Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2015; 60:(1 Suppl): 131–143 doi: 10.1111/adj.12292

Cultural aspects of ageing and health promotion RJ Mari~ no* *Oral Health Cooperative Research Centre, Melbourne Dental School, The University of Melbourne, Victoria, Australia.

ABSTRACT The emphasis of Australian Government policy is on the promotion of good health in later life and positive experiences with ageing. Conceptually, a new gerontology framework has replaced the study of disease, decline, loss and disability. Within this framework, health promotion offers a mechanism by which individuals can be assisted to create environments that offer better opportunities for continued participation in society and improved quality of health and self-care. Oral health is instrumental to older people’s health, life satisfaction, quality of life and perception of self. Australia is culturally diverse, composed of numerous ethno-cultural groups coexisting within a larger, predominant culture, creating a multicultural and multiracial society. However, despite this cultural diversity, the well documented ageing profile of the Australian population and repeated calls for comprehensive geriatric assessment, the oral health of older adults remains a challenge for oral health providers and for society. A major challenge will be to translate existing knowledge and experience of disease prevention and health promotion into appropriate programmes for older adults. Health promotion is the key to improving oral health in later life as it encourages older adults to be proactive in regard to their health. Therefore, increased efforts should be directed towards identifying opportunities for health promotion activities and the development of community based models that encourage older people to improve and maintain their oral health. Ignoring opportunities for health promotion may increase inequalities in oral health and may lead to even greater demands for curative and oral rehabilitative services from these groups This article firstly provides a brief rationale for oral health promotion. Its second part explores the influence of culture on health beliefs, behaviours and outcomes in older adults and how oral health can relate to cultural background. The last section presents the results of an oral health promotion programme for older adults. Keywords: Cultural aspects, health promotion, older adults. Abbreviations and acronyms: CALD = culturally and linguistically diverse; ORHIS = Oral Health Information Seminars/Sheets; WHO = World Health Organization.

INTRODUCTION The 21st century is typified by several emerging trends, including globalization, the greying of the population, a fast-changing technological world and, related to the last trend, dissemination of health information via the Internet. There is strong evidence of these trends in the Australian context. According to the 2012 Census, 65 years and over older adults made up 14.2% of the total population.1 In addition to this, Australia is composed of numerous ethno-cultural groups coexisting within a larger, predominant culture, creating a multicultural and multiracial society. According to recent data, 27% of Australia’s total population (5.3 million people) are estimated to have been born overseas – more than half of which were born in countries that speak languages other than English, including an increasing number from sub-Saharan Africa and Asia.2 Australians from culturally and linguistically diverse (CALD) backgrounds represent a growing proportion © 2015 Australian Dental Association

of the population. In 2006, Italians and Greeks, together with Vietnamese and Chinese, were among the largest CALD groups in Australia.2 The Australian Bureau of Statistics also reports that over 750 000 Australians aged 65 and over were born overseas.3 This older CALD population is projected to grow more rapidly in the coming decades, reaching at least one million by 2011 and approaching 1.5 million by 2026.4 This would represent more than 30% of older Australians. Migration in Australia occurred in waves over time, resulting in migrant communities ageing in different patterns depending on their migration history to Australia.5 Consequently, some overseas born Australian populations will have a relatively young age profile, while others will be older. Additionally, while some migrants would have arrived young and grown old in Australia, others came as refugees, or older under a family migration visa. Settlement experiences also vary for each migrant, depending on factors such as their English language 131

~o RJ Marin command and communication ability, migration circumstances, whether they have family and friends in Australia, financial capacities, whether or not they joined the labour force, and the geographical location of migrant communities. Migrants with cultural characteristics, such as values, beliefs, rules and meanings, which are markedly different from the dominant society will experience greater difficulties relative to immigrant groups whose cultural values are closer to the dominant society. Research suggests that within the ‘ethnic aged’ population those that are newly arrived or speak little English are less integrated into mainstream Australia, more vulnerable, and more common on the Family (Reunification) Visa.6 These cultural characteristics, together with other barriers – real or otherwise – such as unfamiliarity with location of services, fear of, and hostility towards members of the mainstream society, premigration cultural beliefs, and knowledge of Australian ways will impact on every aspect of their lives and may create different experiences and needs for immigrant groups and unique sets of health risks. Thus, the health needs of CALD communities are exacerbated by a number of factors which pose special challenges to an Australian health care system aiming to fully meet the dynamic needs of a CALD society. Under this situation, different approaches towards developing programmes and policy may be required for people from different cultures. These are important challenges to oral health providers and for society. As the population ages, a major challenge in the future will be to translate existing knowledge and sound experience of disease prevention and health promotion into appropriate programmes.7 The need to provide cost-effective health support to this expanding segment of the population will be a cause of concern and a challenge for both government and health professionals. On the other hand, older people could be a valuable resource, rather than a burden to society, if they are relatively healthy. Older people in good health can contribute to society, their families, their communities and to economic productivity via formal or informal channels, e.g. through volunteer work, etc.8 However, despite the well documented ageing profile of the Australian population and repeated calls for comprehensive geriatric assessment,9,10 little research has focused on the oral health needs of older adults and there are few health promotion programmes designed to improve their oral health status. This article is divided into three parts. The first part provides a brief rationale for oral health promotion among older adults. It explores models used to explain the health and social outcomes of immigrant groups. The second part explores the influence of culture on health beliefs, behaviours and outcomes in 132

