DOI: 10.1111/j.1741-6612.2010.00395.x Research Understanding oral health beliefs and practices among Cantonese-speaking older Australians ajag_395 Rodrigo Mariño Melbourne Dental School, University of Melbourne, Melbourne, Victoria, Australia Victor Minichiello School of Health, Faculty of The Professions, University of New England, Armidale, New South Wales, Australia Michael I MacEntee Faculty of Dentistry, University of British Columbia, Vancouver, British Columbia, Canada Aim: The present study was conducted to explore how older immigrants from Hong Kong or Southern China manage their oral health in Melbourne. Methods: We used six focus groups involving 50 Cantonese-speaking immigrants who were 55 years and over and living in Melbourne. Results: Four major themes relevant to oral health care emerged from the discussion: (i) traditional Chinese health beliefs; (ii) traditional medicine and oral health; (iii) attitudes towards dentists; and (iv) access to oral health-care services. Language, communication and cost of dentistry were identified as major barriers to oral health care. Conclusion: Older Chinese immigrants in Melbourne have concerns about oral health care that are similar to other ethnic groups, they want more oral health-related support from government, and many of they return to China or Hong Kong for dental treatment. Key words: China-born, older adults, oral health, traditional culture. Introduction In Australia, the China-born population is one of the fastest growing groups among new arrivals. The Census in 2006 recorded 206 506 China-born persons, which is an increase of 44.8% since 2001 [1]. Chinese migration to Australia occurred over time in waves, consequently they are ageing differently. One group of 65- to 75-year-olds arrived as young adults; another arrived as older people under the family reunion program [2]; while a third group who came mostly as entrepreneurs or skilled migrants from Hong Kong and Macau dominated immigration in the early 1990s but diminished substantially shortly before and after the reunification of these territories with China [3]. Correspondence to: Associate Professor Rodrigo Mariño, Melbourne Dental School, University of Melbourne. Email: rmarino@unimelb.edu.au Australasian Journal on Ageing, Vol 29 No 1 March 2010, 21–26 © 2010 The Authors Journal compilation © 2010 ACOTA 21..26 Few studies have examined the oral health and perceptions of older Chinese living in Australia. However, there have been reports that ethnic groups are ‘not receiving the same level of health care in diagnosis, treatment and preventative services that the average population receives’ [4]. This oversight undermines basic principles of equity and access to care, and more importantly, the principle of equity of health outcome [4–6]. Consequently, we focused our study on China-born older people who speak Cantonese, and we used focus group discussions (FGD) to understand issues surrounding the social meaning of oral health in the life [7]. Methods Following ethical approval from the University of Melbourne and approvals from the Chinese Health Foundation of Australia, we recruited Cantonese-speaking men and women aged 55 years or older who were born in China. We selected 55 years to identify older people following recommendations from the AIHW Dental Statistics and Research Unit in expectation that it will help to inform policy makers and program planners [8]. We recruited Cantonese speakers because more than half of older China-born residents in Melbourne speak it [9]. Volunteers for the FGDs were recruited through the older people’s network of the Chinese Health Foundation of Australia. Recruits lived in one of two neighbourhoods – Box Hill (an area of relative social advantage) and North Melbourne (an area of relative social disadvantage) – each with large populations from Hong Kong and Guangzhou. Participants were invited to an FGD consisting of either men or women under the assumption that they would feel more comfortable in this situation discussing sensitive issues, such as oral hygiene, sexual attractiveness and appearance. However, two of the FGDs were mixed. Prior to discussions, participants answered a short questionnaire in Cantonese seeking socio-information about the background, immigration and use of oral health services. FGDs occurred between September and October 2007, involved four to 10 participants per group, and lasted between 45 and 90 minutes. Participants were recruited to create diverse discussion groups with different oral health-related experiences (e.g. users vs non-users of dental services; subjects living independently vs those living with children). All discussions were in Cantonese led by one bilingual Cantonese-speaking facilitator who was a professional community worker and well-known in the neighbourhoods. She had a training session with the principal investigator before each FGD, and she began the discussion by explaining the 21 M a r i ñ o Table 1: Vignette and questions used to prompt the focus group discussions† Raymond and Iris have been married for 