The study investigated the patterns and predictive factors of PDS use among refugees in Victoria, using existing administrative data over a four-year period. There was a significant heterogeneity within the study population in terms of the combined patterns and rates of utilisation of different types of CoCs and eleven major service areas as well as the location attributes of clinic sites where they availed PDS. Six distinct profiles of PDS use were identified, described, and subsequently investigated. Together, the findings of this study further the understanding of access and utilisation of PDS among Victorian refugees.
This study is the first to employ LPA to develop profiles of refugee population based on their dental service utilisation pattern. According to the LPA model, the majority of refugees (about 52%) who attended PDS during the study period had a higher probability of using restorative or orthodontic services as part of general CoC. Another 32% predominantly used emergency CoC for extractions or endodontic procedures. Notably, only a very small proportion of refugees (about 9%) used prophylactic and preventive services. These identified patterns were consistent with previous studies which found a low use of preventive services [9, 27], high use of oral surgery and endodontic services [12], and a high proportion of those seeking emergency dental care [3] among refugee populations. Refugees tend to use dental services only when in severe pain or when self-treatments do not work [28]. Consequently, they have a problem-oriented pattern of dental attendance, wherein services are sought infrequently and primarily for treating dental problems [29]. Evidence suggests that a visiting pattern comprising regular dental check-ups and preventive (or interceptive) care is associated with decrease in the use of emergency dental services [30] and better oral health outcomes [31]. Regrettably, this so-called ‘favourable’ utilisation pattern was observed only among a small proportion of refugees in this study.
It was expected that the location characteristics of clinic of service reception have a pattern in accordance with the type of CoC and service area. In Victoria, publicly funded specialist services are primarily provided at the RDHM [7], which is in the city of Melbourne; non-specialist general and emergency CoCs are provided at the RDHM and other community dental clinics. Clients diagnosed as needing further specialist dental services, at any of the community dental clinics across the state, are referred to the RDHM. Although no studies among Victorian refugees focused on this restricted availability of certain types of services, this might be an important factor influencing their utilisation. In England where circumstances are similar surrounding the provision of government funded emergency dental services, refugees have noted that the number and location of clinics providing urgent care posed a significant barrier in securing appointments and physically accessing the clinic location [32]. As evident in this study, refugees most frequently seek specialist services. This is because, in many instances, the dental disease is well advanced at the time of refugees’ dental visit which inevitably necessitates specialist intervention [27]. The lack of specialist services in their area of residence, combined with the inability or unwillingness of refugees to travel far distances to avail specialist services, attests to the higher utilisation rates of emergency extraction services at community dental clinics within the clients’ SA2, seen in this study. Expanding the provision of specialist services in areas with high refugee resettlement could improve timely uptake of these services.
Examination of refugee characteristics within and across the groups showed a clear distinction between the profiles. Overall, females and young and middle-aged adults (16–45 years) had the most utilisation among the identified profiles, except denture users group (Table 1). This compared favourably with dental visits among the general populations in Australia [29]. Whereas these findings are encouraging, considering the higher burden of dental disease among refugee males and children compared to those in general population [33], a higher uptake among these groups would have been expected. In refugee families, the dental health-related attitude of parents is critical in determining their children’s utilisation pattern, as they are the decision-makers for their children’s dental care needs [34]. So, the lower use among younger age groups may primarily be attributed to their parents. Interestingly though, there was a very high uptake of orthodontic services among children and adolescents (0–15 years), relative to other services, including preventive services. This finding is also substantiated in a study among Australian refugees which reported that the most frequent oral health concern of refugee children or their parents was cosmetic related [4]. Another reason could be that some refugees (with high orthodontic treatment need) can avail orthodontic treatment at no cost via PDS, as opposed to the very expensive private alternatives. Although use of orthodontic services for cosmetic reasons suggest a considerable improvement in oral health attitudes or service awareness among resettled refugees, the findings highlight the need for strategies to improve uptake of preventive services among the 0–15 years group. High utilisation among female refugees is contrary to the literature. It is generally believed that most refugee families have a male dominant structure in which female health-related decisions are made by males [35]. While the study findings suggest otherwise, the reasons for this could be manifold including individual family circumstances, mix of cultural groups within the sample, and differences in the lengths of stay and levels of assimilation to the Australian culture among the study population.