older adults and how oral health can relate to cultural background, including oral health status, beliefs, attitudes, and knowledge, as well as oral health related practises, use of general health care services, and barriers to care. The last section presents examples from successful oral health promotion programmes in older adults. Health, oral health and health promotion Older Australians in the new millennium constitute a group with diverse and complex dental needs, compared to previous older adult cohorts. They form a group at special risk of oral diseases which need timely intervention. Coronal and root caries, tooth wear and periodontal disease are some common dental problems among dentate older adults. In addition, there is evidence of dynamic and complex relationships between oral health and general health as they share risk factors.11,12 Moreover, oral diseases can exacerbate underlying general diseases and complicate their favourable management. For example, periodontal diseases have been associated with coronary heart disease, atherosclerosis, subclinical lower extremity artery disease, stroke/cerebrovascular disease, metabolic/lipid disorders and obesity, and poor glycaemic control in diabetes.14–16 Poor oral health among older adults has also been linked to aspiration pneumonia.17 In Australia, the emphasis of government policy is on the promotion of good health and positive experiences of ageing in later life. Still, oral health services for older adults are treatment-based and very few oral health promotion activities are available aimed at older adults. Conceptually, health promotion, as both a concept and intervention, offers a mechanism by which individuals can be assisted to create better environments that offer opportunities for continued participation in society and improved quality of health and self-care.18 Health promotion aims to maintain and improve health status by providing a health service to the well. It encourages older adults to be proactive, not just responsive in regard to their health. When risk factors for chronic diseases and functional decline are minimized and protective factors are maximized, people enjoy longer life and higher quality of life. Addressing the needs of older people from CALD backgrounds The needs of older adults from CALD backgrounds are not different from those of any ageing community, in terms of their physical, emotional or social needs. However, their needs differ because of their cultural and linguistic backgrounds. In a country with a © 2015 Australian Dental Association

Cultural aspects of ageing and health promotion sizable older CALD population, this poses challenges to the various social and health services. Settlement processes and policies in Australia can also make the migration process harder for older migrants, especially those with limited English proficiency and those who have migrated at a later age in their life. For Novak-Zezula,19 a key variable in the situation constructing inequalities in health among ethnic minorities is that these groups are ‘not receiving the same level of health care in diagnosis, treatment and preventative services that the average population receives’, undermining the basic principles of equity and access as put forward under multiculturalism, and more importantly, the equity of outcome. A number of government agencies back this up with research evidence.20–23 These inequalities are very complex to solve, e.g. is it an information gap because people do not know about the services,24 or a cultural norm (i.e. self-reliance, filial obligations),25 or is it caused by the service providers and long waiting lists which are stopping people getting through and accessing services? Problems facing CALD older populations when accessing health services can be classified into six areas: (1) Language and communication. A lot of discussion and resources have been put into eliminating language barriers, e.g. with interpreting services. Many hospitals and large health centres have teams of health professionals who supply services for local migrant communities. Health professionals may access a priority telephone line to have an interpreter for the duration of the consultation. Government policies are heavily focused on language. The Department of Immigration and Border Protection provides funding for English language tuition; onsite and telephone interpreting and translating through the Translating and Interpreting Service (http://www.immi.gov.au/live/ pages/tis-national.aspx). In the state of Victoria, the Victorian Department of Human Services places great emphasis on ‘increasing’ language services as a key to improving health service quality and access. However, improving language command is not the only element to consider when dealing with ethnic groups. The communication process is complex, and goes beyond language. Communication breakdown may be caused not only by word differentiation, but also because the language represents a different structure of reasoning, world views, value orientations and belief systems.27–29 For this reason, this section has stressed communication, and not language, as the main aspect of cross-cultural interaction between health professionals and patients. Furthermore, Mari~ no et al.24 found that while language may not be a problem for basic communication, communication © 2015 Australian Dental Association

