|Year : 2017 | Volume
| Issue : 4 | Page : 334-339
The one with no-one: Oral health and quality of life among rohingya refugee: A cross-sectional study
Lav Kumar Niraj, Ashish Singla, Ritu Gupta, Basavaraj Patthi, Kuldeep Dhama, Irfan Ali
Department of Public Health Dentistry, Divya Jyoti College of Dental Sciences and Research, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||13-Dec-2017|
Dr. Lav Kumar Niraj
Department of Public Health Dentistry, Divya Jyoti college of Dental Science and Research, Niwari Road, Modinagar, Ghaziabad - 201 204, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Rohingyas are considered to be one of the largest population who has immigrated in India throughout the past. The needs and health status of the immigrants are vital due to their input to the health of the country. The oral health professional confronts many challenges in treating them due to their different cultures. Aim: The aim is to assess the oral health status and oral health-related quality of life among Rohingya refugees staying in refugee camps in New Delhi India. Materials and Methods: Out of the total 212 people, 201 (94.81%) people agreed to be the part of the study who are residing in the refugee camp. Assessment of the oral health status and oral health-related quality of life was peformed in accordance with criteria laid down by the WHO in oral health assessment survey basic methods, 2013 and oral health impact Profile-14. The data were statistically analyzed using descriptive statistics such as mean, standard deviation, and percentage and Spearman's rank correlation coefficient test. The level of significance was set at 5%. Results: Caries prevalence was found to be 83.92% among adults aged 15 years and above. Periodontal disease with gingival bleeding was present among the entire study population. Caries prevalence was found to be 85.23% among children below 15 years. A decayed tooth, missing tooth, decayed missing filled tooth was found to be highly, significantly correlated with the functional limitation, physical pain, psychological discomfort. Conclusion: The most common dental problems were gingival or periodontal problems, dental caries, and decayed teeth due to the high level of unmet needs in the study population which highlights the need for a comprehensive dental care program. Further, research has to be conducted on the oral health of refugees living in developing countries like India and treatment camps are of the urgent need to provide the dental services.
Keywords: Dental caries, health literacy, immigrants, oral health, refugees
|How to cite this article:|
Niraj LK, Singla A, Gupta R, Patthi B, Dhama K, Ali I. The one with no-one: Oral health and quality of life among rohingya refugee: A cross-sectional study. J Indian Assoc Public Health Dent 2017;15:334-9
|How to cite this URL:|
Niraj LK, Singla A, Gupta R, Patthi B, Dhama K, Ali I. The one with no-one: Oral health and quality of life among rohingya refugee: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2021 May 6];15:334-9. Available from: https://www.jiaphd.org/text.asp?2017/15/4/334/220727
| Introduction|| |
Poor oral health has certain common risk factors which not only leads to chronic diseases but also have a negative impact on quality of life. The dental disease prevalence among refugees has been reported to be high. For example, lingering pain from a diseased tooth can prohibit food intake and thus compromise nutrition., According to the United Nations High Commissioner for Human Rights (UNHCR) Australia, definition for a refugee as someone who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.”
Rohingya's are the principal minority in Myanmar. Thousands of people in the North western state of Rakhine has been imposed to leave the countries such as Malaysia, Indonesia, and Bangladesh among others, due to government-supported torture and violence. Although the number of Rohingya's community is relatively less in India when compared to other nations, they give enough competition for their survival. On June 20, 2016-United Nation High Commissioner for Human Rights released a fresh report on the condition of minorities in Myanmar, urged the government to take certain steps to eradicate the “systemic discrimination” and human rights violations against mainly the Rohingya Muslims in Rakhine state.
According to the United Nations, International Covenant on Economic Social and Cultural Right orders member states to ensure that all categories of migrants receive the utmost attainable standard of physical and mental health; however, still the systemic discrimination and social isolation has often resulted in poor general health and oral health among the refugee population. Earlier studies conducted by Ghiabi et al. revealed that the prevalence of untreated dental decay and gingivitis among refugees was 85% and 98%, respectively.
One of the major determinants of the poor oral health of these populations is the lack of access to the restorative and preventive dental services. The other determinants include poor oral hygiene, dietary factors, sociocultural factors and health literacy. The linguistic and cultural factors might also play an important role in the determining access to the oral hygiene services and oral hygiene practices among these populations.
The impact of poor oral health on quality of life is of urgent importance for these populations because they are not the part of this habitual health-care system, have limited financial resources, living with reduced access to nutritious food and clean water, and have lost their social support network., Rohingya people living in the community are not eligible for Centre link benefits and are not eligible to work in India, and hence, they face severe financial barriers to accessing private dental services. They may not be able to access certain public dental health services and also for emergency treatment and relief of pain.
