An introduction to oral health

inequalities among Indigenous

and non-Indigenous populations

Gloria C. Mejia

Eleanor J. Parker*

Lisa M. Jamieson

University of Adelaide, Australia

Indigenous People

• UN has no official definition of “indigenous people”

- adopted an inclusive understanding based on self-identification and recognition by a community with distinct social, environmental, economic, historical and political structures (WHO, 2007; Unicef, 2004; United Nations, 2006).

• Estimated 370 million Indigenous people in the world (WHO, 2007)

• Internationally, Indigenous populations are considered vulnerable because of their susceptibility to health-related outcomes and events (United Nations, 2008).

International Data

• In most countries, systematic oral health data on a national scale is lacking.

• There is some information from a limited number of national oral health surveys that reveal important findings.

• National surveys often not truly representative of Indigenous groups.

Overview

• AIM:

– to provide background information on the oral health inequalities experienced by Indigenous populations residing in the United States, Canada, Brazil, Australia and New Zealand.

• the five nations were selected for reasons pertaining to availability of oral health-related inequality information

United States of America

• Indigenous people: those who identify as being American Indian or Alaska Native

• United States government recognises more than 560 American Indian or Alaska Native tribes and communities.

• Indigenous people are estimated to compromise 1.4 percent of the total United States household population.(US Census Bureau 2007).

United States of America

• Indian Health Services 1999 survey:

Children:

– 2–5 year olds: 68% had untreated dental decay, 3x more than children in the general population

– 6–12 year-olds: untreated dental decay in both the primary and permanent dentition ranged between 60% and 75%

– for the permanent dentition, 46% of American Indian or Alaska Native children had untreated decay compared to 11% of their counterparts

Adults:

– 68% of 35–44 year-olds had untreated decay

– Mean DMFT of 14.4.

– 61.3% aged 55+ years had untreated decay and a mean DMFT of 16.2 (IHS, 1999).

Canada

• Indigenous people : those identifying as North American Indian (First Nations people), Métis and Inuit.

• Total Indigenous Canadian population increased by 45% in the last decade, to almost 4% of the total population (Statistics Canada 2008).

• Until 1996, national health surveys in Canada specifically excluded First Nations people living on reserves and Inuit communities in the provinces (FNIRHS, 1997).

Canada

• 1990–91: national study of 6 and 12 year-old Indigenous children : 91% experienced dental disease (FNIRHS, 1997)

.

• 1996: 95% of six-year-olds and 89% of 12 year-olds had experienced dental caries (FNIRHS, 1997).

• Around 22% of respondents reported experiencing

dental pain or problems in the past month (FNIRHS, 1997).

Canada

2002–2003 survey (RHS 2003)

• For adults, revealed increasing dental treatment needs for all types of services since 1997, particularly for urgent dental care.

• Youth (12-17 years): 79% reported having received dental care within the past year, however, nearly 37% reported needing restorative work and 19% reported experiencing dental pain in the previous month.

• Pre-school-aged children:

– 11% of 1–2 year olds had received restorations

– prevalence of early childhood caries estimated as being approximately 12% for 0–2 year olds and 29% for children 3–5 years.

Brazil

• The Indigenous population in Brazil totals approximately 735,000 people, based on those self-declaring Indigenous status in the national census.

• Referred to as Indians, the Indigenous groups are a diverse population, representing many different language and distinct cultural bands (Instituto Brasileiro de Geografia e Estatística, 2005).

Brazil• Need for preventive care and caries treatment for

children and adolescents has been demonstrated.(Carneiro et al 2008; Arantes et al 2001)

• High levels of untreated dental caries and low levels of restored and missing teeth signify the lack of access to appropriate dental services for Indian communities. (Rignotto et al, 2001; Carneiro et al 2008; Arantes et al, 2001)

• Regional survey: – 22% of children 0–5 yrs were caries-free;

– 5–7 years mean dmft of 8.5

– adults over fifty years a DMFT of 19.3

– caries experience of Indian children in this region was greater than that of children in other Brazilian studies (Rignotto et al, 2001).

Australia

• 2.5% of the Australian population self-identify as being of Aboriginal or Torres Strait Islander descent (ABS 2008).

• National estimates indicate that Indigenous Australians have – higher rates of edentulism,

– higher percentage of reported toothache,

– lower mean number of dental visits

– more likely to visit for a problem rather than for a check-up

– receive lower mean number of dental fillings compared to the non-Indigenous population (Brennan and Carter, 1998; AIHW, 2000).

Australia

• 2.3 fold difference in the prevalence of untreated coronal decay between Indigenous and non-Indigenous Australians (Roberts-Thomson and Do, 2007).

• Despite the general improvement in children’s oral health and decreasing levels of dental caries from 1977 to 1993, caries levels among Indigenous children have increased (Cooper et al 1987, Davies et al 1997).