difficulties occurred when more detailed explanations or exchange of information was required, limiting the possibility of discussing preventive messages. In addition, participants in that study also preferred having a dentist who was bilingual rather than using an interpreter. Communication occurs not only in verbal interchange, but also as an interpersonal process involving non-verbal communication – which is largely an unconscious part of the communication system and either augments or impedes the communication process.29,30 Knowledge of proper ways of non-verbal communication in different cultures, in the form of handshaking, greetings, eye contact, gestures and physical contacts, may facilitate common understanding, but should also be interpreted with caution as they do not necessarily have the same meaning across cultures. Therefore, a programme that proves to be successful for mainstream patients may not be culturally (i.e. linguistically or psychologically) accessible, effective, or appropriate for other groups of patients because the content is based on mainstream practices and assumptions. Focusing on patients’ limitations, such as language rather than cultural characteristics, can create serious problems in formulating effective approaches. Additionally, little or no attempt has also been made to understand what happens after the interface with the dental care service took place and after the service has been provided. Furthermore, a study among dental students found that even when the background of students are so-called diverse, there was a common cultural profile to which all students subscribed.31 Although older immigrants will have different experiences and needs, a recent study in Melbourne suggests that health professionals who are sensitive to cultural traditions are more successful in achieving good oral health among older immigrants.32 (2) Lack of information. Inequalities may also be due to a lack of knowledge about rights and responsibilities in the Australian system, and what services are available, including oral health services.23,24,33,34 Lack of information about oral health services was raised as a concern in a study on older Southern European migrants in Melbourne.24 The study indicated that while proximity to services is important, people also needed to know what services were available and how to access them. This lack of information regarding service provision has also been noted in the Hogan Review35 which found that current arrangements in community and aged care did not ensure equity of access for people from ethnic minorities. A lack of knowledge about 133

Cultural aspects of ageing and health promotion arrival, have superior health to the host population. Although there is a huge within-group variation, migrant populations, particularly those born in nonEnglish speaking countries, have lower rates of disease, lower hospitalization and lower mortality rates than comparative Australian-born groups. They also tend to have lower self-reported health status, less healthy lifestyles, and are less likely to use preventive services.49 However, migrant populations are more likely to report poorer subjective health status, and more likely to be admitted to hospital than the Australian-born population. Nonetheless, they appear to be less susceptible to some chronic illness, and live longer than the Australian-born population.49 This is known as the ‘healthy migrant effect’ and is noted in death and disability rates, as well as lower lifestyle related risk factors.49 This effect is believed to derive from two main factors: self-selection of migrants (those willing, healthy and financially able to migrate) and the government selection process (health, education, language and job skills). However, it has been noted that this health advantage diminishes over time with certain health risk factors and diseases becoming more prevalent among some specific country groups. The loss of this ‘health advantage’ – as measured by health behaviours, morbidity and mortality – can be seen after two to four decades of residence. Although migrants have a better health status upon arrival, in terms of oral health, there are no data on whether there is a ‘healthy migrant effect’ in oral health or not. Oral health status is not an issue in determining whether an individual meets the health requirements for permanent residence; however, examiners do perform oral exams as a part of health examinations. But there is certainly no indication that a selective immigration factor is in operation for orally healthier people and such an explanation would not apply to those coming into a new country under family reunion or refugee status.50 However, there is not a widely accepted explanatory mechanism which helps to understand the cultural, ethnic or racial influence on the outcomes such as oral health. Furthermore, there is no reason for causal association between ethnicity, race or country of birth and oral health based on biological factors. Studies have noted that ‘the health status of immigrants is variably affected by ethnicity, class, gender, age and migration experiences’,51 as a well as the burden of disease associated with their over-representation in the lower socio-economic status. Non-English speaking migrants entering on a business or economic visa are far better than other migrants in English language proficiency and health status. Those with the highest risk of health concerns are those aged 75 years and over, newly arrived, low income, limited social support, living alone in rented accommodation, little © 2015 Australian Dental Association

