Challenges in Oral Health Provision and Utilization in the Australian Indigenous Population: A Scoping Review

Oral health is a vital area of public health. Access to dental services are particularly important among Indigenous populations at a global level. This scoping review aimed to investigate challenges in the provision and utilization of oral health services among Indigenous Australians. The ndings may be an important contribution to the literature and facilitate policymakers in reducing inequities in dental service access and utilisation among this vulnerable population. Methods This scoping review was conducted up to June 10, 2020. Five main databases were searched, including PUBMED, SCOPUS, ISI Web of Science, EMBASE and PROQUEST. The main key words were: oral health, dental health, utilization, provision, access, Indigenous, Native, Aboriginal and Torres Strait Islander. Arksey and O’Malley`s protocol was applied, which comprises 5 steps of: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data and collating and; (5) summarising and reporting results. Thematic analysis was used to summarize and analyse the data applying MAX QDA 10 software for qualitative data analysis. For a better understanding of the themes and subthemes, a thematic network was presented. Results show that there are six main themes and fourteen sub-themes affecting Indigenous Australians` utilization and provision of oral health services. Personal characteristics, Socio-economic status and challenges regarding access were that the main factors inuencing utilization of oral health services. The ndings suggest that challenges relating to public health, policymaking and service provision can affect Indigenous Australians provision to oral health services. deeper


Introduction
Oral health is an integral component of public health. Optimal oral health leads to an increase in quality of life and general health [1]. Limitations in dental public health systems, however, can lead to insu cient or oral health [2]. Various studies have focused on the effects of these challenges on vulnerable groups and minorities [3,4].
One of the most vulnerable groups in Australia is the Indigenous community, which comprises approximately 3% of Australia's total population [5,6]. Indigenous Australians have much poorer oral health, irrespective of indictor used, than their non-Indigenous counterparts [7]. For example, Indigenous Australians have a higher rate of dental caries, more untreated teeth, more periodontal problems, lower levels of oral health literacy and lower reported quality of life compared to other people in the community [7][8][9].
Various challenges have been posed in providing dental services to Indigenous Australians. These include fears of judgement, geographical access, higher costs of preventive and curative services, long waiting times and poor oral health literacy [10,11]. There is some evidence that an under-utilisation of dental services can worsen and intensify the oral health conditions of Indigenous Australians [12].
One of the key goals of the Australian Government is to provide adequate access to dental services and to reduce oral health inequality among Indigenous and non-Indigenous Australians [13]. Indigenous Australians (those identifying as Aboriginal and/or Torres Strait Islander) are prioritized in the oral health plans at both a national and state-level [14,15]. However, access and utilisation of dental public health services among Indigenous Australians remains low [7,16,17]. This has many consequences, with dental problems leading to emotional, physical and nancial impacts [12], as well as feelings of shame about personal appearance and self-esteem [8].
Given the lack of empirical evidence on the challenges in the utilisation and provision of oral health services for Indigenous Australians, it became apparent that a scoping study was needed. Therefore, this scoping review aimed to investigate the challenges in oral health provision and utilization among Indigenous Australians to better enable policymakers to make equitable and fair choices regarding funding for oral health services.

Method
This scoping review was conducted up to June 10, 2020. We implemented content analysis and thematic network answer the question: "what are the main challenges in provision and utilization of the oral health services among Indigenous Australians. The scoping review instrument developed by Arksey and O'Malley [18] was applied to construct a comprehensive map of evidence on the research question [19].
The following 6 steps were thus used [18]:

I. Identifying the research question
The research question of a scoping review determines the scope of the study and provides the parameters for the initial search. At the same time, a scoping review question should include the Population, Content and Context (PPC) of the study [18].
In this study, the population comprised Indigenous Australians. The content was the challenges and barriers in the provision and utilization of oral health services. The context was the historical, social, cultural and political nuances that have shaped Indigenous Australian health and wellbeing for the last 250 years.
The research question for this study was nalized as: "what are the main challenges of oral health provision and utilization among Indigenous Australians"?

II. Identifying the relevant studies
Five scienti c databases were searched systematically from January 1, 2000, to June 10, 2020. These included PUBMED, SCOPUS, PROQUEST, EMBASE and Web of Science. The search was conducted by applying the following keywords: oral health, dental health, oral care, oral hygiene and delivery, provision, providing, utilization, use, access and challenges, problems, barriers, obstacles, indigence, native, aboriginal, original Australian, Torres Strait Islander and, Australia. The logical operator OR was used between the synonymous keywords, and the logical operator AND was applied to combine them. Table 1 shows details of the search strategy of the scoping review.