• Twice the levels of dental caries in both the deciduous and permanent dentitions of children than their non-Indigenous counterparts, with a greater proportion of untreated decay (ARCPOH 2004; Jamieson et al., 2007).

New Zealand

• Indigenous people are those with Máori ancestry, forming approximately 17% of the population in 2006 (Statistics New Zealand 2007).

• No recent national-level oral health data available.

• Community-level studies have consistently demonstrated that Máori children are around 3 times more likely than non-Máori to have experienced dental caries than non-Máori children (Thomson et al 2003; Thomson 1993; Thomson et al 2002).

New Zealand

• Demonstrated increasing oral health inequalities for children (1995-2000) culminating in 5-year-old Máorichildren having caries severity nearly 40 percent greater than their counterparts of non-Maori descent (Thomson et al 2002).

• In both fluoridated and non-fluoridated areas,Máorichildren have higher caries experience and less children caries-free than their non-Máori counterparts for both deciduous and permanent dentitions at ages 5 and 12 respectively (Lee, Dennison 2004).

Discussion

• Notable similarities in oral health inequalities exist for all Indigenous groups discussed, despite the marked differences in geography, culture, language and history experienced by these groups.

• Evidence suggests that these inequalities are increasing.

Key factors contributing to

inequalities

Historical factors

• Indigenous peoples have experienced attempts to have

their identities negated and erased.

• Indigenous populations consistently suffering isolation,

discrimination and alienation.

• Such upstream factors are known to strongly influence

health outcomes (Paradies, 2006).

Key factors contributing to

inequalitiesCulturally inappropriate oral health service provision

• Evidence suggests that the general oral health service provision framework is not an appropriate form of providing oral health care to Indigenous populations (Nash

and Nagel, 2005).

• Service provision frameworks are typified by a Western ideology that does not embrace the holistic approach to health favoured by Indigenous peoples (Hughes, 2004)

• Cultural factors become an additional barrier when oral health care providers ignore or undermine traditional medical practices, attitudes and health knowledge.

Key factors contributing to

inequalitiesGeographic factors

• Many Indigenous communities in the five observed nations are rurally or remotely located, and consequently do not have access to clean water, adequate sewage systems, electricity or paved roads.

• All of these affect both oral health service provision and the regular supply of both oral health-promoting foods (for example, fresh produce) and oral self-care devices (for example, toothbrushes and toothpaste).

Key factors contributing to

inequalitiesSocial determinants

• Without exception, the Indigenous populations in each of the five observed nations are socially impoverished in relation to their non-Indigenous counterparts (United Nations,

2008).

• The role of social determinants in oral health is undisputed, with social disadvantage being one of the strongest predictors of poor oral health outcomes, over and above individual-level risk factors such as high sugar diet and infrequent tooth brushing (Poulton et al., 2002).

Key factors contributing to

inequalities

Reliable national level data

• The lack of regularly collected, reliable and

representative Indigenous oral health information

available at a national level contributes to the continued

marginalisation of Indigenous populations.

• Difficult to monitor oral health-related outcomes and to

implement programs to maintain, promote or restore oral

health.

Conclusion

• The oral health inequalities experienced by Indigenous

populations in the United States, Canada, Brazil,

Australia and New Zealand are marked.

• There is a need for :

– Measures that embrace the historical context, geographic

barriers, social determinants, culturally-appropriate oral health

service provision

– Population and individual preventive programs

– National level Indigenous oral epidemiological surveys

References• Arantes R, Santos RV, Coimbra CE Jr. Oral health among the Xavante Indians in

Pimentel Barbose, Mato Grosso, Brazil. Cad Saude Publica. 2001;17:375–84.

• Australian Bureau of Statistics. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2008, Canberra; Australian Institute of Health and Welfare, 2008.

• Australian Institute of Health and Welfare Dental Statistics and Research Unit. Oral health and access to dental services among Indigenous Australians. Adelaide; The University of Adelaide 2000.

• Australian Research Centre for Population Oral Health. Oral health of Aboriginal Australians. Aust Dent J. 2004;49:151–153.

• Brennan DS, Carter KD. Adult access to dental care- Indigenous Australians.Australian Institute of Health and Welfare Dental Statistics and Research Series No. 16, The University of Adelaide, 1998.

• Carneiro MC, Santos RV, Garnelo L, Rebelo MA, Coimbra CE Jr. Dental caries and need for dental care among the Baniwa Indians, Rio Negro, Amazonas. Cien Saude Colet. 2008;13:1985–1992.

