When the mothers did not direct children to brush teeth after eating sweets, their children were more likely to have decayed teeth (aOR = 3.54, 95% CI 1.04–12.03). Children’s filled teeth were related to their dental regular check-ups (aOR = 2.28, 95% CI 1.26–4.10). Disparities in oral health among immigrant and native children were observed. The findings suggest that culturally adequate oral health promotion intervention programs should be implemented for immigrants. © 2014 S. Karger AG, Basel
Recently, Taiwan has been faced with the migration of large numbers of women from Southeast Asian countries. These women are colloquially called ‘foreign brides’ or ‘alien brides’ because their marriages were arranged by marriage brokers. The importation of Southeast Asian brides began in 1987 in rural areas of Taiwan. This form of arranged transnational marriages has created a special phenomenon of ‘marriage trades’ that is popular among the lower middle classes. Arranged intermarriage is one type of cross-border migration flow of women. The majority are from Vietnam and Indonesia. The aggregate number of Southeast Asian wives was estimated at more Dr. Hsiao-Ling Huang, PhD Department of Oral Hygiene, College of Dental Medicine Kaohsiung Medical University 100, Shih-Chuan 1st Road, Kaohsiung, 80708 (Taiwan) E-Mail hhuang @ kmu.edu.tw
than 466,000 in 2012, or approximately one third of Taiwanese marriages [Ministry of the Interior, 2012]. By 2011, 1 in 10 children was born to a foreign spouse. This particular group of immigrant women is highly susceptible and vulnerable to health problems because of language barriers, cultural conflicts, social and interpersonal isolation and a lack of support systems. This segregation has gradually led to inferior medical care for these women and their children [Lin and Hsiao, 2007]. Compared to native mothers, immigrant mothers have difficulty accessing the health care system [Yang and Wang, 2003]. Therefore, health inequalities among immigrant mothers and children and their native counterparts exist [Mendoza, 2009]. Dental caries affects general health and quality of life in preschool children [Sheiham, 2006; Wong et al., 2011]. With growing transnational marriages in Taiwan, health disparities have been demonstrated in maternal and child health. Previous studies conducted in Europe and the United States noted the worsening dental status of immigrant children [Maserejian et al., 2008; Chinn et al., 2011]. The risk factors for preschool children with caries experience were associated with parental educational level, parental attention to the child’s tooth brushing habits, parental brushing habits and frequency of sugar intake among parents [Skeie et al., 2006; Finlayson et al., 2007; Wigen and Wang, 2010; Tapias-Ledesma et al., 2011]. Unlike in previous studies investigating immigrants’ oral health, our participants were immigrant women in arranged transnational marriages and their children. This study assesses the oral health disparities and oral health care needs of immigrant children in order to assist in the planning of a cross-culturally appropriate intervention program. The 5-year Lay Health Advisor Approach to Promote Oral Health Program (LHA-POHP), aimed at promoting the oral health of new immigrant children, was first implemented in the Kaohsiung area in 2011. The LHA’s strategies are feasible and effective for promoting health care, especially among disparate immigrant and children populations [Kim et al., 2004; Plescia et al., 2008]. Prior to this study, no oral health promotion programs for mixed marriage preschool children and their mothers were conducted. The aim of the study was to collect baseline data of the LHA-POHP to explore the disparities and factors associated with oral health among immigrant children. Materials and Methods Data were obtained from the baseline data of the LHA-POHP. A community-based survey was conducted to collect baseline data in February 2011. This survey assessed oral health disparities be-
576
Caries Res 2014;48:575–583 DOI: 10.1159/000351680
tween immigrant and native children and their potential determinants to obtain baseline data and intervening factors. Both oral health examinations and maternal questionnaires were used to assess the oral health status of children and its potential determinants among the mothers. Study Design The data of immigrants were collected from 20 communities selected from a list of 87 Kaohsiung communities, which were based on the high proportion of Vietnamese and Indonesian mothers who received care from the Kaohsiung Health Sector. The native children were selected from kindergarten schools using systematic random sampling. Fifteen schools were randomly selected from a list of kindergartens that was provided by the Education Bureau of Kaohsiung City. All of the schools agreed to participate in the study, and in the winter of 2011, all children aged 4–6 years were invited to participate. Participants A total of 590 (440 native, 150 immigrant) children aged 4–6 years and their mothers completed the questionnaire and oral examination. The response rate for natives and immigrants was 96.1 and 78.5%, respectively. A sample size calculation was established by comparing proportions between the values found in native and immigrant children, with an 80% power and 5% significance, respectively. The sample size was estimated at 422 natives and 89 immigrants. Oral Examination Each child was examined by one well-trained dental hygienist. Calibration courses and training sessions were performed before and during the study, based on the caries index. Intra-rater reliability was found to be 0.92. The examinations were conducted in accordance with the primary dentition caries experience. The instruments of oral examination included an oral health checklist developed by the World Health Organization [World Health Organization, 1997], tongue spatula, flashlight, dental mirror and standard dental explorer. Caries was registered by tooth and tooth surface. Teeth were given a code according to their status: decayed (d), missing (m) or filled (f) tooth (t) and surface (s). The dmft/ dmfs was based on 20 primary teeth and each tooth recorded once. Questionnaire Development The questionnaire was modified from an established and validated questionnaire used in recent studies [Finlayson et al., 2005; Skeie et al., 2006]. The self-administered questionnaire was reviewed by a panel of experts and children’s mothers for assessment of its content and validity. To ensure that the content was understood by our participants, the questionnaire was piloted to 50 mother samples in a kindergarten. Based on the results of the pilot testing, items were revised to enhance clarification and appropriateness. The questionnaire used response formats of closed-ended items, such as dichotomous, ordinal and multiple-level response choices, to assess oral health behavior and its relevant variables. The questionnaire was first developed in Chinese and then translated into Vietnamese and Indonesian by bilingual experts. To ensure translation accuracy, the two versions were translated back into Chinese and then verified for accuracy by senior researchers. In January 2011, a self-reported questionnaire was given to all participating mothers under examination conditions overseen by trained LHA program research staff.
Lin/Yen/Chang/Ting/Chen/Chen/Peng/ Chen/Hu/Huang
Oral Health Indices The oral health measures used to determine dmft in this study included the number of decayed, missing and filled primary teeth. A more detailed index is the dmfs that is calculated per tooth surface. The maximum value for dmfs is 88 for 20 teeth. They are used to estimate the degree to which dentition has been affected by dental caries on the day of examination. The significant caries index (SiC) was determined by adopting the mean dmft of one third of the children with the highest caries values.
Table 1. Characteristics of participants in the native and immigrant groups
Independent Variables Oral health behavior items were included in the analysis. These items were used to reflect the mothers’ and children’s oral health behavior. Participants responded to questions such as ‘Daily frequency of brushing’ and ‘The frequency of sugary beverages consumed per week’. An overview of the items in each behavior variable is shown in online supplementary table 1 (for online suppl. material, see www.karger.com/doi/10.1159/000351680).