40 years, and lived for most of their lives in Guangdong Province. Their children immigrated to Hong Kong for work, and then moved to Melbourne when they had children. Raymond and Iris were asked by their oldest son to live with them in Melbourne, and encouraged them with information about the quality of life in Australia. After much thought, they decide to join their son and his family in Melbourne. Raymond has dentures made before he left China but now they are loose and uncomfortable, so he refuses to wear them even when he meets his son's friends. Iris is annoyed by Raymond's appearance without teeth. Iris also has new dentures which she wears constantly even though they are uncomfortable. She feels that her family cannot afford to have them fixed or replaced, but she uses them to look as young as possible in their new country. She tells Raymond that she does not want to be in his company when they leave the house because he looks too old without teeth, and she believes this makes it difficult for them to make friends. Raymond is annoyed by Iris's constant complaints. Focus group prompts Health-related Behaviour Do you think that Raymond and Iris are behaving correctly? Is it important to look young? How should Raymond and Iris resolve their difficulties? How might people fix a painful tooth or denture without going to a dentist? Health-related Beliefs Is it easy to get help for most health problems (does this include dentures)? Are most dentists, doctors and other professional people honest? How do most of your friends keep healthy? Is it easy to get healthy food today? Social Supports What do you like and dislike about living with your children? Do families behave differently today compared to when you were young? How does the government help you with social supports to stay healthy? R , M i n i c h i e l l o V, M a c E n t e e M Table 2: Sociodemographic and immigration characteristics of 50 Chinese older people who participated in focus group discussions % Age group 60 years or less 61–70 years 71–80 years More than 80 years Sex Male Female Living arrangement Alone With spouse With children With spouse and children Level of education No formal education Complete and incomplete primary Some secondary or less Secondary complete Tertiary education Year of arrival in Australia Before 1985 Between 1985 and 1994 After 1995 Use of oral health services 12 month or less More than 12 months Place of birth China Hong Kong 10.0 40.0 46.0 4.0 30.0 70.0 32.0 45.0 20.0 12.0 2.0 18.0 18.0 34.0 28.0 22.0 44.0 34.0 58.0 42.0 58.0 42.0 †Adapted from Brondani et al. 2008 [12]. objectives and decorum, and requesting permission to soundrecord and transcribe the discussion verbatim for analysis. Questions posed by the facilitator were prompted at the beginning of each discussion by a situational vignette that focused attention on the psychosocial impact of dental problems on two older adults (Table 1). Concerns about the mouth can be intimate and difficult to discuss in a group [10], consequently the vignette offered an effective prompt for exploring ideas without necessarily exposing personal intimacies within the group [11–16]. Furthermore, this format has been demonstrated to be culturally acceptable for older Chinese [17,18]. Analysis The audio recordings of each FGD were translated and transcribed from Cantonese to English. The principal investigator analysed the transcription of each discussion before proceeding to the next FGD so that unresolved issues raised by one group could be explored further by the succeeding group. Finally, before the detailed analysis of all the transcripts using a software program (NVivo) [19], a bilingual investigator not involved in the discussions verified the accuracy of the Cantonese-to-English translations. The software program facilitates tracking associations between emerging themes within the context in which they were discussed. The themes 22 were coded by one investigator and checked by another to provide an independent perspective on our findings [20]. Findings Profile of participants The sample derived from the six FGDs included 50 older Chinese participants of whom 29 were born in mainland China and 21 born in Hong Kong (Table 2) Most (58%) of the participants reported attending a dentist during the preceding year. Themes Themes that emerged from the response to the vignette depicting the relationship between the two characters, Raymond and Iris, were organised under four major categories: (i) traditional Chinese health beliefs; (ii) traditional medicine and oral health; (iii) attitudes towards dentists; and (iv) access to oral health services. Traditional Chinese health beliefs The poor oral health and related behaviour of the two characters was deemed a health concern by the participants. The denture is not just an appearance issue, but a health issue too. (F-FGD1) Australasian Journal on Ageing, Vol 29 No 1 March 2010, 21–26 © 2010 The Authors Journal compilation © 2010 ACOTA O r a l h e a l t h b e l i e f s There was general belief that oral health was related to good