Our research aimed to apply a modified version of the Levesque model to examine the relationship between dental service approachability, dental care attendance and self-reported gum disease among women pregnant with an Aboriginal child in South Australia. The hypothesis was that participants with a perceived need for dental care would have a higher uptake of dental care, resulting in better oral health outcome. The findings showed that service-related factors were associated with dental attendance, which was consistent with the modified model. However, little effect was observed between service-related factors and self-reported gum disease, and no association was observed between dental attendance and self-rated gum disease. The results highlight the limitations of using the modified model in a quantitative study such as the one implemented.
Participants’ ability to navigate the dental care system was the key demand-side service approachability factor in utilising dental service. Previous research findings also reported Indigenous persons with higher skills in navigating dental services have higher compliance in long term dental treatment[38]. In this case, a person’s language capacity, knowing the information of location and contacts of dental clinics played an important role in the accomplishment of the dental care journey[38, 39]. However, due to the complexity of the Australian health system, many Indigenous and other socially or culturally marginalised groups struggle to adequately navigate the health system[40]. For some Indigenous Australians, mainstream dental services (private or public) may be the only options for dental care, because dental services may not be provided by their local Aboriginal community-controlled health service. Barriers to successfully navigate mainstream dental services include language and cultural barriers. Empirical research has demonstrated that awareness of dental service availability may be limited for some Indigenous people[21], and also midwives[39]. Making dental service systems more navigable is crucial, given the negative impacts that poor dental care utilisation on oral health outcomes.
For Indigenous Australians to better navigate dental care systems, information in accessible formats is required[41]. According to Robards[41], navigation systems that integrate technologies, such as social media, may facilitate Indigenous Australians to better understand, connect and engage with dental care. Such interventions should be based in the Indigenous community setting. During the COVID-19 crises, Summer noted[42] that the application of social media channels shared through trustworthy local community networks enabled fast and effective health information sharing. Although dental care service provision may not always be available in the Aboriginal Community Controlled Health Organisation setting, such organisations had an indispensable role in the dissemination of health information, and a leading role of enhancing communication among Indigenous communities[43].
Based on these findings, future navigation programs that embrace social media and related technology might be more effective and economically friendly for women pregnant with an Indigenous child. Such services should be easy to contact to make health system navigation more approachable and understandable. Navigation support is just one example of improving system navigation. The health navigator program – targeting both Indigenous and non-Indigenous Australians - was increasingly used among patients with chronic disease who have difficulties in accessing health service, which improved the process of care[44]. There is evidence [45, 46] that Indigenous Liaison Officers can improve the engagement of Aboriginal families with health professionals, and may have a positive impact on diagnosis. There are some Aboriginal Liaison Programs for dental care[47, 48], although no study specifically examined its effect on uptake of dental care, the project was proven to be successful in dental referral to mainstream dental service[48]. There has been a Midwifery-Initiated Oral Health Dental Service program. In this program, midwives provided oral assessments and referrals to local and free public dental care for pregnant women. The referral letter included the contact details of a dentist, a checklist of date of visit, number of visits and treatment to better navigate participants to the service and to facilitate them to complete the course of recommended treatment[49]. The program was effective and promising in the improved uptake of dental care, and may be a beneficial pathway forward to implement among Indigenous populations [50].
One of our study hypotheses was that participants who had a perceived need for dental care would have better oral health than their counterparts with no perceived need; however, this did not prove to be the case. This suggests that the motivations or reason for participants’ perceived need for dental care were mixed and complicated. For example, the last visit for a dental appointment may have been for a check-up (a good oral health-related behaviour) and because of a problem. Thus, uptake of dental care within one year was not a good indicator for oral health outcome; reason for that last visit would have been a more reliable indicator for the phenomenon we were aiming to measure.
The design of the questionnaire enabled comparison with Aboriginal or non-Aboriginal pregnant women. A higher demand for dental care among Aboriginal women during pregnancy can be observed in this study(85.8%) compared with non-Aboriginal pregnant women in the United States (50.1%)[51]. The rate of dental visit < 12 months in this study(35.7%) was very close to a comparable study in New Zealand(37.7%)[19]. However, non-Aboriginal pregnant women in high-income countries have nearly two times the rate of regular dental visiting, with approximately 70%-92% reported to have accessed dental care in the last 12 months[6, 52].
This study was the first study to describe dental uptake and service approachability for women pregnant with an Indigenous child in Australia. The modified model[25] used is well recognised in health service research, but has been mostly used in qualitative research in the Indigenous Australian context[27]. To the best of our knowledge, it has never been used in dental care. This study was also the first to test the association between approachability of dental care with dental uptake and self-reported gum disease among an Indigenous population. Most of studies[27] focus on provision of transport and reduction of cost to improve the accessibility of health care for Aboriginal people. Less empirical research has focused on the phases before actual interaction with the health care service, including participant motivation and capability to contact the service. This study reiterates the importance of system navigation in accessing dental care, which might also give more directions to improve accessibility of primary health care for Indigenous people. Indications for future research include: 1) Dental health literacy on how to navigate dental systems is important in the access outcome of dental care. Navigation support could be integrated with technologies, based on local community networks and collaborating with midwives. 2) The effect that approachability of a given service has on health outcomes (dental attendance). Motivations for visiting a dentist differ, and this has an impact on oral health outcomes. Previous uptake of dental care was not a good indicator of oral health. There is a need for better analytical approaches, and different measures of exposures and outcomes to better illustrate the impact that utilisation of dental care has on oral health outcomes.
The study limitations include; social desirability bias may have influenced participant responses; And no clinical data collected to ascertain objective measures of dental health. Our study was cross-sectional, meaning no assumptions of causality can be made.