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1.  Self-efficacy and self-rated oral health among pregnant aboriginal Australian women 
BMC Oral Health  2014;14:29.
Background
Self-efficacy plays an important role in oral health-related behaviours. There is little known about associations between self-efficacy and subjective oral health among populations at heightened risk of dental disease. This study aimed to determine if low self-efficacy was associated with poor self-rated oral health after adjusting for confounding among a convenience sample of pregnant women.
Methods
We used self-reported data from 446 Australian women pregnant with an Aboriginal child (age range 14–43 years) to evaluate self-rated oral health, self-efficacy and socio-demographic, psychosocial, social cognitive and risk factors. Hierarchical entry of explanatory variables into logistic regression models estimated prevalence odds ratios (POR) and 95% confidence intervals (95% CI) for fair or poor self-rated oral health.
Results
In an unadjusted model, those with low self-efficacy had 2.40 times the odds of rating their oral health as ‘fair’ or ‘poor’ (95% CI 1.54–3.74). Addition of socio-demographic factors attenuated the effect of low self-efficacy on poor self-rated oral health by 10 percent (POR 2.19, 95% CI 1.37–3.51). Addition of the psychosocial factors attenuated the odds by 17 percent (POR 2.07, 95% CI 1.28–3.36), while addition of the social cognitive variable fatalism increased the odds by 1 percent (POR 2.42, 95% CI 1.55–3.78). Inclusion of the behavioural risk factor ‘not brushing previous day’ attenuated the odds by 15 percent (POR 2.11, 95%CI 1.32–3.36). In the final model, which included all covariates, the odds were attenuated by 32 percent (POR 1.80, 95% CI 1.05, 3.08).
Conclusions
Low self-efficacy persisted as a risk indicator for poor self-rated oral health after adjusting for confounding among this vulnerable population.
doi:10.1186/1472-6831-14-29
PMCID: PMC3976034  PMID: 24690235
2.  Oral health literacy comparisons between Indigenous Australians and American Indians 
Community dental health  2013;30(1):52-57.
Objectives
To compare oral health literacy (OHL) levels between two profoundly disadvantaged groups, Indigenous Australians and American Indians, and to explore differences in socio-demographic, dental service utilisation, self-reported oral health indicators, and oral health-related quality of life (OHRQoL) correlates of OHL among the above.
Methods
OHL was measured using REALD-30 among convenience samples of 468 Indigenous Australians (aged 17–72 years, 63% female) and 254 female American Indians (aged 18–57 years). Covariates included socio-demography, dental utilisation, self-reported oral health status (OHS), perceived treatment needs and OHRQoL (prevalence, severity and extent of OHIP-14 ‘impacts’). Descriptive and bivariate methods were used for data presentation and analysis, and between-sample comparisons relied upon empirical contrasts of sample-specific estimates and correlation coefficients.
Results
OHL scores were: Indigenous Australians - 15.0 (95% CL=14.2, 15.8) and American Indians - 13.7 (95% CL=13.1, 14.4). In both populations, OHL strongly correlated with educational attainment, and was lower among participants with infrequent dental attendance and perceived restorative treatment needs. A significant inverse association between OHL and prevalence of OHRQoL impacts was found among American Indians (rho=−0.23; 95% CL=−0.34, −0.12) but not among Indigenous Australians.
Conclusions
Our findings indicate that OHL levels were comparable between the two groups and lower compared to previously reported estimates among diverse populations. Although the patterns of association of OHL with most examined domains of correlates were similar between the two groups, this study found evidence of heterogeneity in the domains of self-reported OHS and OHRQoL.
PMCID: PMC3709981  PMID: 23550508
oral health literacy; oral health; Indigenous populations; Australian Indigenous; Native American; American Indian; quality of life
3.  An oral health literacy intervention for Indigenous adults in a rural setting in Australia 
BMC Public Health  2012;12:461.