nutrition, and proper chewing leads to overall good health. Chewing was identified as the start of the digestion, while difficulties related to digestive problems, constipation, anaemia and other systemic disorders. Social contacts were seen by older Chinese as a way of maintaining participation in their preferred activities, as well as engaging in social activities and staying healthy. If [Raymond] is left alone he will feel more isolated when he moves away from home and thus will feel older and may more easily get sick. (F-FGD1) Oral health was described also as a quality of life matter that influences self-confidence, social life, social isolation, relationships and enjoyment of life. The couple need to acknowledge and accept that they are old, and agree that he looks older without dentures. A denture gives one confidence and allows a better quality of life. (F-FGD1) Appearance. Participants had the view that Westerners emphasise external appearance, oral hygiene and orthodontic treatment more than internal health. However, they acknowledged that good appearance would lead to more confidence, as one participant said: Good looks give people confidence and health. Society needs people with confidence. Damaged teeth can be extracted or filled, white hair can be dyed. Youth has natural beauty. Older people need man-make beauty. (F-FGD1) There was a sense of acceptance that changes in appearance were part of the ageing process. One female participant emphasised the difference between internal and external beauty: To me ethically, the good or bad of a person is not based on their appearance . . . Dentally, good appearance is fine, but personal health is more important than teeth. (F-FGD5) Others remarked that appearance was important in the early stages of life, although one participant emphasised the importance of appearance and looking young: a m o n g o l d e r C a n t o n e s e I don’t want to get my dentures replaced yet because I am still eating comfortably – but my appearance doesn’t seem appealing (F-FGD1) For others, appearance was not as important. Good oral health was more a thing of self-respect and respect for other people. However, although appearance was considered an important element of good health, this is a generation marked by WW II and a prudent life in China or Hong Kong before emigrating. When asked to describe their life in China, participants identified economic hardship, which disturbed their dental health. We do not have enough education on dental health. Our parents didn’t teach us either. . . . In WW II time, under Japanese occupation, we did not have toothbrushes. We used our fingers or a cloth to brush our teeth. We were too poor and could not afford toothbrushes. (F-FGD5) Traditional medicine and oral health The FGD participants valued traditional Chinese medicine (TCM) in general and used Chinese herbs to promote health and prevent illness. Some participants mentioned a number of traditional remedies, such as herbal teas, and acupuncture for oral pain relief: We could drink Traditional Herbal Tea, like (Leung Cha), Gold and Silver Flowers (Kam Ung Fa) [Lonicera japonica Thunb], chrysanthemum. Artemisia capillaris decreases ‘heat’ (M-FGD6). Nonetheless, in general, they did not rely on traditional remedies to cure their dental problems. Most of them indicated that they used over-the-counter medicine for toothaches. Attitudes towards dentists There was a general agreement that dentists in Australia were technically competent, and more so than in China, although Chinese because of the easier communications was preferred for treatment of minor disorders. Overall, the view was that Australia has superior health-care and social services, especially when serious concerns arise. I think teeth should be fixed first. Looking younger is important. Without dentures one will look old affecting facial appearance (F-FGD3) [in China] there are a lot of doctors, [and it is] easy to communicate with the doctors. Consultation with doctors is cheaper there. A major operation is better done in Australia because it is more reliable in the hospitals and cheaper. (M-FGD5) For others, eating comfortably was more important than appearance: However, the participants did not think this was true for oral health care. Australasian Journal on Ageing, Vol 29 No 1 March 2010, 21–26 © 2010 The Authors Journal compilation © 2010 ACOTA 23 M a r i ñ o R , M i n i c h i e l l o V, M a c E n t e e M Medical and psychological care for elderly is good, but [not so for] dental care. Hopefully the government will put more emphasis on dental services. (F-FGD1) Other than dental services, it is easy to access medical and other services, [I] wish government could provide more subsidies or help for old people. (F-FGD1) Apparently, there are more dentists in China and treatment is more readily obtained and cheaper even when the airfare from Australia to China is included. Unaware of services. Translators were helpful with dentists who did not speak Cantonese, and when seeking information about health, however, several participants