Key Challenges for Indigenous Peoples of Canada in terms of Oral Health Provision and Utilization: A Scoping Review

Hussain, Ahmed

doi:https://doi.org/10.1155/2022/7511213

International Journal of Dentistry

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Abstract Introduction Methods Results Discussion Conclusion Data Availability Conflicts of Interest Acknowledgments References Copyright Related Articles

Review Article | Open Access

Volume 2022 | Article ID 7511213 | https://doi.org/10.1155/2022/7511213

Key Challenges for Indigenous Peoples of Canada in terms of Oral Health Provision and Utilization: A Scoping Review

Ahmed Hussain¹

Academic Editor: Gaetano Isola

Received03 Jun 2022

Revised05 Sept 2022

Accepted12 Sept 2022

Published27 Sept 2022

Abstract

Background. The oral health of Indigenous peoples in Canada is lacking compared with their non-Indigenous counterparts. This scoping assessment aimed to investigate the obstacles of providing and using oral healthcare among Indigenous peoples in Canada. Methods. The scoping review took place between December 15, 2021 and January 10, 2022. Five key databases were examined: PubMed, Scopus, ISI Web of Science, Embase, and PROQUEST. The data were analyzed using NVIVO software to facilitate understanding of the major themes, subthemes, and codes provided. Results. Seven major themes and eighteen subthemes were identified as impacting the oral health provision and utilization of Indigenous peoples in Canada. The major themes are individual characteristics, affordability, availability, accessibility, accommodation, acceptability, and public or government policy. Thus, to improve the oral health of the Indigenous peoples in Canada, an integrated approach is required to address these obstacles. Conclusions. To address the oral health disparities among Indigenous peoples in Canada, policymakers should adopt an integrated approach.

1. Introduction

Oral health is important for good physical, mental, and psychological well-being [1]. Indigenous peoples have long been suffering from disparities in the Canadian healthcare system [2]. These disparities are even more evident in respect to the oral health of Indigenous peoples. Researchers used already collected data (such as the data from the Canadian Community Health Survey), questionnaires, and examinations to confirm these disparities [3–5]. Dental services have been provided to eligible First Nations and Inuit peoples through the Noninsured health benefits (NIHB) program. Different strategies have been implemented to eliminate these disparities, such as the First Nations oral health strategy teeth for life, the Inuit oral health action plan healthy teeth, healthy lives, British Colombia’s First Nations and aboriginal oral health strategy healthy smiles for life [6–8]. However, the efforts implemented so far are not enough to bridge the gap between the oral health of Indigenous peoples of Canada and their nonindigenous counterparts.

Although the temporomandibular joint function is an integral part of the stomatognathic system [9, 10], no studies was published in this aspect related to the oral health of the Indigenous people of Canada.

From our initial scan of research articles published that identify obstacles in the provision and utilization of oral healthcare for Indigenous peoples of Canada, these articles have been limited to specific areas in Canada, specific physical or psychological characteristics, and may not reflect the current situation as they were published years ago. The intent of this scoping review was to thoroughly map the available literature regarding the challenges encountered by Indigenous peoples in achieving good oral health. It will allow us to identify and better understand knowledge gaps and focus on how these challenges could be addressed.

2. Methods

The approach was based on the five-stage system by Arksey and O’Malley with addition of a sixth stage presented by Levac et al. [11]. The approach is likewise supported by the Joanna Briggs Institute’s approach for conducting scoping reviews [12]. Thus, the six stages included: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, (5) collating, summarizing, and reporting the results, and (6) consultation with pertinent partners (optional) [11].

2.1. Identifying the Research Question

The following research question was used to determine the scope of the review and provide boundaries for the underlying search: ‘What are the key challenges for Indigenous people in Canada in terms of oral healthcare provision and utilization?’

2.2. Identifying the Relevant Studies

The research keywords/methodology was adopted from the study by Bastani et al.[13] with modifications. Five scientific databases were thoroughly searched (PUBMED, SCOPUS, PROQUEST, EMBASE, and Web of Science). In brief, with the support of an experienced librarian at the University of Saskatchewan, a precise search strategy was developed, utilizing particular MeSH terms [14] and keywords to gather pertinent material on the topic of interest. The Boolean concepts ‘OR,’ ‘AND,’ and ‘NOT’ were combined to generate groups of keywords and medical subject titles. The search strategy was created for Medline using the Ovid interface (Table 1), and then adapted as necessary to enable a similar search on each of the other electronic platforms. Oral health, dental health, oral care, oral hygiene and delivery, provision, providing, utilization, use, access and challenges, problems, barriers, obstacles, Indigenous, native, aboriginal, First Nations, Metis, Inuit, and Canada were used in the search. Between the synonymous terms, the logical operator OR was utilized, and the logical operator AND was used to combine them.