III. Study selection
Using the above search strategy, 187 articles were selected. This was reduced to 151 after exclusion of duplicates. The manuscripts were rst scanned by their titles and abstracts by two of the researchers separately (YS and FO). The selected abstracts were saved in libraries applying EndNote X7.1, by Thomson Reuters. A PRISMA owchart summarizes this process (Fig. 1). The full texts were then studied individually. In the event of a disagreement (about 2 of the articles), a third researcher (AG) read the paper to achieve consensus. Inclusion criteria included papers with full English text, qualitative or quantitative designs, original research articles or reviews were included. Exclusion criteria included only abstracts in English, letters, commentaries and editorials.
IV. Charting the data A data extraction form was applied according to the aim of the study. This form contained the author`s name, study title, study topic, study design, year and place of publication and key determinants of specialty selection. After all the included articles were extracted, a content-analysis approach was applied.
V. Collating, summarising and reporting the results Thematic analysis was used to summarize and categorize the data. Thematic analysis is an inductive approach for content analysis in order to make themes from the data content [20]. Analysis was conducted via six steps as follows: In the rst step, familiarization with data occurs through reading of the content several times. Then the initial codes were identi ed based on the research question and study aim. After reviewing these preliminary codes, the nal codes were created. The nal codes were merged and categorized to create sub-themes. In the fth step, the main themes were re ned and labelled. Finally, for a better understanding of the themes and subthemes, the results were both tabulated and a thematic network was presented applying MAX QDA 10 software for qualitative data analysis.

Results
As indicated in Fig. 1, of the 187 initially included articles, 24 were selected for the scoping review. All 24 manuscripts except one was published between 2007 and 2020. Thirteen articles (54.2%) involved quantitative data and six (25%) followed a qualitative approach. One study (4.1%) adopted a mix method approach, with the remaining four manuscripts being review articles or discussion papers (16.7%) ( Table 2 Appendix).
There were six main themes and fourteen-related sub-themes identi ed that indicated the challenges of oral health provision and utilization in the Indigenous Australian context (Table 3). Cost is likely to be a signi cant barrier (specially in women).

Non-nancial access
Consent issues.

Geographic barriers in accessing oral health services
Challenges beyond their control as individuals, including accessing dental services The rst theme was identi ed as 'personal characteristics', with ve sub-themes including age, sex, physiological status, psychological status and health literacy status (Table 3). These themes demonstrated how oral health utilization can be in uenced and shaped by the personal characteristics of Indigenous Australians. Among the personal characteristics, age is considered as a determinant criterion.
Children [30,38], teenagers [12] and elders [21] are supposed as the important age groups. Moreover, women [12,21,34] are more vulnerable to lack of access and utilization to oral health services. Oral health literacy was considered as a risk indicator for poor self-reported oral health outcomes among the indigenous groups [9]. Low levels of oral health literacy may contribute to lack of attention to oral health and late and emergency dental referrals [7] so it will be important for the policy makers to identify more vulnerable groups and help them to become impovered.
The second theme identi ed was socio-economic status This theme comprised economic status and social and cultural status of the Indigenous Australian population that poses many challenges in the utilization of oral health services. Financial concerns of the families [23,35], transportation problems [8,29] and living in remote areas [39] were among some of the economic challenges of oral health utilization. Cultural barriers included di culty in communication [36], language barriers [29] and low selfe ciency [34].
Public health limitations are among other challenges that restrict provision of optimal oral health services among Indigenous Australians. Public health issues in this regard are divided into public health behaviours and public health facilities. The main concept among the Indigenous population according to our ndings include beliefs [8] and perceptions [22] that affect oral health-related behaviours. These behaviours range from daily tooth brushing and uoride toothpaste use to consumption of sugary foods and carbonated beverages [25]. Along with public behaviours, public facilities can affect a population's provision to oral health services. Our ndings indicated that the communities which have inadequate levels of natural uoride in the drinking water and high levels of dental caries need greater access to dental public health facilities [27]. Water uoridation units in the more populated remote Indigenous communities (ie more than 500 people) [27] is a good example of an equitable and cost-saving dental public health intervention.
Policy making challenges including resource allocation and the governments` actions and interventions are considered as the fourth challenges of provision to oral health services (Table 3). Allocating adequate funding to the oral health needs of Indigenous Australians [27,28] was the strongest sub-theme. Including programs that aimed to reduce early childhood caries, increasing services to remote communities, developing the role of Aboriginal health workers, improving oral health literacy, establishing water uoridation and providing periodontal therapy are some effective interventions that can be compounded by the complex interplay between psychosocial and cultural determinants of both Indigenous Australians and oral health professionals. Public health behaviour and public health facilities were two of the sub-themes in this regard.
Service provision challenges were identi ed as the fth theme in uencing oral health provision among Indigenous Australians. The emphasis on surgeries as opposed to preventive services was noted [32], together with lack of integration between preventive primary health care systems and dental services [31,33]. A lack of an existing comprehensive primary health care model [24] can lead to a decrease in provision of oral health services. It was apparent that many Indigenous Australians were unaware of how to make an emergency dental visit and had limited understanding of the prevention of dental disease [35].
Finally, access challenges including nancial and non-nancial access were among other identi ed challenges that reduce Indigenous Australian utilization of dental services. Di culties in contacting patients [36], geographic barriers in accessing oral health services [37], high rates of failure to attend appointments [36] contribute to this. Cost of dental services [26,31] was a signi cant barrier restricting many Indigenous Australians' access to oral health services.
For a better understanding of the challenges impacting the utilization and provision of oral health services among Indigenous Australians, Fig. 2 clari es the conceptual map of the present scoping review through a thematic network.