Rohingya refugees from Myanmar have spread out widely into various geographic locations of India. Their immigrant status disposes them to various social and political pressure sowing them to be run-down compared to the citizens of the country. This leads to a crucial deprivation of health facilities provided to the community predisposing them to various illnesses. Since there is no published data available pertaining to the oral health status of Rohingya refugees; there is a requisite to evaluate the oral health status and their related quality of life. Hence, the current study was conducted with an aim to evaluate the oral health status and oral health-related quality of life (OHRQoL) among the Rohingya refugees staying in Refugee camps in New Delhi, India.
| Materials and Methods|| |
A cross-sectional study was conducted among Rohingya people residing in KalindiKunj, (ShaheenBagh, JJ Colony, BodolaGoung and Hastall) New Delhi over 4 months from October 2016 to January 2017. The study protocol was approved by the Institutional Ethical Committee and Review Board. The permission and consent were taken from the Undertaking NGO Zakat Foundation of India, New Delhi.
The standardization and calibration of the data collection methods were done through two-day training sessions which were organized by the Department of Public Health Dentistry. The training session included a revaluation of the criteria outlined, followed by an examination of adult patients based on simulation of field technique for reliability. Cohen's kappa was 0.97 which was assessed through intra-examiner reliability.
As of March 2016, UNHCR in India had registered 35,000 refugees among whom around 13,000 are Rohingya's. According to the Undertaking NGO Zakat Foundation of India, this community is of approximately 212 living in Kalindi Kunj, New Delhi. Nonprobability judgement sampling was done and those who present on the day of examination and fulfilled the inclusion and exclusion criteria were included in the study. Intellectual disabled, known cognitive impairment or traumatic brain injury; and medical diagnoses requiring antibiotic prophylaxis for oral examination have been excluded from the study.
All the data collected was recorded in a structured pro forma by a trained assistant. The research interview comprised of a well-designed questionnaire demographic variables and oral hygiene practices. The questions were explained to them in the local language, i.e., in hindi and then the answers were recorded by the examiner. The assessment of oral health status was done through WHO Oral Health Assessment Form (2013) as well as OHRQoL was evaluated using Oral Health Impact Profile-14 (OHIP-14) items questionnaire.
Data were entered into Microsoft Excel 2010 and differences between the groups were analyzed using Statistical Package for Social Sciences (SPSS) Version 20.0; IBM SPSS Inc., Chicago, IL, USA. Descriptive statistics such as mean, standard deviation, and percentage were used. Spearman's rank correlation coefficient was used to measure the association between components of the decayed missing, filled tooth (DMFT), gingival bleeding, pocket more than 4-5 mm with OHIP-14 dimensions. Any value of P < 0.05 were considered as statistically significant.
| Results|| |
Out of 212 subjects, 201 (94.81%) agreed to be the part of the study wherein 106 (52.7%) were males and 95 (47.3%) were females. The age of the study population ranged from 4 to 76 years with the mean age of 21.36 ± 16.30 years. Around 50% of the sample population had completed their primary education, whereas 49.1% were illiterate. The majority of the population (27.86%) used finger and toothpowder for brushing their teeth, and only 13.93% of participants had visited the dentist [Table 1].
Caries prevalence was found to be 83.92% among adults aged 15 years and above. Periodontal disease was present in the entire population and pocket 4–5 mm was found in 53.57%. Mean number of sound teeth, crown caries and gingival bleeding was 19.38 ± 3.843, 4.81 ± 2.061 and 11.79 ± 1.712, respectively [Table 2].
Caries prevalence was found to be 85.23% among children below 15 years. Mean number of sound teeth, crown caries, gingival bleeding was found to be 18.43 ± 3.33, 4.36 ± 2.36, and4.11 ± 2.78, respectively. Mean score of decayed tooth (DT), missing tooth (MT), filled teeth (FT) and DMFT was 2.14 ± 2.70, 0.00 ± 0.000, 0.00 ± 0.00, and 2.16 ± 2.75, respectively. Mean score of MT, FT, DMFT was 0.07 ± 0.365, 0.00 ± 0.000, and 4.50 ± 2.523, respectively [Table 3].
The highest mean score was seen for the dimension psychological disability; 3.23 ± 0.455 followed by handicap; 3.03 ± 0.360 and least was for physical disability; 2.34 ± 0.566. The Painful aching was reported among 97.4%, which leads to limited food choices, trouble in biting and chewing and prevented from speaking and limited contacts with people. For the subscale social disability/handicap, 100% reported being irritable with other people because of problems in their teeth or mouth, with a mean score of 2.81 and 100% had reported of difficulty in doing their usual job, and their work performance was affected because of the problem in their teeth or mouth. For the dimension of handicap, 100% had felt life, in general, was less satisfying due to problems in their teeth or mouth, with a mean score of 3.03and 100.0% had reported of being totally unable to function due to problems in their teeth or mouth with a mean score of 3.03 [Table 4].