The search strategy’s eligibility criteria were created as per the PCC (Population-Concept-Context). Studies included in this review were those reporting on Indigenous people in Canada (population) oral health (concept) related to the obstacles of provision (context). Studies published in English language from January 1, 2000 to December 21, 2021 were included. Retained articles were original research articles (qualitative and quantitative).

The exclusion criteria included study protocols, reviews, abstracts, opinions, editorials, letters, commentaries, and conference abstracts were excluded as this scoping review targeted peer-reviewed literature. Data collected prior to the date mentioned were excluded. Studies not originally published in English were excluded. The study selection and screening process is in accordance with the Preferred Reported Items in Systematic Reviews and Meta-Analyses (PRISMA) (Figure 1).

2.3. Selecting Studies

For this study, the screening process was as follows: the title and abstract of all retrieved citations (191 articles) were exported to an excel sheet. After removing duplicates and assessing the remaining articles against the inclusion criteria, 18 articles were included in the study. The method is summarized in a flowchart (Figure 1).

2.4. Charting the Data

The complete texts of the included articles were examined one-by-one, and the researcher used a data charting method (form) to extract the key study features. The author’s name, year of publication, research title, study subject, study abstract, study design, and outcomes were included in the form.

2.5. Collating, Summarizing, and Reporting the Results

A summary (Table2) was generated of the included studies [11] to synthesize and summarize the findings. Qualitative descriptive analysis of the content was undertaken using NVivo V.12. The research questions were answered using a thematic analysis. We added to/modified the major themes published earlier in the Canadian Academy of Health Sciences (CAHS) report ‘Improving access to oral health care for vulnerable people living in Canada’ [31]. The codes are categorized depending on how closely they are related and linked [32, 33].

3. Results

3.1. Study Selection

A total of 18 articles were used in the study (Table 2). For description, even though Indigenous peoples is the terminology presently in use in Canada, Table 2 retains the terminology used in the original article as some studies are from different locales or previous time periods.

3.2. Study Characteristics

The CAHS outline from the report ‘Improving access to oral health care for vulnerable people living in Canada’ report was used as a framework. However, we added to the outline as it was not inclusive of all the factors. There were 7 major themes and 18 subthemes that outline the challenges of oral health utilization by Indigenous peoples in Canada (Table 3). Figure 2 shows a better understanding of the challenges that may be impacting the provision and utilization of oral healthcare.

3.3. The Impact of Individual Characteristics

Age, sex, medical status, psychological status, education, employment, oral health literacy, habits, lifestyle, and historical background were identified as the subthemes of the individual characteristic theme. These subthemes highlighted how Indigenous peoples’ personal qualities might impact and shape oral healthcare utilization. In respect to age, young age or children are affected by early childhood caries (ECC), which can have long-lasting negative effects on their development [21, 25]. In addition, the elderly population seemed to experience more challenges in oral health [24, 34]. In respect to sex, in some studies [16] being a male is a risk factor, whereas in other studies being a woman, especially a pregnant woman [5], is a risk factor of having challenges with oral health. The link between poor physical/medical health and poor oral health has been pointed out [16]. The psychological status, such as the fear of dentist/needles and children being uncooperative, is a risk factor toward oral health utilization [25]. Having a higher education and employment were significantly related to better oral hygiene habits [26]. Limited oral health knowledge and habits such as smoking further reduce the quality of oral health of the individual [24, 26, 30, 35]. Insufficient knowledge of or inability to access healthy food choices is considered a barrier to good oral health [4, 20, 29]. Other factors such as poor access to clean water, fluoridated water, adequate sewage systems, electricity, or paved roads have affected oral health negatively [36]. Behaviors that do not support oral health and the gap between proper oral health knowledge and behavior have been mentioned as a limiting factor to achieving adequate oral health [24]. We should also keep in mind the shadows of historical factors (isolation, discrimination, and alienation) as a negative determinant to oral health [28].

3.4. The Impact of Affordability, Availability, and Accessibility

Affordability was represented as a major theme, with economic status as a subtheme, and encompasses lack of dental insurance, lack of affordability of oral hygiene supplies, and healthy food. Low income and scarce housing are risk factors for poor oral health experienced by Indigenous peoples in Canada [15, 17, 37]. Availability was a factor, which correlates to the lack of human resources, funding, and the uncertainty of many oral health programs [17, 36]. Accessibility also has an effect on oral health outcomes, and studies revealed that living in remote areas with no transportation affect the person’s ability to access oral care services [26, 36].