Background
Indigenous Australians suffer substantially poorer oral health than their non-Indigenous counterparts and new approaches are needed to address these disparities. Previous work in Port Augusta, South Australia, a regional town with a large Indigenous community, revealed associations between low oral health literacy scores and self-reported oral health outcomes. This study aims to determine if implementation of a functional, context-specific oral health literacy intervention improves oral health literacy-related outcomes measured by use of dental services, and assessment of oral health knowledge, oral health self-care and oral health- related self-efficacy.
Methods/design
This is a randomised controlled trial (RCT) that utilises a delayed intervention design. Participants are Indigenous adults, aged 18 years and older, who plan to reside in Port Augusta or a nearby community for the next two years. The intervention group will receive the intervention from the outset of the study while the control group will be offered the intervention 12 months following their enrolment in the study. The intervention consists of a series of five culturally sensitive, oral health education workshops delivered over a 12 month period by Indigenous project officers. Workshops consist of presentations, hands-on activities, interactive displays, group discussions and role plays. The themes addressed in the workshops are underpinned by oral health literacy concepts, and incorporate oral health-related self-efficacy, oral health-related fatalism, oral health knowledge, access to dental care and rights and entitlements as a patient. Data will be collected through a self-report questionnaire at baseline, at 12 months and at 24 months. The primary outcome measure is oral health literacy. Secondary outcome measures include oral health knowledge, oral health self-care, use of dental services, oral health-related self-efficacy and oral health-related fatalism.
Discussion
This study uses a functional, context-specific oral health literacy intervention to improve oral health literacy-related outcomes amongst rural-dwelling Indigenous adults. Outcomes of this study will have implications for policy and planning by providing evidence for the effectiveness of such interventions as well as provide a model for working with Indigenous communities.
doi:10.1186/1471-2458-12-461
PMCID: PMC3416720  PMID: 22716205
4.  Reducing disease burden and health inequalities arising from chronic disease among Indigenous children: an early childhood caries intervention 
BMC Public Health  2012;12:323.
Background
This study seeks to determine if implementing a culturally-appropriate early childhood caries (ECC) intervention reduces dental disease burden and oral health inequalities among Indigenous children living in South Australia, Australia.
Methods/Design
This paper describes the study protocol for a randomised controlled trial conducted among Indigenous children living in South Australia with an anticipated sample of 400. The ECC intervention consists of four components: (1) provision of dental care; (2) fluoride varnish application to the teeth of children; (3) motivational interviewing and (4) anticipatory guidance. Participants are randomly assigned to two intervention groups, immediate (n = 200) or delayed (n = 200). Provision of dental care (1) occurs during pregnancy in the immediate intervention group or when children are 24-months in the delayed intervention group. Interventions (2), (3) and (4) occur when children are 6-, 12- and 18-months in the immediate intervention group or 24-, 30- and 36-months in the delayed intervention group. Hence, all participants receive the ECC intervention, though it is delayed 24 months for participants who are randomised to the control-delayed arm. In both groups, self-reported data will be collected at baseline (pregnancy) and when children are 24- and 36-months; and child clinical oral health status will be determined during standardised examinations conducted at 24- and 36-months by two calibrated dental professionals.
Discussion
Expected outcomes will address whether exposure to a culturally-appropriate ECC intervention is effective in reducing dental disease burden and oral health inequalities among Indigenous children living in South Australia.
doi:10.1186/1471-2458-12-323
PMCID: PMC3413605  PMID: 22551058
5.  The effect of a periodontal intervention on cardiovascular risk markers in Indigenous Australians with periodontal disease: the PerioCardio study 
BMC Public Health  2011;11:729.
Background
Indigenous Australians experience an overwhelming burden of chronic disease, including cardiovascular diseases. Periodontal disease (inflammation of the tissues surrounding teeth) is also widespread, and may contribute to the risk of cardiovascular diseases via pathogenic inflammatory pathways. This study will assess measures of vascular health and inflammation in Indigenous Australian adults with periodontal disease, and determine if intensive periodontal therapy improves these measures over a 12 month follow-up. The aims of the study are: (i) to determine whether there is a dose response relationship between extent and severity of periodontal disease and measures of vascular health and inflammation among Indigenous Australian adults with moderate to severe periodontal disease; and (ii) to determine the effects of periodontal treatment on changes in measures of vascular health and inflammation in a cohort of Indigenous Australians.