to no English – of which, ‘nearly half of the ethnic aged have two of these characteristics, and 10 per cent have 3 or 4’.51 Townsend and Davidson52 proposed four categories of explanations for health inequalities: artefactual, selection, material/structural and behavioural/cultural. The artefactual category suggests that inequalities are not real, but artificial, due to the measuring instrument, the methodology, or the statistical analysis used. Selection inequalities imply that the differences are caused by a health selection process. The third category, materialistic/structuralist, emphasizes the role of external environment, such as socio-economic and socio-demographic factors. The behavioural category argues that health differences are based on the way different groups choose to lead their lives. In the present discussion, such factors as dietary habits, alcohol or tobacco consumption, use of health and preventive care services, oral hygiene practices, etc. would fit into this category. This explanatory category has been criticized because it appears to be locating the problem in the minority culture (blaming the victim).53 However, the data show that the cultural norm is, at times, conducive to a good health outcome. Health promotion in older adults There are several ways in which the oral health of older adults might be improved; however, goals in dentistry cannot be reached solely on the basis of providing clinical treatment only. As for any age, health promotion and self-managed disease preventive measures are important for achieving better oral health outcomes. Health promotion interventions are key to improving oral health in later life as it encourages older adults to be proactive in regard to their health. Therefore, increased efforts should be directed to identifying opportunities for health promotion activities and the development of community based models that encourage older people to improve and maintain their oral health.54,55 Ignoring opportunities for these activities may increase inequalities in oral health and may lead to even greater demands for curative and oral rehabilitative services in these groups. Furthermore, to ignore opportunities for health promotion and disease prevention in these groups is unfair, and may increase inequalities in health standards. Highlighting this phenomenon, in 2000, the World Health Organization (WHO) reiterated the priority of health for older people through its programme ‘Ageing and life-course’ underpinned by the concept of ‘active ageing’.56 Active ageing is the cornerstone for improving the health status and quality of life of senior citizens, who bear the highest burden of chronic diseases and co-morbidities.56,57 Active ageing 135

Cultural aspects of ageing and health promotion arrival, have superior health to the host population. Although there is a huge within-group variation, migrant populations, particularly those born in nonEnglish speaking countries, have lower rates of disease, lower hospitalization and lower mortality rates than comparative Australian-born groups. They also tend to have lower self-reported health status, less healthy lifestyles, and are less likely to use preventive services.49 However, migrant populations are more likely to report poorer subjective health status, and more likely to be admitted to hospital than the Australian-born population. Nonetheless, they appear to be less susceptible to some chronic illness, and live longer than the Australian-born population.49 This is known as the ‘healthy migrant effect’ and is noted in death and disability rates, as well as lower lifestyle related risk factors.49 This effect is believed to derive from two main factors: self-selection of migrants (those willing, healthy and financially able to migrate) and the government selection process (health, education, language and job skills). However, it has been noted that this health advantage diminishes over time with certain health risk factors and diseases becoming more prevalent among some specific country groups. The loss of this ‘health advantage’ – as measured by health behaviours, morbidity and mortality – can be seen after two to four decades of residence. Although migrants have a better health status upon arrival, in terms of oral health, there are no data on whether there is a ‘healthy migrant effect’ in oral health or not. Oral health status is not an issue in determining whether an individual meets the health requirements for permanent residence; however, examiners do perform oral exams as a part of health examinations. But there is certainly no indication that a selective immigration factor is in operation for orally healthier people and such an explanation would not apply to those coming into a new country under family reunion or refugee status.50 However, there is not a widely accepted explanatory mechanism which helps to understand the cultural, ethnic or racial influence on the outcomes such as oral health. Furthermore, there is no reason for causal association between ethnicity, race or country of birth and oral health based on biological factors. Studies have noted that ‘the health status of immigrants is variably affected by ethnicity, class, gender, age and migration experiences’,51 as a well as the burden of disease associated with their over-representation in the lower socio-economic status. Non-English speaking migrants entering on a business or economic visa are far better than other migrants in English language proficiency and health status. Those with the highest risk of health concerns are those aged 75 years and over, newly arrived, low income, limited social support, living alone in rented accommodation, little © 2015 Australian Dental Association

to no English – of which, ‘nearly half of the ethnic aged have two of these characteristics, and 10 per cent have 3 or 4’.51 Townsend and Davidson52 proposed four categories of explanations for health inequalities: artefactual, selection, material/structural and behavioural/cultural. The artefactual category suggests that inequalities are not real, but artificial, due to the measuring instrument, the methodology, or the statistical analysis used. Selection inequalities imply that the differences are caused by a health selection process. The third category, materialistic/structuralist, emphasizes the role of external environment, such as socio-economic and socio-demographic factors. The behavioural category argues that health differences are based on the way different groups choose to lead their lives. In the present discussion, such factors as dietary habits, alcohol or tobacco consumption, use of health and preventive care services, oral hygiene practices, etc. would fit into this category. This explanatory category has been criticized because it appears to be locating the problem in the minority culture (blaming the victim).53 However, the data show that the cultural norm is, at times, conducive to a good health outcome. Health promotion in older adults There are several ways in which the oral health of older adults might be improved; however, goals in dentistry cannot be reached solely on the basis of providing clinical treatment only. As for any age, health promotion and self-managed disease preventive measures are important for achieving better oral health outcomes. Health promotion interventions are key to improving oral health in later life as it encourages older adults to be proactive in regard to their health. Therefore, increased efforts should be directed to identifying opportunities for health promotion activities and the development of community based models that encourage older people to improve and maintain their oral health.54,55 Ignoring opportunities for these activities may increase inequalities in oral health and may lead to even greater demands for curative and oral rehabilitative services in these groups. Furthermore, to ignore opportunities for health promotion and disease prevention in these groups is unfair, and may increase inequalities in health standards. Highlighting this phenomenon, in 2000, the World Health Organization (WHO) reiterated the priority of health for older people through its programme ‘Ageing and life-course’ underpinned by the concept of ‘active ageing’.56 Active ageing is the cornerstone for improving the health status and quality of life of senior citizens, who bear the highest burden of chronic diseases and co-morbidities.56,57 Active ageing 135