explained that they did not know how to find a translator. On the other hand, one participant noted that having information about health services was a matter of self-initiative: Professional honesty. There were concerns about the focus on payments for medical services in Australia, as one participant said: ‘GPs only care about having your Medicare card swiped’ (M-FGD5). There was a more favourable view of dentists who they perceived generally as honest. Still, they questioned the need for the high cost of dentistry or the reason behind certain procedures. [The dentist] is very commercial and makes you feel he wants to sell you some service to pay off his new equipment. (M-FGD2) Access to oral health services There was concern expressed about access to services, and about several community and personal barriers to dental care. For some, language was a concern affecting daily life, while for others, the role of interpreting services and the availability of Chinese-speaking general practitioners (GPs) was seen as crucial to improving access to health care. One participant was satisfied with the availability of health, social and community services, and he acknowledged their role in reducing language barriers. However, another participant explained that: I know there is a phone number that you can call for government translation service through the phone, but it takes a long time and the services are inadequate (F-FGD4). Still, despite availability of translation services, most of the participants preferred to attend Chinese dentists. If you go out more often, read the Chinese newspapers, or participate in the community activities and functions, you will be able to get more information or advice. (F-FGD4) They were keen to get government support for more health services and related knowledge. For example, in the selection of healthy food and good health products: [i]t is easy to find the health products and supplements, but there are too many to choose from, [and] I am not quite sure whether their claims are right or not. (M-FGD2) While one participant highlighted access to health information ‘regarding food, hygiene, and health awareness’ (M-FGD2) as an advantage of living in Australia, another emphasised the need and importance of government using the native languages of immigrants to convey messages and develop age-related policies: Hopefully you could transmit these dental problems to the government, and set up some affordable policy for us old people – especially when we have financial and language difficulties. (F-FGD1) Despite this complaint about access to services, there was widespread agreement that the quality of health services, including oral health care, was generally better in Australia. Still, some preferred that they ‘could choose whether to see a GP, specialist consultant or even a professor’ or that health care was cheaper and with more choice in China (M-FGD5). Discussion Cost of care. This was not seen as a problem for medical and social services, especially for geriatric care, but it was a barrier for dentistry. Visits to the dentist were expensive, but could not be delayed or avoided indefinitely. Participants acknowledged the priority of oral health and recognised that ‘although a denture is expensive, it is a must . . . [you] have to save money from other things to provide for fixing the dental problem’ (F-FGD1). Waiting lists. The time required to get appointments with dentists for other than emergency care, particularly within the public system, caused much annoyance. These were requests for governmental subsidy of dental services comparable to medical care. 24 The present study was undertaken with the purpose of exploring the role of oral health and related conditions within the lives of older adults who had immigrated to Melbourne from Hong Kong and Southern China. Consistent with other reports on the Chinese community living in Melbourne [21], oral health was a concern for these participants and appearance of their teeth was seen as important to their self-image and well-being. Oral health and natural teeth were important to comfort, lack of pain, tasting of food and enjoyment of meals. It was described as a condition that influenced quality of life, self-confidence, social life, relationships and overall enjoyment. It has a significant influence on nutrition and selection of healthy foods. Chewing was the start of digestion and difficulties in chewing could cause Australasian Journal on Ageing, Vol 29 No 1 March 2010, 21–26 © 2010 The Authors Journal compilation © 2010 ACOTA O r a l h e a l t h b e l i e f s systemic diseases, such as anaemia. Appearance for this group of Chinese immigrants relates to improved social life and self-respect, which on its own ground would lead to a better quality of life. Improved oral health, quality of life and better mood lead to an improved health status. Previous studies within Chinese communities in Australia and elsewhere found less use of oral health-care services by immigrants compared to others [5,22,23]. Dental services in Australia are provided