3.5. The Impact of Accommodation, Acceptability, and Public/Government

Limitations in respect to the major theme of accommodation that compromise the provision of oral care include lack of financial incentive for the oral care provider and lack of accurate and complete health records [17, 28, 36]. This is further complicated by language barriers. Factors related to acceptability theme play a significant role in achieving good oral health. The lack of understanding/integration of the wholistic conceptualization causes a lack of community engagement [5, 17, 20]. Finally, the public/government as a major theme, with a policy subtheme shows a negative impact on oral healthcare due to low prioritization of oral health, budgetary constraints, and the policy gap between the federal and provincial powers [22]. Decision makers use the lack of scientific evidence about the effectiveness of certain modules to their hesitation to keep funding them [19].

4. Discussion

There are many obstacles and limitations faced by Indigenous peoples in Canada when it comes to accessing and utilizing oral healthcare. Earlier studies [36] identified four types of variables as barriers to oral health treatment among Indigenous peoples in Canada. These variables are affordability, accessibility, accommodation, and acceptability. Two more variables were added by our study—individual characteristics and public/government.

Individual characteristics, such as age (especially in children and the elderly), sex, medical status, psychological status, education, employment, oral health literacy level, habits, lifestyle, and behaviors, all have been found to reduce oral health usage among Indigenous peoples. This is in accordance with our previously published research where we found that age; gender; medical status; poor habits, such as smoking; limited level of education; and no employment resulted in poorer self-predicted oral health [3]. Bastani et al. reported similar findings for the Australian Indigenous population [13].

The economic status of Indigenous peoples has affected the affordability of oral health services. Low-income individuals cannot afford dental care, oral hygiene supplies, and healthy food. A similar pattern was reported in other parts of the world [38, 39].

The limited availability of oral health resources negatively impacted the oral health of the Indigenous peoples in Canada. For example, the lack of human resources on reserves in addition to the lack of funding for community programs and facilities led to the disruption of some dental services. Many programs operate on uncertain year-to-year funding cycles. Watt et al. reported a similar pattern, as he showed how resources facilitated access to oral healthcare [39].

Our results showed that living in remote areas, where the only oral health provider is miles away with no transportation services, significantly limits regular access to oral care. Such a barrier is clearly indicated in the First Nations” report [36].

The absence of financial incentive for pediatric residents, as an example, to do oral exams or apply fluoride is a limiting factor. Their busy schedules and a lack of accurate or complete medical records can make it even more challenging to provide oral healthcare [17]. The language barrier for some Indigenous peoples in Canada, as they do not speak English or French, has limited their access to oral health and made them more reliant on their community healers [34, 40].

Community acceptability plays an important role in integrating oral health programs. Racism and ignoring or undermining the traditional medical practice, through the lack of integration of the wholistic conceptualization of health, led to the lack of trust between the community and the oral health providers. This is because of the lack of proper training of the oral health providers [5, 34, 41].

Indigenous communities face numerous competing challenges, and this has led to low prioritization for oral healthcare. When there are budgetary constraints, oral healthcare programs often suffer the most. This is because of the lack of scientific research results that show the importance of these programs to the federal and provincial governments. National and local policymakers may consider designing and managing successful population-level initiatives to meet the oral health needs of all socially excluded communities, including the Indigenous population [13].

Given the multitude of factors that have been identified as having an effect on oral healthcare provision and utilization for Indigenous peoples in Canada, alternative approaches are necessary to bridge the gap and improve oral health outcomes. One approach is to provide oral care in an integrated form. Integrated care is emphasized as one of the basic concepts of primary care and defined as a coherent and coordinated set of services that are planned, managed, and delivered to individual service users across a range of organizations and by a range of cooperating professionals and informal carers [42].

4.1. Limitations

This review used previously published literature related to the oral health of Indigenous peoples in Canada. The number of studies included is not large. However, a similar pattern was recognized among medical health providers. We see a similar pattern in other parts of the world, such as in Australia.

5. Conclusion

Our findings suggest factors related to the individual characteristics, affordability, availability, accessibility, accommodation, acceptability, and public/government can limit Indigenous peoples’ access to and provision of oral healthcare. Policymakers should look at addressing each one of these obstacles in a practical and interdisciplinary way to improve the oral health of the Indigenous peoples in Canada.

Data Availability

The data are included in the Materials and Methods section.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors would like to acknowledge the contributions of all their colleagues.

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Copyright

Copyright © 2022 Ahmed Hussain. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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