Methods/Design
This study will be a randomised, controlled trial, with predominantly blinded assessment of outcome measures and blinded statistical analysis. All participants will receive the periodontal intervention benefits (with the intervention delayed 12 months in participants who are randomised to the control arm). Participants will be Indigenous adults aged ≥25 years from urban centres within the Top End of the Northern Territory, Australia. Participants assessed to have moderate or severe periodontal disease will be randomised to the study's intervention or control arm. The intervention involves intensive removal of subgingival and supragingival calculus and plaque biofilm by scaling and root-planing. Study visits at baseline, 3 and 12 months, will incorporate questionnaires, non-fasting blood and urine samples, body measurements, blood pressure, periodontal assessment and non-invasive measures of vascular health (pulse wave velocity and carotid intima-media thickness). Primary outcome measures are pulse wave velocity and carotid intima-media thickness.
Discussion
The study will assess the periodontal-cardiovascular disease relationship among Indigenous Australian adults with periodontal disease, and the effectiveness of an intervention aimed at improving periodontal and cardiovascular health. Efforts to understand and improve Indigenous oral health and cardiovascular risk may serve as an important means of reducing the gap between Indigenous and non-Indigenous health in Australia.
Trial Registration
Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000817044
doi:10.1186/1471-2458-11-729
PMCID: PMC3189892  PMID: 21943132
6.  Oral health and social and emotional well-being in a birth cohort of Aboriginal Australian young adults 
BMC Public Health  2011;11:656.
Background
Social and emotional well-being is an important component of overall health. In the Indigenous Australian context, risk indicators of poor social and emotional well-being include social determinants such as poor education, employment, income and housing as well as substance use, racial discrimination and cultural knowledge. This study sought to investigate associations between oral health-related factors and social and emotional well-being in a birth cohort of young Aboriginal adults residing in the northern region of Australia's Northern Territory.
Methods
Data were collected on five validated domains of social and emotional well-being: anxiety, resilience, depression, suicide and overall mental health. Independent variables included socio-demographics, dental health behaviour, dental disease experience, oral health-related quality of life, substance use, racial discrimination and cultural knowledge.
Results
After adjusting for other covariates, poor oral health-related items were associated with each of the social and emotional well-being domains. Specifically, anxiety was associated with being female, having one or more decayed teeth and racial discrimination. Resilience was associated with being male, having a job, owning a toothbrush, having one or more filled teeth and knowing a lot about Indigenous culture; while being female, having experienced dental pain in the past year, use of alcohol, use of marijuana and racial discrimination were associated with depression. Suicide was associated with being female, having experience of untreated dental decay and racial discrimination; while being female, having experience of dental disease in one or more teeth, being dissatisfied about dental appearance and racial discrimination were associated with poor mental health.
Conclusion
The results suggest there may be value in including oral health-related initiatives when exploring the role of physical conditions on Indigenous social and emotional well-being.
doi:10.1186/1471-2458-11-656
PMCID: PMC3176220  PMID: 21851641
7.  Hospitalized head injuries among older people in Australia, 1998/1999 to 2004/2005 
Injury Prevention  2007;13(4):243-247.
Objective
To explore rates of hospitalized head injury among older Australians by a range of risk indicators.
Design
Head injury data for 60+‐year‐olds were obtained from the Australian Institute of Health and Welfare Hospital Morbidity Database from 1998/1999 to 2004/2005. Poisson regression modeling was used to examine head injury rates in relation to age, sex, Indigenous status, location, and injury type.
Results
Rates of hospitalized head injury among the older population increased 1.4‐fold between 1998/1999 (582.8 per 100 000) and 2004/2005 (844.3 per 100 000) (p<0.001). Those aged 85+ years had 10.8 times the rate of their 60–64‐year‐old counterparts (95% CI 10.6 to 11.0) after adjustment for other covariates. Men had 1.1 times the rate of women (95% CI 1.1 to 1.2), and those living in rural/remote areas had 3.1 times the rate of their metropolitan‐dwelling counterparts (95% CI 3.0 to 3.1). Those identifying themselves as Indigenous had 1.7 times the rate of non‐Indigenous persons (95% CI 1.6 to 1.8). The most prevalent injuries were open wounds of the head (38.0%), followed by superficial injuries (24.7%) and intracranial trauma (18.3%). Falls accounted for 81.4% of all head injury admissions.