overwhelmingly by private dentists as a private fee-for-service. There is no Commonwealth funding for dental services as for medical services. Access to public dental care for older citizens is based largely on whether or not they meet financial criteria, which is usually determined by whether or not an older person holds a Commonwealth Healthcare or a Pensioner Benefit Card. Older people compete for access to public dental care with other cardholders on a first-come first-served basis. This leaves some members of the Australian community with no or limited access to oral health-care services. Some older immigrants who have not been in Australia for very long need greater assistance or welfare compared to more established immigrants who have work or a pension. This discussion is very important as currently, there is a proposal by the Federal government to make dentistry universally available to the community, regardless of people’s ability to pay, through ‘Denticare’. This policy initiative is aimed at reducing the cost of dental treatment and public dental waiting lists. Such scheme could impact on reducing inequalities in oral health outcome as a result of class, ethnicity or age. This represents an important discussion about a national dental health scheme in Australia. Data from the present study add to this discussion by presenting the perspective of older migrants. Australasian Journal on Ageing, Vol 29 No 1 March 2010, 21–26 © 2010 The Authors Journal compilation © 2010 ACOTA o l d e r C a n t o n e s e that traditional and home remedies work better than modern medicine [27,28]. In the present study, some participants mentioned Chinese herbs and medicine or teas, while others mentioned acupuncture and other methods to manage oral health problems. However, participants were also open to Western dentistry approaches. Still, traditional beliefs, practices and concepts are well-established and usually remain unchanged in immigrant groups [29]. Cultural beliefs, lifestyles, traditional health-care practices and susceptibility to diseases can have profound effects on use of services [30,31]. Strong reliance on self-care and home remedies can delay visits to a dentist, because professional help is only sought when home remedies fail [32]. Further research is needed to understand the connection between using TCM and the social and cultural meanings of health and oral health within such a cultural discourse. An understanding of traditional practices can assist clinicians serving immigrants and help to provide culturally sensitive health promotion programs [33]. The direct out-of-pocket expense of dentistry compounded by communication difficulties entice many older migrants to return to China for dental treatments as part of a ‘holiday treatment plan’ [33]. However, this deprives them of the benefits of interventions. The study involved migrants who arrived in Australia over a long period of time (Table 2). It will be interesting to compare oral health concepts and practices of the first wave who arrived before 1985, and who mostly have a rural background and poor education, with the second wave, who arrived after 1985, and who are mostly from a middle class background. This exploration of Chinese immigrants will be the subject of future study. Key Points Additionally, participants expressed several areas where government support, in the form of specific oral health education and interventions, would be helpful. As other reports on Chinese migrants, there were no major cultural barriers in accessing oral health-care services [24], rather, as highlighted by Rao et al. [25] and Black et al. [6], inequalities in accessing services stem for a lack of knowledge about rights and responsibilities in the Australian system, and about available services. However, correct information is equally important. Poor language may make it difficult to consult nonCantonese-speaking dentists and physicians [23]. Language is also a major barrier when conveying preventive health-care messages to immigrants [26]. Increasing the number of ethnic dental staff among oral health professionals is important; however, it does not alone solve the issue of access to oral health care. Understanding people’s present and past experiences is important to put findings into perspective. For example, a fascinating area in our study was ‘traditional dentistry’. TCM is used widely among Chinese older adults in Australia who tend to believe a m o n g • Majority of informants had visited a dentist in the last 12 months. • Oral health was related to appearance, nutrition and healthy eating. • Participants did not rely on traditional remedies to cure their immediate dental problems. • Language, communication and cost were major barriers to accessing oral health care. • Participants wanted government to increase dental services to a level comparable with medical care, and to use the Chinese language to promote preventive treatment. References 1 Department of Immigration and Citizenship. China-born Community. 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