Discussion
Our ndings indicate that many Indigenous Australians encounter challenges and barriers in the utilization and provision of oral health services. Our ndings are corroborated by El-Yous et al (2019), who identi ed three categories of determinants as the barrier to oral health services among vulnerable groups. These three determinants include individual, organizational and policy level barriers [40] that can be matched to the present results to some extent.  [42].
Similar to our ndings regarding socio-economic status, El-Yous et al (2019) described how "cultural differences in oral healthcare seeking behaviour" was one cultural barrier and the "limited ability to express need for dental treatment" as the main economic challenge [40]. Watt et al. (2019) provided evidence that Indigenous populations at a global level are vulnerable adult population groups in utilizing oral health services. They described how a population`s social class, income, education, psychosocial factors and social relationships are considered as the intermediate determinants that affect the utilization of oral health services [43]. Biordi et al. (2015) also emphasized how barriers to utilize oral healthcare remain signi cant in low-income children [44]. In that the Indigenous Australian context, access to social supportive packages may help overcome the economic barriers of oral healthcare utilization.
Watt et al. described how resources were an enabler to access oral health services [43], with Dahlan et al. (2019) also referring to social support as a determinant of access to oral healthcare among immigrants and ethnic minorities [45]. A report for the Waterloo Region Oral Health Coalition in Canada (2017) emphasized how cost is a huge barrier to accessing oral health care along with the clients` oral health literacy, fear and anxiety [46]. tour ndings identify public health challenges as one of the barriers to provision of oral health services among Indigenous Australians. This is supported by Levesque et al. (2013) who emphasized that ability to perceive health care needs containing health beliefs, expectations and literacy can lead to access to health care services [47]. Similarly, Göstemeyer et al. (2019) indicated that lack of oral health knowledge, beliefs and behaviors can act as barriers to access oral healthcare. They described how oral hygiene of patients was a determinant barrier in provision of oral and dental treatment [48]. Regular dental visits together with access to water uoridation and other public health interventions are both bene cial and cost-effective in this regard.
Policy makers have a multi-disciplinary role in improving provision of the oral health services. They can set the agenda to include wider discussion around provision of oral services, advocate stakeholders and allocate more resources to this area. Designing and managing of effective population-level interventions can be considered by national and local policy makers to support the oral health needs of all socially excluded populations, Indigenous Australians among them.
Balasubramanian et al (2019) have shown that some problems in dental service utilisation arise from narrow approaches to dental education and imbalances among the skills, jobs and competencies of oral service providers. Macro challenges of the health care system exist, including imbalanced geographic distribution and an increasing divide between the 'professions' interests, and needs of the population [49]. These problems can restrict both access and utilisation of oral health services.

Limitations
Study limitations include: a quantitative approach for analysing oral health indicators among Indigenous Australians would have provided useful information in conjunction with the scoping review. That would have enabled the present results to be triangulated with the face to face interviews from Indigenous participants to better explore other probable reasons of challenges in the utilization of oral health services.

Conclusion
Our ndings indicate that the utilization and provision of oral health services for Indigenous Australians can be restricted via personal and socioeconomic factors. Challenges relating to policy making, service providing, public health and access can affect their utilization and provision. Policy makers in a national and local level can plan to decrease these limitations although most need long term, multidisciplinary interventions.

Delecrations
Ethics approval and consent to participate Not applicable.

Consent for publication
Not applicable.

Availability of data and material
All data generated or analysed during this study are included in this published article and the appendix.

Competing interests
The authors declare that they have no competing interests.

Funding
There was no funding.
Authors' contributions PB is designed the study and nalize the dasta analysis. YS, AG and FO are collected the data and extracted the data. LJ is technically edited and nalized the article.  Figure 1 The PRISMA owchart of the scoping review