As noted earlier, a significant aspect in distinguishing the identified profiles, that was not examined in this study, was utilisation by length of stay in Australia. Newly arrived refugees in Australia were found to have a higher burden of dental disease [2, 36] owing to pre-arrival oral health attitudes and beliefs, compounded by the poor hygiene practices and lack of access to proper dental care during their extended lengths of stay in refugee camps and course of migration to the host country. To address these previously unmet and accumulated needs, it is expected that there would be a higher volume of visits during the early periods post resettlement among these groups. On the contrary, they have less knowledge and understanding of the Australian dental health system than those who have lived here for a considerable time. So, it would be critical to analyse and compare the utilisation patterns among these two cohorts of refugees. Unfortunately, this critical information was not available in the Dental Health Program dataset. Upon availability of relevant data, this requires to be further examined in future research studies.
In addition to describing the profile characteristics, the study also determined the predictors of refugee PDS utilisation pattern. At the individual-level, the primary correlates were age and gender. Ethnicity of refugees, based on their region of birth, had a consistently positive association with PDS utilisation pattern, except for denture and orthodontic services use among Sub-Saharan refugees (Table 2). However, there was a considerable difference in the likelihood across profiles among different ethnic groups. Burden of oral diseases may vary among refugees based on their ethnicity owing to the cultural or religious norms, dietary preferences, oral hygiene practices, oral health related attitude including access to dental care in their home country, and their ability to assimilate to the host country’s culture [33, 37]. To some extent, this might have had a decisive influence on their utilisation pattern. Considering the inclination of refugees to resettle in ethnic clusters [38], other factors that could explain the differences may be related to the cultural and social support available to each of these ethnic groups in their communities of settlement. The relationship between the remaining individual variables and utilisation patterns were mixed across the groups.
The role of refugees’ context in predicting their PDS utilisation pattern was confirmed in the current study. About 26% of the variation in refugees’ PDS utilisation patterns was due to the differences in the characteristics of their place of residence (i.e., SA2). A clear gradient was observed between higher SA2-level socioeconomic disadvantage of refugees and increased likelihood of emergency extraction service use. The association between area-level socioeconomic disadvantage and dental service utilisation pattern among refugees reflects on the importance of contextual-level factors in determining PDS utilisation among refugees. This finding is new and an important one. Refugees living in the rural areas were 52% more likely to use emergency extraction services than their metropolitan and regional counterparts. This effect was evident even after adjusting for socioeconomic disadvantage, physical accessibility to community dental clinics via different travel modes and availability of dental professionals, which are considered primary barriers to access among rural residents in Australia [5]. As such, this finding is particularly significant, as it points to factors associated with higher use of extraction services, beyond those considered in the analysis. Such factors may include, but are not limited to, oral health promotion activities [39], social, cultural, or religious networks disseminating information on dental services [37], and presence of community organisations supporting rural refugees in accessing dental care. With refugee resettlement shifting to rural areas [40], it is critical to reorient the public dental system to address these growing inequalities among rural refugee populations.
One interesting finding was the significant association between the delivery of RHP in CHCs in refugees’ residential SA2 and a lower likelihood of restorative and endodontic services uptake, compared to preventive services. Notably, there was also a corresponding increase in the use of extractions among refugees in these SA2s. The RHP was implemented by the Victorian Department of Health to improve access to primary health care among refugees. The program is delivered by trained refugee health nurses who identify refugees’ health issues (including oral health problems), make appropriate specialist referrals, and coordinate their care pathway [19]. The findings from this study suggest that while the RHP initiative may be helpful until the point of making dental referrals, there is limited follow up on these referrals among refugees. This accords with findings from a study among refugee children in Western Australia, which showed that less than 50% of those referred to community dental clinics by refugee health nurses followed up and subsequently availed required care [41]. Integrating oral health care within general health settings (e.g., primary care) would help bypass known and unknown barriers related to follow up on referrals and improve uptake of certain services. For example, oral health professionals located at the Refugee Health Program sites within the CHCs can implement preventive or interceptive measures during refugees’ primary care visits. Such a model of care was successfully implemented in Queensland and was found to be effective in improving access to preventive care among new refugees, as well as cost-effective [42]. Alternately, non-dental health care professionals (e.g., refugee health nurses) can also be trained to conduct oral health screening and deliver basic care within general health settings [41].