Conclusions
The oldest old were disproportionately represented among those sustaining hospitalized head injuries, along with men, those living in rural/remote areas, and Indigenous persons. Given the increasing proportion of older people in Western societies and the costs of treating hospitalized head injuries, the ability to reduce risk of such trauma in this age group is of critical public health importance.
doi:10.1136/ip.2007.015354
PMCID: PMC2598353  PMID: 17686934
head injury; hospitalizations; older people; rural; indigenous
8.  Associations between Indigenous Australian oral health literacy and self-reported oral health outcomes 
BMC Oral Health  2010;10:3.
Objectives
To determine oral health literacy (REALD-30) and oral health literacy-related outcome associations, and to calculate if oral health literacy-related outcomes are risk indicators for poor self-reported oral health among rural-dwelling Indigenous Australians.
Methods
468 participants (aged 17-72 years, 63% female) completed a self-report questionnaire. REALD-30 and oral health literacy-related outcome associations were determined through bivariate analysis. Multivariate modelling was used to calculate risk indicators for poor self-reported oral health.
Results
REALD-30 scores were lower among those who believed teeth should be infrequently brushed, believed cordial was good for teeth, did not own a toothbrush or owned a toothbrush but brushed irregularly. Tooth removal risk indicators included being older, problem-based dental attendance and believing cordial was good for teeth. Poor self-rated oral health risk indicators included being older, healthcare card ownership, difficulty paying dental bills, problem-based dental attendance, believing teeth should be brushed infrequently and irregular brushing. Perceived need for dental care risk indicators included being female and problem-based dental attendance. Perceived gum disease risk indicators included being older and irregular brushing. Feeling uncomfortable about oro-facial appearance risk indicators included problem-based dental attendance and irregular brushing. Food avoidance risk indicators were being female, difficulty paying dental bills, problem-based dental attendance and irregular brushing. Poor oral health-related quality of life risk indicators included difficulty paying dental bills and problem-based dental attendance.
Conclusions
REALD-30 was significantly associated with oral health literacy-related outcomes. Oral health literacy-related outcomes were risk indicators for each of the poor self-reported oral health domains among this marginalised population.
doi:10.1186/1472-6831-10-3
PMCID: PMC2859391  PMID: 20346124
9.  Risk indicators for severe impaired oral health among indigenous Australian young adults 
BMC Oral Health  2010;10:1.
Background
Oral health impairment comprises three conceptual domains; pain, appearance and function. This study sought to: (1) estimate the prevalence of severe oral health impairment as assessed by a summary oral health impairment measure, including aspects of dental pain, dissatisfaction with dental appearance and difficulty eating, among a birth cohort of Indigenous Australian young adults (n = 442, age range 16-20 years); (2) compare prevalence according to demographic, socio-economic, behavioural, dental service utilisation and oral health outcome risk indicators; and (3) ascertain the independent contribution of those risk indicators to severe oral health impairment in this population.
Methods
Data were from the Aboriginal Birth Cohort (ABC) study, a prospective longitudinal investigation of Aboriginal individuals born 1987-1990 at an Australian regional hospital. Data for this analysis pertained to Wave-3 of the study only. Severe oral health impairment was defined as reported experience of toothache, poor dental appearance and food avoidance in the last 12 months. Logistic regression models were used to evaluate effects of demographic, socio-economic, behavioural, dental service utilisation and clinical oral disease indicators on severe oral health impairment. Effects were quantified as odds ratios (OR).