~o RJ Marin is accomplished by strategies to encourage and empower older adults with the requisite skills and knowledge to maintain good physical, psychological, social and spiritual health.57 In this context, one widely acclaimed strategy is to promote health related learning so that older adults are able to gain the awareness and knowledge necessary for self-care and illness prevention.58 Health promotion, health education, health maintenance and healthier lifestyles all depend on individuals completing certain behaviours.59 Many examples of innovating approaches focusing on health promotion can be found in the literature. Nonetheless, interactive educational efforts, like group health education sessions, have been regarded as an effective approach for older adult learning.60,61 There has been research on the effectiveness of this approach in achieving health promotion goals in the areas of physical activity,62 macular degeneration information,63 breast cancer,64 diabetes and nutritional information,65 and oral health.66 The importance of lifelong learning is well established in the literature and in recent decades it has received increased attention.67 Contrary to the myth that it is too late for older adults to benefit from changing their lifelong habits,68 studies show that lifestyle modifications have been successfully implemented even in the very old, provided that co-morbidities are not overwhelming.59,65,69,70 Failure to change or poor performance might be related to other noncognitive factors.71 For example, Resnick72 studying health promotion activities in older adults, reported that the most common reason for not performing health promoting and disease prevention measures (e.g. diet, exercise, stress management, tobacco avoidance, etc.) was ‘not being told to’ by the primary health care provider. Other myths about the effect of health promotion on older adults, include that: older adults are not willing to change their attitudes and behaviours; they are immune to the benefits of oral health promotion; they are difficult to recruit and work with; lifestyle and behavioural changes will have minimal impact on the physical health and longevity of older adults; and health promotion will not be cost-effective for older adults.73 Contrary to such myths, recent research has provided evidence on positive outcomes of oral health promotion activities among older adults in the Australian context.66,74 Still, despite the experiences in health promotion and the amount of health promotion material available, few studies provide strong evidence on how best to provide health promotion and disease prevention services to older adult populations. While most oral health promotion interventions have been criticized methodologically, long-term behavioural changes have 136

been successfully achieved in senior citizens through behavioural self-management techniques, including oral health.75 These oral health experiences would indicate that successful interventions have been groupbased interventions delivering well-organized packages of educational techniques, with high participant involvement. Experiences in health promotion with older adult groups would indicate that group learning sessions, followed by printed material, best meet the social and learning needs of older adults. The literature also indicates that health promotion activities should include active participation by those interested in their planning, implementation and evaluation.66,76 This will ensure that health promotion activities are based on the target group’s own goals and needs.76 This increases the participant’s sense of programme ownership, which is an important goal for health promotion. This is also consistent with a contemporary paradigm shift in the philosophy and approaches of oral health promotion among older adults; namely, from traditional geriatric oral health promotion using the empty vessel approach, in which the professional ‘poured’ knowledge into the ‘empty’ patient, to a customized, interactive, client-centred approach.77 In this regard, tailored health promotion interventions have been demonstrated to be more effective than non-tailored ‘one size fits all’ interventions because tailoring customizes health information to match selected characteristics for each person,78,79 and customized information is more likely to be read, retained and seen as personally meaningful.80 The use of interactive behavioural change technology, such as computer-generated mailings, Internet-delivered interventions, and automated telephone counselling, have been shown to be more effective than general practitioner’s advice in primary care.81 Information technology (IT) has enabled health professionals to alter health information so that it is tailored or customized to each person.79 Internet-delivered tailored interventions mimic the process of individual counselling by means of ‘expert systems’. Oral health promotion programme for older adults The use of community venues such as libraries to deliver oral health promotion programmes incorporates the three basic pillars on which the WHO’s proposed policy frame work on active ageing rests, as applied to oral health; namely, health, social participation and security.11 Social venues provide a focal point for interactive learning and knowledge, and skillexchange ventures. In addition, such an intervention could be targeted to similar social environments such as church based community groups, recreational centres, social clubs, and health care centres.82 © 2015 Australian Dental Association