The study findings add new knowledge on the association between spatial accessibility to dental services and the pattern of utilisation. The latest Australian National Oral Health Plan emphasises the importance of understanding this relationship in order to improve service delivery for vulnerable population groups (including refugees) [5]. The current study found a significant association between potential spatial accessibility to PDS via driving and public transit modes of travel and the utilisation patterns among refugees. Overall, refugees in SA2s least accessible via any travel mode used PDS less than those in most accessible SA2s, which reflects on the impact of potential accessibility on realised service utilisation. Bivariate associations revealed significantly higher likelihood in the use of extraction services than preventive services, with increase in accessibility via any travel mode. When adjusted for the effects of other variables in the multivariate analysis, these associations remained significant. Predominant sections of the metropolitan area have good road and public transit network, and therefore, high potential accessibility to PDS via any travel mode [43]. Clearly, this finding implies that irrespective of the level of opportunity to access services, refugees continue to incline toward attending PDS in a problem-oriented manner.
Together, the individual and contextual level factors explained about 40% of the total difference in the utilisation pattern across SA2s; meaning that the remaining 60% variation is due to other factors not included in this study. One of the most important individual-level factors is subjective or objective oral health need, which was found to significantly impact refugee dental service utilisation [35]. Among others, oral health literacy, length of stay in the host country and cultural assimilation were also shown to be positively associated with the utilisation [9, 12]. As well, factors related to the dental health organisation such as cultural competence and responsiveness of dental and support staff, and appropriateness of care provided have been noted to be potential in determining refugees’ utilisation behaviour [35]. Future research should examine the role of these factors on their utilisation pattern.
Strengths and Limitations
This study was the first to have comprehensively evaluated utilisation of PDS among a large sample of refugees in Victoria using administrative data over multiple years. Homogeneity in refugees’ patterns of PDS utilisation was demonstrated using LPA based on multiple indicators including the attributes of dental care and clinic of care reception. This enabled capturing meaningful variations in the complex interactions among different dimensions of PDS utilisation, rather than relying on any one dimension (e.g., either CoC or service type). Moreover, refugees were classified into profiles based on model-based cut-off thresholds derived from within the data, minimising any classification errors that may arise from using arbitrary cut-offs for grouping (e.g., above or below a mean value) [22]. Furthermore, the role of individual and contextual level predictors of PDS utilisation pattern was analysed using a multilevel design.
There are some limitations, primarily arising from the clinical records data. Refugee clients were identified within the Dental Health Program dataset based on how these individuals were identified and recorded by the public dental clinic staff in the Titanium® system. Although there are a flexible set of criteria available to them to identify an individual as a refugee [44], there is no one agreed upon definition. As such, there may be inconsistencies across clinics. The variables included in the LPA and multilevel analysis were restricted by the availability and completeness of clinical records data. This precluded the evaluation of some important factors known to impact dental service use. For example, there was a large amount missing data (missing for about 52% clients) for variables indicating the oral health status, such as decayed, missing and filled teeth.
Some methodological limitations are worth mentioning. The Dental Health Program dataset does not capture information on those who do not utilise public dental services. As such, factors influencing non-utilisation of public dental services were not evaluated. As well, the study findings are only pertaining to refugees’ utilisation of publicly funded dental services. It is possible that some refugees attend private services for either specific or all of their dental needs [12]. Profiles developed through LPA are not exclusive [22], i.e., there might be overlap in the services used by refugees in different groups. The assignment of individuals was based on their highest probability of belonging to a particular utilisation pattern, which was in turn based on their mean utilisation rates in each of the indicators. Although the data permitted, longitudinal trend in the utilisation was not captured. Finally, as with any study of this design, the findings cannot be generalized outside the study population, i.e., refugees attending PDS in Victoria.