Results
The percent of participants with severe oral health impairment was 16.3 (95% CI 12.9-19.7). In the multivariate model, severe oral health impairment was associated with untreated dental decay (OR 4.0, 95% CI 1.6-9.6). In addition to that clinical indicator, greater odds of severe oral health impairment were associated with being female (OR 2.0, 95% CI 1.2-3.6), being aged 19-20 years (OR 2.1, 95% CI 1.2-3.6), soft drink consumption every day or a few days a week (OR 2.6, 95% 1.2-5.6) and non-ownership of a toothbrush (OR 1.9, 95% CI 1.1-3.4).
Conclusions
Severe oral health impairment was prevalent among this population. The findings suggest that public health strategies that address prevention and treatment of dental disease, self-regulation of soft drink consumption and ownership of oral self-care devices are needed if severe oral health impairment among Indigenous Australian young adults is to be reduced.
doi:10.1186/1472-6831-10-1
PMCID: PMC2827466  PMID: 20102640
10.  Australian Aboriginal Birth Cohort study: follow-up processes at 20 years 
Background
In 1987, a prospective study of an Australian Aboriginal Birth Cohort was established focusing on the relationships of fetal and childhood growth with the risk of chronic adult disease. However as the study is being conducted in a highly marginalized population it is also an important resource for cross-sectional descriptive and analytical studies. The aim of this paper is to describe the processes of the third follow up which was conducted 20 years after recruitment at birth.
Methods
Progressive steps in a multiphase protocol were used for tracing, with modifications for the expected rural or urban location of the participants.
Results
Of the original 686 cohort participants recruited 68 were untraced and 27 were known to have died. Of the 591 available for examination 122 were not examined; 11 of these were refusals and the remainder were not seen for logistical reasons relating to inclement weather, mobility of participants and single participants living in very remote locations.
Conclusion
The high retention rate of this follow-up 20 years after birth recruitment is a testament to the development of successful multiphase protocols aimed at overcoming the challenges of tracing a cohort over a widespread remote area and also to the perseverance of the study personnel. We also interpret the high retention rate as a reflection of the good will of the wider Aboriginal community towards this study and that researchers interactions with the community were positive. The continued follow-up of this life course study now seems feasible and there are plans to trace and reexamine the cohort at age 25 years.
doi:10.1186/1472-698X-9-23
PMCID: PMC2761846  PMID: 19775475
11.  Oral health investigations of indigenous participants in remote settings: a methods paper describing the dental component of wave III of an Australian Aboriginal birth cohort study 
BMC Oral Health  2008;8:24.
Background
A prospective Aboriginal Birth Cohort (ABC) study has been underway in Australia's Northern Territory since 1987. Inclusion of oral epidemiological information in a follow-up study required flexible and novel approaches with unconventional techniques. Documenting these procedures may be of value to researchers interested in including oral health components in remotely-located studies. The objectives are to compare and describe dental data collection methods in wave III of the ABC study with a more conventional oral health investigation.
Methods
The Australian National Survey of Adult Oral Health (NSAOH) was considered the 'conventional' study. Differences between this investigation and the dental component of the ABC study were assessed in terms of ethics, location, recruitment, consent, privacy, equipment, examination, clinical data collection and replication. In the ABC study, recording of clinical data by different voice recording techniques were described and assessed for ease-of-use portability, reliability, time-efficiency and cost-effectiveness.
Results
Conventional investigation recruitment was by post and telephone. Participants self presented. Examinations took place in dental clinics, using customised dental chairs with standard dental lights attached. For all examinations, a dental assistant recorded dental data directly onto a laptop computer. By contrast, follow-up of ABC study participants involved a multi-phase protocol with reliance on locally-employed Indigenous advocates bringing participants to the examination point. Dental examinations occurred in settings ranging from health centre clinic rooms to improvised spaces outdoors. The dental chair was a lightweight, portable reclining camp chair and the dental light a fire-fighter's head torch with rechargeable batteries. The digital voice recorder was considered the most suitable instrument for clinical dental data collection in the ABC study in comparison with computer-based voice-recording software.