• Cooper MH, Schmanschula RG, Craig GG. Caries experience of Aboriginal children in the Orana Region of New South Wales. Aust Dent J. 1987;32:292–294

• Davies MJ, Spencer AJ, Slade GD. Trends in dental caries experience of school children in Australia: 1977 to 1993. Aust Dent J. 1997;42:389–394

References• First Nations and Inuit Regional Health Survey (FNRHS). First Nations and Inuit

Regional Health Survey Steering Commitee, 1997. ISBN 0-9685388-0-0 Available at: http://www.rhs-ers.ca/english/pdf/rhs1997/rhs_1997_final_report.pdf [Accessed: September, 2009]

• Hughes J. Gender, equity, and Indigenous women’s health in the Americas. Pan-American Health Organization. Washington DC, 2004. Available at

• Indian Health Service. An Oral Health Survey of American Indian and Alaska Native Dental Patients: Findings, Regional Differences and National Comparisons. US Department of Health and Human Services, Indian Health Service, Division of Oral Health, Office of Clinical and Preventive Services, United States, 1999.

• Instituto Brasileiro de Geografia e Estatística. Demographic Trends: an analysis of indigenous populations based on sample results of Demographic Censuses 1991 and 2000. Rio de Janeiro, Brazil, 2005.

• Jamieson LM, Armfield J, Roberts-Thomson KF. Oral Health of Aboriginal and Torres Strait Islander children. Canberra: Australian Institute of Health and Welfare, 2007.

• Lee M, Dennison PJ. Water fluoridation and dental caries in 5- and 12- year old children from Centerbury and Wellington. NZ Dent J. 2004;100:10–15.

• Nash DA, Nagel RJ. Confronting oral health disparities among American Indian/Alaska Native children: the pediatric oral health therapist. Am J Public Health..2005;95:1325–1329.

References• Paradies Y. A review of psychosocial stress and chronic disease for 4th world

indigenous peoples and African Americans. Ethn Dis. 2006;16:295–308.

• Poulton R, Caspi A, Milne BJ, Thomson WM, Taylor A, Sears MR, Moffitt TE. Association between children's experience of socioeconomic disadvantage and adult health: a life-course study. Lancet. 2002;360:1640–1645.

• First Nations Regional Longitudinal Health Survey 2002-2003 (RHS). Results for adults, youth and children living in First Nations communities. Assembly of First Nations/First Nations Information Governance Committee, 2003 ISBN: 1-894804-33-3.

• Rigonatto DDL, Antunes JLF, Frazao P. Dental caries experience in Indians of the Upper Xingu, Brazil. Rev Inst Med Trop S Paulo. 2001;43:93–98.

• Roberts-Thomson K and Do L. Oral health status. In: Slade GD, Spencer AJ, Roberts-Thomson KF (Editors). Australia’s dental generations: the National Survey of Adult Oral Health 2004-06. AIHW cat. No. DEN 165. Canberra: Australian Institute of Health and Welfare (Dental Statistics and Research Series No. 34). 2007; 81-142.

• Statistics Canada. Aboriginal Peoples in Canada in 2006: Inuit, Metis and First Nations, 2006 Census. Ottawa, Statistics Canada, 2008.

• Statistics New Zealand. QuickStats about Maori, Census 2006, revised 2007.Wellington, Statistics New Zealand, 2008.

• Thomson WM. Ethnicity and child dental status in the Manawatu-Wanganui Area Health Board. NZ Dent J. 1993;89:12–14.

References• Thomson WM, Ayers KM, Broughton JR. Child oral health inequalities in New

Zealand: a background paper to the Public Health Advisory Committee National Health Committee. Wellington, 2003.

• Thomson WM, Williams SM, Dennison PJ, Peacock DW. Were NZ’s structural changes to the welfare state in the early 1990s associated with a measureable increase in the oral health inequalities among children? Aust NZ J Public Health.2002;26:525–530

• UNICEF. Ensuring the rights of indigenous children. Unicef Innocenti Research Centre, Innocenti Digest II, Florence: UNICEF, 2004. ISSN: 1028-3528.

• United Nations General Assembly. United Nations Declaration on the Rights of Indigenous Peoples. New York; United Nations, 2008.

• United Nations Development Program. Human Development Report 2005, Geneva, United Nations Development Program, 2005.

• United Nations. Fifth session of the United Nations Permanent Forum on Indigenous Issues 2006. Press Kit: Fact sheet : Indigenous peoples and identity. Available at: http://www.un.org/esa/socdev/unpfii/documents/5session_factsheet1.pdf [Accessed: October, 2009]

• United States Census Bureau. The American Community- American Indians and Alaska Natives: 2004. Washington; United States Department of Commerce, 2007.

• World Health Organization (WHO). Health of indigenous peoples. Fact sheet No. 326. October 2007. Available at: http://www.who.int/mediacentre/factsheets/fs326/en/index.html [Accessed: September, 2009]