A total of thirty-three women participated in this study. Of the thirty-one who were willing to report their age, respondents ranged from 21 to 58 years, with an average of 31 and mode of 29 years. At the time of interview 13 women reported that they were in paid employment outside of the home and 19 were not. The number of reported children ranged from one to nine. Three women chose not to respond to that question. Of those who did, 20 participants had more than three children and ten respondents had three or less. With a UK average family size of 2.4 children [20
] family sizes within this sample are significantly larger than average [15
On analysis key themes emerged from the data relating to 'Oral health knowledge and beliefs' and 'Dental access'. It is essential that these themes are understood in the context of this community whose values are significantly different from those of wider society.
Oral Health Knowledge and Beliefs
The first stage of the interviews and focus groups explored existing oral health knowledge and beliefs, including causes and prevention of oral diseases. Knowledge about oral disease and how to prevent it was very limited. Expressed beliefs did not reflect contemporary knowledge and demonstrated a lack of perceived control over oral health.
Lacking contemporary knowledge
When asked about prevention, a minority of participants spoke the importance of brushing teeth at least twice a day, there was very little awareness shown about the importance of the role of diet and sugar consumption and the contribution that fluoride makes to preventing dental caries. The health of primary (deciduous) teeth was not perceived as important as they would be replaced by adult teeth. Furthermore, the need to visit the dentist regularly was mentioned by only a minority of women.
"Front baby teeth just get all rotten. I was trying to be very careful brushing the teeth, she doesn't have bottles to bed, and she doesn't have sugar bottles only milk bottles once a day and not when she's sleeping......they all [dentists] gave me such a what for that I'm not taking care properly". (12 h)
"Those are anyway their first teeth, so even if they get decay it's not the end of the world sort of thing, it doesn't go down to the roots or anything." (14 h)
These quotes show a strong lack of understanding of the value of oral health in infants and the benefits of positive oral health related behaviours for future oral health.
When asked about the causes of poor oral health, a link with pregnancy was reported by some participants.
"I find it with every child I have problems with one of my teeth". (18 h)
"It's like my first outing to the, after having a baby is to the dentist." (34 h)
Part of the perceived lack of controlwas demonstrated by the view that tooth decay was a hereditary process rather than a shared cultural/behavioural issue, and it was suggested that poor teeth in parents or grandparents could be seen in children.
"I've got half the family with excellent teeth, then half the children always have to visit the dentist regularly. We can't help it." (15 h)
Culturally influenced diet
The role of diet within the culture was generally deemed more important than the risks to health or oral health. There was a general lack of awareness, alongside a reluctance to admit, the full impact of diet on oral disease. Sweets were used within the community as a reward, and sweets, cakes and sugar laden foods were seen as a staple and important part of religious ceremonies and celebrations. The pervasiveness of high sugar foods within the community was presented as the reason for not, or being unable to limit sugar consumption. Sugar consumption, and sweets in particular, were highlighted as an issue and some participants spoke about the inability to prevent their children from obtaining sweets which are readily available in kosher shops.
"You know a lot of kosher shops, and stuff like that, have mounds of sugary foods. I hate going shopping with the children; they just think they have to put everything into the basket. It's so tempting for them, and it's in your face." (15 r)
Both the lack of general knowledge and awareness of positive and negative oral health behaviours and the particular attitude towards diet need to be understood in the context of a media isolated community. Health promotion campaigns conducted through any form of secular media are unlikely to reach this community. In addition, in a largely homogenous and segregated community, shaped by religious observance where food is integral to ceremonies and celebrations, messages about diet and sugar consumption need to be handled sensitively. Furthermore, messages need to be made accessible to the community through targeted information and campaigns in appropriate media such as Jewish papers, or through community groups and schools. The availability of sugar in the wider environment is a challenge for society as a whole [21
], as sweets have also been shown to be promoted in both large and small community shops, and has been the subject of a number of high profile public health campaigns [22
]. In addition, the consumption of sweets and high sugar food is an international problem and not just a national on [23
]. In this study there was talk about school health eating policies being useful within girls' schools but little evidence of direct action being taken to reduce sugar consumption by the community as a whole.
In common with the lack of knowledge and related beliefs, competing priorities led to the widespread 'non-prioritisation' of oral healthcare within the home. Prioritising oral healthcare relates to the emphasis placed on oral hygiene and oral healthcare within the family. In this sample this was encapsulated in the supervision of toothbrushing. In common with the lack of knowledge and related beliefs, competing priorities led to the widespread non-prioritisation of oral healthcare within the home to the extent that mothers took an active role. A minority of mothers talked about the importance of supervising their children's toothbrushing and oral hygiene practices but many spoke of a lack of time to supervise their children's oral hygiene.
"There is something with larger families, you know it is hard to stay on top of everything and teeth become secondary. A lot of mothers know what to do, they just can't get there." (17 t)
The common solution to this problem was to delegate supervision to older children. Otherwise activity went unsupervised. In summary, this group of mothers demonstrated a lack of contemporary knowledge, cultural influences on diet, problems with competing priorities, and a perceived lack of control over oral health. They welcomed community support.