Cultural aspects of ageing and health promotion The following study describes the results of a community based oral health promotion programme designed to address the needs and barriers to oral health care of Italian and Greek adults living in Melbourne, Australia.66 It involved active, independentliving older adults, 55 years or older who participated in clubs for older persons. The study included both qualitative and quantitative research components. The oral health intervention consisted of oral health seminars and oral health information sheets. Seminars consisted of a series of informational sessions about oral health offered in the context of focus group discussions facilitated by a bilingual research assistant every two weeks at local social clubs for elders. The assistant asked the older adults group questions about oral health care. As part of the pre-intervention data collection, all participants underwent an oral health interview and a standard oral health examination. The format of the seminars was developed on the basis of a thorough evidence based literature review on health promotion in older adults. Furthermore, it was also based on the format suggested by the participants themselves during the focus group discussions. The oral health intervention, known as ORHIS (Oral Health Information Seminars/Sheets), consisted of two components: the oral health seminars and the oral health information sheets. The information sheets component has 10 presentations. Topics selected were those that participants had identified as relevant to their needs and for which they wanted information and new skills during the group discussions, as well as those identified by the findings from the clinical examinations and oral health interviews. The intervention programme included 10 oral health promotion topics: (1) Getting old in Melbourne? Expected oral changes. (2) Oral diseases: dental caries. (3) Oral diseases: periodontal disease. (4) What to do with remaining teeth. (5) Oral cancer. (6) Dentures care. (7) Dry mouth. (8) Are you receiving oral health care? (9) Oral health and diet. (10) The relationship between oral health and general health. Those presentations were aimed at: (a) dispelling myths about dentistry and older adults; (b) improving attitudes to prevention oriented oral health behaviours in older adults; (c) reducing barriers to accessing oral health services and stimulating demand of non-emergency dental services; (d) increasing the knowledge of preventing dental caries (coronal and root), oral cancer, and periodontal disease; © 2015 Australian Dental Association

(e) increasing self-care practices, including brushing and flossing; and (f) increasing the awareness of the need to care for prosthetic appliances and increasing self-care practices, including brushing and flossing. The process involved: • A script for the session and a first version of the ORHIS for each topic was prepared prior to the first discussion cycle. • At each session participants had the opportunity to challenge material and discuss content, discard known information and request additional information. • At the end of this cycle a second script and version of the ORHIS was prepared. • The second cycle addressed deficiencies identified in the first round and noted any outstanding issues on the topic. • A second version of the ORHIS was distributed and discussed among group participants. The outcome of this cycle was used to develop the final ORHIS for that topic. The final content of each ORHIS was derived using an iterative process as shown in Fig. 1. The final versions of the 10 themes were written in the participants’ native languages and then given to all participants in an appropriately designed folder, a total of nine pages including a summary (one-half to two-thirds of a page) on the assigned topic. The material enhanced the oral health related knowledge and attitudes of the participants, and increased the proportion of participants who had a dental visit or treatment.66 The study demonstrated that following the educational sessions, the groups differed significantly in those areas where it was possible to achieve changes in the short-term. Another study was designed to evaluate the effectiveness of a culturally appropriate, community based oral health promotion programme, based on a cognitive behavioural approach, aimed at impacting on the

Fig. 1 The ORHIS development process. 137

~o RJ Marin self-efficacy, gingival health and oral hygiene of Italian older adults living in Melbourne, Australia.83 Participants were non-randomly allocated to either the control or the intervention group. A quasi-experimental design was chosen with a separate sample pretest-post-test non-equivalent control group to evaluate the intervention. The model and resources used were based on the ORHIS model. A research assistant acted as peer educator and conducted 4 one-to-one oral hygiene sessions at the clubs premises demonstrating toothbrushing, dental flossing and denture cleaning. The intervention did not involve any direct oral health professional input and no form of periodontal treatment was provided throughout the study period. Gingival health (gingival bleeding) was assessed together with dental plaque levels. Participants completed the intervention schedule; controlling for pre-test scores, the intervention group was significantly more likely than the control group to have improved gingival status (e.g. gingival bleeding) and self-efficacy. No significant effect outcomes were present regarding dental plaque. The ORHIS programme was successful in improving oral health knowledge and attitudes among the target group and led to improvement in preventive behaviours. It was also certainly sustainable with minimal external input. As such, it represents an extremely helpful approach for the design of oral health interventions in older migrant adults. A particular strength of the programme was that it was supported by theories of behavioural change among older adults.71,84 and principles of geragogy (theory of teaching to the elderly).85 Internet based oral health promotion The ability to access and use health information is a fundamental skill which allows people to make informed decisions and helps them maintain their health.86 The Internet and computers are becoming increasingly easy to use, fast and inexpensive. More importantly, the Internet allows access to information and communication with others when and if people want to, rather than being ‘captive’.87 The explosion of IT has transformed the health-information and health-care seeking behaviour of people. There is a discernible IT revolution in health care supported by the rapid development of Internet and broadband, and driven by those enthusiasts who seek online health services and health information.88 Despite the popular notion of older adults as a disadvantaged group for accessing and using the Internet, wary of information technology, there are many positive outcomes reported by older Internet surfers.89 Technology is being developed to make IT more accessible and easier to operate by older adults.90 It 138