|Table 4: Distribution of responses and mean scores for the oral health impact profile-14|
Click here to view
Correlation between the variables of oral health status and OHIP-14. DT, MT, and DMFT was found to be highly significant when correlated with the functional limitation, physical pain, and psychological discomfort and MT was also significant with the physical disability. Gingival bleeding was not significant with the any of the dimensions of OHIP-14. Furthermore, a mean number of teeth affected by pocket measuring 4–5 mm was significantly correlated with the all dimensions of OHIP-14 except physical disability and handicap. The highest correlation was found between functional limitation and DMFT [Table 5].
|Table 5: Correlation between the variables of oral health status and oral health impact profile-14|
Click here to view
| Discussion|| |
Oral health is an important constituent of general health and quality of life. However, poor oral health affects one's physical, psychological, and social well-being, as well as one's quality of life. The migrant population is often forced to live the life of destitute and despair due to lack of access to resources essentially housing, education, healthcare services and employment opportunities. This often predisposes this vulnerable section of society to increased health risks and poor oral health., There is no literature available on the oral health status of Rohingya refugees population in India. Thus, the study was undertaken to assess the oral health status and OHRQoL among the Rohingya refugees in New Delhi, India.
The prevalence of dental caries among the adult subjects (Above 15 years) was found to be 83.93% which is similar to the findings of the study done on immigrants and refugees in Nova Scotia, Canada by Ghiabi et al. where the prevalence of dental caries was 85%. The mean caries experience (DMFT) was found to be 5.38 among the Rohingya refugees. The findings are in agreement with the study done on Somalian refugees (5.5) by Geltman et al. The higher caries in the present study can be attributed to poor oral hygiene habits, low utilization of dental health services and low socioeconomic background of the study subjects. In the present study, the decayed component was quite high among the Rohingya refugees (3.63), which is in contrast to the findings of the study done on Somalian refugees where the Missing component was predominant (2.76).
In the present study, the prevalence of dental caries was found to be 85.23% among children which are higher when compared to the findings of the study done by the Quach et al.(2015) among the Australian refugees which revealed that 66.9% of the children had dental caries. The mean dmft (4.50) among the Rohingya refugee children was also higher in the present study as compared to the mean dmft (1.67) reported by Havaldar K S et al. in among the Tibetan refugees.
In this study, all the study subjects had gingival bleeding and mean a number of teeth affected by gingival bleeding was 11.79 ± 1.71. The findings of the prevalence of gingivitis among adults were similar to the Ghiabi et al. (98%). A total of 52.53% of adults had periodontal pockets, with the mean number of teeth affected by pocket measuring 4–5 mm was 1.36 ± 1.58. The results are in agreement with the study conducted by Mahajan et al. among Tibetan refugee residing in Shimla where a mean number of sextants with pocket measuring 4–5 mm and ≥6 mm was 0.07 ± 0.37, but in the present study, none of the study subjects had periodontal pocket measuring 6 mm or more.
The OHRQoL was assessed using OHIP-14 domains. There was no literature found on the refugees pertaining to the association between the OHRQoL and caries and periodontal pocket prevalence. A statistically significant correlation was found between the domains of the OHIP-14 such as functional limitation, physical pain, and psychological discomfort with the pocket present, DMFT, MT, DT except gingival bleeding. The gingival bleeding was present in the entire individuals examined; this could be due to poor oral hygiene practice and lack of awareness regarding maintenance of good oral health that may result in subsequent plaque accumulation, gingivitis and periodontal disease. This lack of attitude and negligence towards one's oral health has a negative impact on the quality of life, leading to more functional disability and physical disability. It is equally essential to lay stress upon improving their attitude toward preventive mechanisms that could reduce the negative impact on their quality of life.
The mean score of social disability, physically challenged and psychological discomfort/disability domain was 2.81, 3.03, and 2.50, respectively. This means that the refugee people were more accepting of greater levels of oral pain and dysfunction, possibly due to having no other choice than to live with it. The painful aching among participants was reported to be 97.4%, which leads to limited food choices, trouble in biting and chewing as well as difficulty in speaking and limited contacts with people.
The dimensions of functional limitation, physical pain and psychological discomfort were found be positively correlated with DT, MT and DMFT component in the present study. The reason for the present finding might be because decayed teeth lead to pain, food lodgment, interference with mastication and the daily routine activity, which is perceived by the patient as a functional limitation, physical pain, and psychological discomfort.
Psychological disability in the present study was significantly correlated to the presence of pockets but non-significant with the DT, MT, and DMFT. For the subscale social disability/handicap, all the participants were reported to be irritable with other people because of problems with their teeth or mouth, with a mean score of 2.81 and all were having difficulty in doing their usual job due to which their work performance was affected because of the problems in their teeth or mouth. However the dimensions of psychological disability, social handicap and handicap were nonsignificantly correlated with the caries component (DT, MT, DMFT).