Conclusion
Oral health examinations among indigenous populations residing in predominantly remote locations are more logistically challenging than are surveys of the general population. However, lack of resources or conventional clinical infrastructures need not compromise the collection of dental data in such studies. Instead, there is a need to be flexible and creative in establishing culturally-sensitive environments with available resources, and to consider non-conventional approaches to data gathering.
doi:10.1186/1472-6831-8-24
PMCID: PMC2527296  PMID: 18702826
12.  Dental general anaesthetic receipt among Australians aged 15+ years, 1998–1999 to 2004–2005 
BMC Oral Health  2008;8:10.
Background
Adults receive dental general anaesthetic (DGA) care when standard dental treatment is not possible. Receipt of DGA care is resource-intensive and not without risk. This study explores DGA receipt among 15+-year-old Australians by a range of risk indicators.
Methods
DGA data were obtained from Australia's Hospital Morbidity Database from 1998–1999 to 2004–2005. Poisson regression modeling was used to examine DGA rates in relation to age, sex, Indigenous status, location and procedure.
Results
The overall DGA rate was 472.79 per 100,000 (95% CI 471.50–474.09). Treatment of impacted teeth (63.7%) was the most common reason for DGA receipt, followed by dental caries treatment (12.4%), although marked variations were seen by age-group. After adjusting for other covariates, DGA rates among 15–19-year-olds were 13.20 (95% CI 12.65–13.78) times higher than their 85+-year-old counterparts. Females had 1.46 (95% CI 1.45–1.47) times the rate of their male counterparts, while those living in rural/remote areas had 2.70 (95% CI 2.68–2.72) times the rate of metropolitan-dwellers. DGA rates for non-Indigenous persons were 4.88 (95% CI 4.73–5.03) times those of Indigenous persons. The DGA rate for 1+ extractions was 461.9 per 100,000 (95% CI 460.6–463.2), compared with a rate of 23.6 per 100,000 (95% CI 23.3–23.9) for 1+ restorations.
Conclusion
Nearly two-thirds of DGAs were for treatment of impacted teeth. Persons aged 15–19 years were disproportionately represented among those receiving DGA care, along with females, rural/remote-dwellers and those identifying as non-Indigenous. More research is required to better understand the public health implications of DGA care among 15+-year-olds, and how the demand for receipt of such care might be reduced.
doi:10.1186/1472-6831-8-10
PMCID: PMC2329614  PMID: 18402707
13.  Dental general anaesthetic trends among Australian children 
BMC Oral Health  2006;6:16.
Background
Children receive dental general anaesthetic (DGA) care when standard dental treatment is not possible. Receipt of DGA care is resource-intensive and not without risk. This study examines trends in receipt of DGA care among Australian children.
Methods
Child DGA data were obtained from the Australian Institute of Health and Welfare Hospital Morbidity Database for 1993–2004. Poisson regression modelling was used to examine DGA rates in relation to age, sex, Indigenous status, location, year and procedure.
Results
There was a 3-fold increase in DGA rates from 1993–1994 (215.8 ± 2.9 per 100,000) to 2003–2004 (731.4 ± 5.3 per 100,000) (P < 0.001). Across all years, children who were aged 0–4 years, male or rural/remote-dwelling had higher DGA rates than their 5–9-year-old, female or metropolitan-dwelling counterparts respectively. There was a 7.0-fold increase in the rate of Indigenous admissions from 1993–1994 (116.5 ± 10.2 per 100,000) to 2003–2004 (806.6 ± 25.7 per 100,000). Extraction rates increased 4.9-fold from 1993–1994 (109.2 ± 2.9 per 100,000) to 2003–2004 (540.0 ± 4.5 per 100,000), while restoration rates increased 3.3-fold in the same observation period (139.5 ± 2.3 per 100,000 in 1993–1994 to 462.6 ± 4.2 per 100,000 in 2003–2004). For admissions in which one or more extractions were received, Indigenous rates were 47% greater than non-Indigenous rates after adjusting for other covariates.
Conclusion
Child DGA rates in Australia are increasing. Children who are pre-school-aged, male, Indigenous or living in a rural/remote location are disproportionally represented among those receiving such care. There are higher rates of extractions as opposed to more conservative procedures, particularly among Indigenous children.
doi:10.1186/1472-6831-6-16
PMCID: PMC1770909  PMID: 17184552

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