has been shown that the Internet can be used as a tool to improve older adults’ knowledge and awareness of their diagnosis, treatments and options for care, and this could eventually become a key instrument in health promotion among ageing populations.91 Nevertheless, there are socio-economic and regional disparities in household access to computer and Internet across Australia known as the digital divide.92 As shown by the Australian Bureau of Statistics, almost three-quarters of Australians aged 55–64 years (71%) and more than one-third of Australian senior citizens (37%) reported having surfed the Internet at any location (home, workplace, house of a neighbour, friend or relative, library, etc.). There are many benefits attributed to the use of this innovative channel, e.g. online health promotion interventions allow older adults to explore the information in their own time, with privacy, and have the opportunity to be supported in self-care efforts, as opposed to being passive dependants. In contrast to conventional modes of health information, such as printed sources, online sites can undergo frequent updates and revisions. Material that is tailored to their needs, that is simple, clear and informative has been shown to be more effective than GPs’ advice in primary care.81 Such health promotions allow people to return to the information whenever they need it and to be confident of locating other useful dental information that is tailored to their needs. The Melbourne Dental School at The University of Melbourne, designed a study to evaluate the impact of a web-based oral health promotion programme aimed at improving the oral health knowledge, attitudes, practices and self-efficacy of independent-living older adults living in Melbourne, Australia.74 The education programme was supported by adapting for the web materials developed and tested under the ORHIS programme.66,83,93 In order to develop an e-learning environment for health promotion, the oral health intervention programme, ‘e-ORHIS’, harnessed user-friendly multimedia web technologies to meet the oral health information needs of older adults. The e-ORHIS were delivered in libraries/community centres, facilitated by trained peer educators, who introduced participants to the online multimedia resources and invited them to engage actively with and contribute to these resources, both as a group and individually. A promotional and instruction kit for use by peer educators was developed to enable the resources to be re-used beyond that phase. The e-ORHIS resources were evaluated and tested among older adults in the City of Whittlesea, Victoria. The study evaluated a group of 44 active, independent-living older adults who responded with higher levels of achievement than they had shown before © 2015 Australian Dental Association

Cultural aspects of ageing and health promotion participating in the web-based oral health programme. A review by Evers94 concluded that although the Internet is an important channel for health promotion, few studies have examined the efficacy of such programmes. The present study demonstrated that after the educational sessions, the groups differed significantly in those areas where short-term changes were possible. The study confirmed the effectiveness of the ORHIS approach in improving oral health knowledge, attitudes and self-efficacy, and provided indications of significant change to encourage further development and refinements. It also provided an additional step towards creating easily accessible oral health resources for older adults and health care providers. Additionally, this project achieved capacity building of older adults in accessing health information and in selfempowerment by use of information and communication technologies. The proposed web-based oral health promotion programme was used not only to inculcate positive attitudes towards oral health, but also to build up the capacity to provide personal oral health care and decision-making in professional oral health care among formal and informal carers for homebound and insti-

tutionalized frail elderly people. Moreover, once the web-based programme is established, it could be delivered to a wider audience of older adults in rural areas by conducting geragogy-based health web-navigating workshops in an integrated approach which incorporates other health websites of interest to older adults. The impact of the e-ORHIS represents an extremely helpful policy approach for the design of oral health interventions. The approach was successful and largely acceptable to the participating communities, and certainly sustainable with minimal external input. In the long term, this approach represents a promising intervention aimed at increasing participants’ control over their oral health and ensuring a reduction in severe oral health treatments and teeth mortality, which in turn would ensure better quality of life. The 10 e-ORHIS presentations are available at: http://www. e-dentalez.com/sitio/oral-health-promotion/ (Fig. 2). SUMMARY Today, more than ever before, older adults are keeping their natural teeth, and improvements in oral health status will continue into the future. Further research is required in order to improve health