Access to dental care
Mothers reported that they and their families did not regularly attend a dentist but overall demonstrated a sense of 'doing what they can'. Only a minority suggested that they attended a dentist at the traditional interval of 'every six months'. A number of issues were raised relating to the provision of dental care as well as problems with accessing dental services related to family pressures, together with generic barriers to care.
Within the community a dentist was usually chosen through personal or family recommendation and a limited number of dentists working within the area were deemed acceptable.
"You just go with them because its kind a community thing. You hear she goes, she goes and you all just go back. I go because my friend goes and she goes and he goes, not that I know if, I don't even trust them." (13 r)
"I just moved here and found him through word of mouth. You go where your family goes. We do not want to go to someone we do not trust. You can hear a name at the Jewish centre and then everyone goes." (25 m)
It is worth noting here that the word of mouth is the most common means of finding dental services amongst adults [24
], and is not unique to this community.
No preference was stated when participants were asked about the importance of ethnic background in relation to practitioner choice, but a number of participants stated that they would prefer a male dentist. Men were generally felt to be more capable and decisive and anecdotal evidence was provided to support this assertion.
"I prefer a male, they are more sure of themselves...a man knows his stuff - it's different." (28 r)
"She's a lady dentist...she's scared to do it." (13 n)
It is worth noting here that whilst participants stated no preference for ethnically specific practitioners the vast majority attended Jewish dentists or dental practices. Once again this ties in with the fact that referrals are passed through the community and also to the lack of contact with many external sources of information such as the list of NHS dentists which is available on the internet through NHS Choices [25
Inadequate capacity and capability
Both the capacity and capability of local dental care were raised as issues by regular and symptomatic attenders alike, focussing on long waiting times, both for appointments and at the surgery itself:
"Why I don't go with my children...when the waiting time is three hours I don't have three hours to spare. That is the only reason." (18 k)
"Most people wait until it is an emergency. I have to wait ages for an appointment. It is difficult to take the children along as well". (27 o)
Dentists accessed by this community were reportedly overstretched due to their limited numbers and face a challenging patient population in an area of London where space is at a premium. Concerns covered surgeries with a lack of play areas and toys to serve this community.
"open up children centres which are friendly to children, toys (so that) children excited to go and not scared." (4 s)
Organisational issues were also mentioned, covering a lack of Sunday clinics and flexible opening times and direct and indirect costs of treatment. The lack of access to salaried community dental services was also raised. Whilst many of these issues are relevant amongst the wider population, lack of play areas and toys, long waiting times and costs are particularly relevant when considering a community where the majority of whom have large families.
Generic barriers to care
In addition to availability, other barriers identified included perceived cost of treatment; travel costs; waiting times, poor dentist patient communications skills [18
] and the pressures resulting from having large families. However, it is possible that the lack of knowledge about dental charges has exacerbated a 'fear of cost' as all children and a number of adult members could be eligible for free dental treatment. Again the experiences raised are pertinent when considered in the context of the community in which these families live. These factors are further exacerbated by issues raised by participants about the organisation and provision of dental care and highlight the impact of multiple barriers to care. Respondents identified the need for extended hours and Sunday opening, together with reducing direct and indirect costs of treatment. Indirect costs could be reduced by provision of local services requiring less travel and greater capacity which would reduce the pressure on services and thus waiting times.
Welcoming community support
One of the final themes to emerge from the data concerned both the ways in which people behave in relation to their oral health and the development of oral health knowledge. Respondents highlighted a lack of time when asked about teaching their children about oral healthcare and it was widely felt that the schools should play a significant role in teaching these kinds of health related topics.
"The children have a lack of knowledge. They should be coming in to schools. Then they would come home from school saying I want to brush my teeth." (24 t)
It was suggested that school health programmes could form an important community initiative to develop personal skills of children who would be better able to care for their own health and possibly strengthen family knowledge about oral health.
"Dentists should come round the schools to help them to brush their teeth, to show the children ho to brush their teeth and to encourage them, because I think the schools do, the children get a lot of encouragement through the teachers definitely." (13 s)
This was evidence of the willingness of the community to receive external support. This could be perceived as being at odds with both the central role of family within this community and its role in teaching and nurturing children. Alternatively it could be seen as an empowering solution in support of the community, in recognition of the respondents' desire to enhance the priority of oral health within the population. Thus the context is germane to making sense of the behaviour exhibited and to determining ways of overcoming these boundaries.
Limitations and Strengths of the Study
Whilst it is acknowledged that this study is limited by its sample size and the fact that fieldnotes replaced recorded transcripts where permission was not granted for recording, the findings represent a unique and valuable insight into this particular community. This study is an important contribution to the literature on the oral health beliefs, behaviours and needs of the orthodox Jewish community in North London. It further adds to understanding of other culturally isolated communities in socially deprived areas. As an indepth case study of an isolated community which appears difficult to access, the study provides a unique insight into the specific needs of women and families from this community. The direct link with the City & Hackney Teaching Primary Care Trust has allowed for the development of culturally acceptable and appropriate interventions in partnership with the community. The findings provided the necessary information to enable the local state-funded health organisation to develop services that meet the needs of this population. To this end it has commissioned a needs assessment of health in this community the dental aspects of which will be informed by this study.