The high level of unmet treatment needs in the study population reflects the poor utilization of dental services. The study shows that there is a need to improve the knowledge and oral hygiene practices to prevent the occurrence of oral diseases that will prove to be yet another financial burden, especially belonging to this group. Furthermore, accessibility to affordable dental care is equally essential for these people. Finally, caries and periodontal disease may cause concern with appearance, lower self-esteem and negative effects on social activities and personal interactions. The present study has several strengths: the study used both clinical indicators of oral health status and a multi-item OHRQoL scale. The further personal interview was preferred compared to original self-reported form because it is well-described in the literature, that the use of the OHIP-14 in the questionnaire format may result in lower completion rates and loss of data which could be linked to the educational level of the participants. Literacy impairments could affect the participants when answering some questions in the questionnaire format. However, the administration of interviews requires more time and resources than the use of questionnaires.
In the present study also has some limitations such as judgement sample may influence its interpretation and generalizability. Hence, results cannot be assumed to apply to the general population. The low sample size could have impacted the results in respect to the effect of sex and oral health status variables on OHRQoL. However, the apparent effect on OHRQoL is in accordance with previous studies. Hence, further studies are needed with definite populations, especially in different social and cultural environment as these factors play an important role in both oral hygiene status and its impact on quality of life.
The need of the hour is to implement the sustainable strategies by the host countries to significantly improve access to oral health care for refugees and asylum seekers. Oral health of newcomers can be improved with the help of local dental institutions and dental professionals and disadvantaged populations by treating patients covered under publicly funded dental programs and supporting the work of organizations seeking to expand and improve these programs by advocating appropriate oral health policies.
| Conclusion|| |
Caries prevalence was found to be 83.92% among adults aged 15 years and above. Periodontal disease with gingival bleeding was present among the entire study population. Caries prevalence was found to be 85.23% among children under the age of 15 years. Caries was found to be highly significantly correlated with the functional limitation, physical pain, and psychological discomfort. Fortunately, the strategies and interventions had been developed to reduce the oral health inequities in this population. However, the government should improve access to oral health care for refugees and also implement sustainable strategies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Linden GJ, Lyons A, Scannapieco FA. Periodontal systemic associations: Review of the evidence. J Clin Periodontol 2013;40 Suppl 14:S8-19.
Cronin A. Periodontal disease is a risk marker for coronary heart disease? Evid Based Dent 2009;10:22.
Carramolino-Cuéllar E, Tomás I, Jiménez-Soriano Y. Relationship between the oral cavity and cardiovascular diseases and metabolic syndrome. Med Oral Patol Oral Cir Bucal 2014;19:e289-94.
Davidson N, Skull S, Calache H, Chesters D, Chalmers J. Equitable access to dental care for an at-risk group: A review of services for australian refugees. Aust N
Z J Public Health 2007;31:73-80.
Johri AD. The Most Unwanted: A Gripping Account of Rohingya Refugees Living in India. The Indian Express; 2017. Available from: https://www.indianexpress.com
. [Last accessed on 2017 Jan 20].
Keboa MT, Hiles N, Macdonald ME. The oral health of refugees and asylum seekers: A scoping review. Global Health 2016;12:59.
Ghiabi E, Matthews DC, Brillant MS. The oral health status of recent immigrants and refugees in Nova Scotia, Canada. J Immigr Minor Health 2014;16:95-101.
Geltman PL, Hunter AJ, Penrose KL, Cochran J, Rybin D, Doros G, et al
. Health literacy, acculturation, and the use of preventive oral health care by Somali refugees living in massachusetts. J Immigr Minor Health 2014;16:622-30.
Redwood-Campbell L, Thind H, Howard M, Koteles J, Fowler N, Kaczorowski J, et al.
Understanding the health of refugee women in host countries: Lessons from the Kosovar re-settlement in Canada. Prehosp Disaster Med 2008;23:322-7.
Singh HK, Scott TE, Henshaw MM, Cote SE, Grodin MA, Piwowarczyk LA, et al.
Oral health status of refugee torture survivors seeking care in the United States. Am J Public Health 2008;98:2181-2.
Quach A, Laemmle-Ruff IL, Polizzi T, Paxton GA. Gaps in smiles and services: A cross-sectional study of dental caries in refugee-background children. BMC Oral Health 2015;15:10.
Havaldar KS, Bhat SS, Hegde SK. Oral health status of tibetan and local school children of Kushalnagar, Mysore district, India: A comparative study. J Indian Soc Pedod Prev Dent 2014;32:125-9.
] [Full text]
Mahajan P. Dental caries status and treatment needs among Tibetan refugees residing in Shimla, Himachal Pradesh, India. Int J Migr Health Soc Care 2013;9:146-54.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]