Fig. 2 e-ORHIS presentations. © 2015 Australian Dental Association

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~o RJ Marin promotion practice. Without this knowledge and understanding, designing health promotion interventions responsive to the specific concerns of older adults is a challenge. Future research should test interventions that are able to address modifiable and non-modifiable ones, including socio-economic and cultural barriers.95 Successful interventions should be acceptable, culturally and linguistically sensitive, and easily adopted. Culture has important influences in many areas. Perceptions, definitions, motivations, and interpersonal behaviours are likely to be processed, evaluated and practised in a similar fashion by members of the same culture. Accepting Helman’s96 proposition that culture, together with such socio-demographic variables as age, gender, education, income level, personality and past experiences are antecedent to behaviour, then health beliefs and behaviours must be seen as an integral part of the culture in which they occur. Health related beliefs, values and practices will have a considerable impact on the definition of health problems, their identification and what action is taken to prevent or address such problems. Thus, culturally derived factors will, to a considerable extent, influence the preventive measures which a cultural group will adopt (e.g. in relation to oral health) and the patterns of health service use. Therefore, it is important when studying any aspect of health amongst immigrants to include consideration of the extent of acculturation as a potentially important intervening variable. Such a perspective requires that attention be directed towards understanding the relationship among some specific cultural variables and health, in the particular situation of the individual. The central point would then be to stress the notion of individualizing the treatment or intervention as the preferred model to deal with health issues, and to emphasize the need to identify and understand those cultural elements that may influence the individual’s perception of illness, its causes, course, ideal treatment and outcome. Nonetheless, health outcomes tend to be explained in simple terms (i.e. lack of resources, language), and the provision of oral health promotion programmes that are culturally responsive and appropriate remains an issue. CONCLUSIONS The goal of a health system is to improve the health of all people living in the society, despite differences in cultural background. For the future of health care systems in multicultural societies like Australia, where different value systems coexist, it is important to study and understand people from different cultures – not only peoples’ health/illness patterns, but also their worldview and value systems, and more particularly 140

their goals concerning health care, as goals, approaches and processes considered appropriate by one culture may be unethical and meaningless for another. This article examined how numerous factors might affect oral health outcomes (oral health status, behaviour, aethiologic views, the treatment that follows and use of oral health care services). It has offered an insight into the mechanism by which cultural factors may be intervening. Focusing only on differences in socio-economic status, or language use and preference to overcome differences, will tend to perpetuate the differences in current health status and behaviours. Within this context, experiences in health promotion with older adult groups indicate that a group learning session, followed by printed or online material, appears to best meet the social and learning needs of older adults. Additionally, the use of community resources would improve the cost-effectiveness of the interventions. DISCLOSURE The author has no conflicts of interest to declare. REFERENCES 1. Australian Bureau of Statistics. 3101.0 – Australian Demographic Statistics, 2012. URL: ‘http://www.abs.gov.au/AUSSTATS/abs@. nsf/allprimarymainfeatures/33970B13F1DF7F56CA257B3B00117 AA2?opendocument’. Accessed November 2014. 2. Australian Bureau of Statistics. 2071.0 – Reflecting a Nation: Stories from the 2011 Census, 2012–2013. URL: http:// www.abs.gov.au/ausstats/[email protected]/lookup/2071.0main+features 902012-2013. Accessed November 2014. 3. Australian Bureau of Statistics. 4102.0 – Australian Social Trends, 2008. URL: http://www.abs.gov.au/ausstats/[email protected]/ Lookup/4102.0main+features12008. Accessed November 2014. 4. Australian Bureau of Statistics. 4102.0 – Australian Social Trends, 2002. URL: http://www.abs.gov.au/AUSSTATS/abs@. nsf/allprimarymainfeatures/778E130171EE7102CA25709F0025 EB7A?opendocumen. Accessed November 2014. 5. Victorian Ethnic Affairs Commission. Statistical Profile of NESB Victorians. Melbourne: VEAC, 1995. 6. Rowland DT. Ethnicity and Ageing. In: Borowski A, Encel S, Ozanne E, eds. Longevity and Social Change in Australia. Sydney: University of New South Wales Press, 2007: 117–141. 7. Petersen PE. Priorities for research for oral health in the 21st Century – the approach of the WHO Global Oral Health Programme. Community Dent Health 2005;22:71–74. 8. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005;33:81–92. 9. Chalmers JM, Spencer AJ, Carter KD, King PL, Wright C. Caring for oral health in Australian residential care. Australian Institute of Health and Welfare. Dental Statistics and Research Series No. 48. Cat. no. DEN 193. Canberra: AIHW, 2009. 10. Wright FAC, List P. Reforming the mission of public dental services. Community Dent Oral Epidemiol 2013;40(Suppl 2):102– 109. © 2015 Australian Dental Association

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© 2015 Australian Dental Association

Address for correspondence: Dr Rodrigo Mari~ no Oral Health Cooperative Research Centre Melbourne Dental School The University of Melbourne Melbourne VIC 3010 Email: [email protected]

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