The literature was scrutinized in relation to five major domains of cultural information, four of them specific to oral health: 1) basic conceptual models or ideas about health and disease, 2) help-seeking for oral conditions, especially use of folk or traditional health remedies, 3) diet, 4) beliefs and practices about teeth and the oral cavity, and 5) oral hygiene practices. Collectively, these domains shape people's cultural beliefs and practices related to oral health and reasons for seeking dental services for themselves and their dependents, such as the elderly and children. Later, we use these domains to organize and present the topical findings.
To identify literature on cultural beliefs and practices regarding oral health, the electronic database for the National Library of Medicine (PUBMED) was searched for all relevant literature published in the English language spanning a twenty-seven year period, 1980 to 2006. The search was limited to the four ethnic groups mentioned above. This time period was selected because a system to collect data on the ethnic background of populations in the US was not in place until the late 1970's e at [17
]; hence the 1980 date to ensure that system was well established. The period ends at 2006, as this was the latest year in which complete data was available for an assessment performed in 2007.
Keywords and MeSH headings were used in many different permutations to identify relevant literature. Descriptors for each of the four ethnic groups were sequentially combined with each term in the following two lists: (1)"traditional medicine", "folk medicine", "cultural beliefs", "ethnicity", "racial", "traditional practices" AND (2) "dental", "dentistry", "oral", "teeth", "gums", "caries", "periodontal". Because using all the search words together in a serial manner yielded significantly lower numbers of relevant articles, each ethnic group's name was combined with one search word from each of the two lists in a step-wise fashion. One example is (Chinese) AND (traditional medicine) AND (dentistry). Search words used are reported in Table .
Summary of keywords and MeSH headings used to identify relevant literature
The search words were pre-tested and refined in order to select the final search terms (by YB and JCB). One author (YB) conducted the PUBMED search using the above strategy on two separate occasions, with identical lists of publications resulting. The titles and abstracts (when available) were read and appropriate articles selected and retrieved for review of the article in its entirety. These selection criteria, developed by YB and JCB, were (a) the article must mention at least one specific belief or practice, and (b) had to name the ethnic group studied. Articles that spoke generically of "cultural influences", or stated "ethnic" or "minority groups" without specifying the name of the population, were excluded. A data abstraction form, available from the corresponding author, was developed to ensure rigorous abstraction of all relevant data. This form included headings to collate information on the name, location and socio-demographic composition (e.g., age, income level) of the ethnic groups studied, sample size, study design, and beliefs reported. Descriptive findings are reported.
Inclusion and exclusion criteria
To capture as much relevant information as possible, all types of literature were included, such as reports of original research, reviews, commentaries, comments, letters and opinions because the volume of publications discussing cultural issues is very slim. Publications were excluded if they reported only quantitative epidemiologic data with no reference to specific beliefs or practices regarding oral health for the group(s) under study, or if the reports were generic overviews linking cultural issues to oral health, but information specific to these four ethnic groups was not presented or could not reasonably be deduced from the original report. A secondary search of the bibliography of the appropriate selected studies was also performed to identify any relevant articles that were not identified by the primary PUBMED search. The relevant literature for each population group was assessed for methodological approach, the nature of the cultural information presented, and its degree of relevance to oral health or the practice of dentistry.
For groups other than the African-American population, the search strategy was not limited to studies published or conducted in the US. For the Chinese, Filipinos, and Hispanic/Latinos immigrant populations, all the literature discovered was reviewed and, if relevant, was included, irrespective of place of study. The three groups of interest are all recent (mainly within the past 30–50 years) immigrants with strong connections still to their countries of origin, connections that can serve to strengthen resistance to changes in beliefs and attitudes. Several reasons support the decision to include relevant studies from outside the US. Changes due to acculturation to a new environment occur in staggered fashion, with change in behaviors occurring long before changes in underlying beliefs. As noted in the introduction, changes in diet, types of health care utilized, access to these services, financial stability, social status and so forth, can – and often do – all change dramatically and rapidly soon after migrating to a new country. Cultural knowledge, beliefs and attitudes about health and sickness, however, especially of causes, recognition and consequences of illness, and proper treatment, change far more slowly, often not until the next generation is born and raised in the new country of residence. So, some included studies refer to these populations in their homelands or in the United Kingdom or Singapore or elsewhere. For African-Americans, however, the literature was restricted to include only studies referring to descendents of populations originating in Africa and brought to the United States as slaves before 1860. Publications referring to other Black or African immigrant populations in the U.S. (e.g., Ethiopian, Black South African, Afro-Caribbean groups) were excluded because compared to African-Americans these groups have had very different socio-political histories and experiences, and have distinctly different cultural beliefs and practices.
This review is intended to assess the knowledge or understanding of the cultural beliefs about oral health for these four selected ethnic groups, and thereby to assess more generally knowledge of cultural issues in the oral health literature.