Discussions on oral health care among elderly Chinese immigrants in Melbourne and Vancouver

Authors


Michael I. MacEntee, Faculty of Dentistry, University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada.
Tel.: 604 822 3564
Fax: 604 827 4448
E-mail: macentee@dentistry.ubc.ca

Abstract

doi: 10.1111/j.1741-2358.2011.00568.x

Discussions on oral health care among elderly Chinese immigrants in Melbourne and Vancouver

Background:  This study explored how elderly Chinese immigrants value and relate to how acculturation influences oral health and subsequent service use.

Methods:  Elders who had immigrated to Melbourne and Vancouver within the previous 15 years were recruited from local community centres and assigned to focus groups of 5–7 participants in Vancouver (4 groups) or Melbourne (5 groups).

Results:  Following an iterative process of thematic analysis, the discussions revealed that immigrants care about the comfort and appearance of their teeth, and they value Western dentistry as a supplement to traditional remedies, but they have difficulty getting culturally sensitive information about oral health care. Accessing dentistry, they explained, is distressing because of language problems and financial costs that impose on their children. Consequently, many immigrants obtain dental treatment in China when they return for occasional visits. They felt that separation of dentistry from national health care programmes in Canada and Australia disregards natural links between oral health and general health.

Conclusions:  The similarity of concerns in both cities suggests that dissemination of information and availability of services are the important themes influencing oral health, and that, beliefs developed over a lifetime play an important role in interpreting oral health in the host country.

Introduction

The purpose of this study was to explore how elderly Chinese immigrants acculturate to their host country. We use the example of how Western concepts of oral health and dentistry serve to influence these immigrants’ beliefs and practices as they adapt to their host country. In this section, we discuss different intersecting factors that contribute to the complexity of acculturating to a new country and its health care system.

Acculturation

Acculturation includes a process of ‘enculturation’, by which connections with the original culture are maintained for several generations after the original migration1–3. Policies in Australia and Canada reunite migrant families, although there are suggestions that older immigrants have difficulties acculturating to their new surroundings4,5. In general, elderly people (65–74 years) in Hong Kong6 and in Guangdong Province7 use traditional Chinese medicine (TCM) and have only a limited knowledge of Western dentistry, so the challenge of acculturation probably explains why Chinese immigrants, despite many years in England, retained many traditional beliefs about health care8–10. It probably explains also why elderly Chinese immigrants in Canada increased their knowledge of dentistry as they grew affluent11, and why Vietnamese immigrants in Australia increased their knowledge of oral health and their use of dental services, but did not improve their oral health12,13.

Social values, well-being and health care

There is growing interest in the influence of family re-unification and acculturation of immigrant families14. Elderly members of large extended families in China generally were disposed to a stoical and utilitarian view of health and disability in accordance with the principles of social stability and harmony. Social supports and health influence well-being in Canada and in China, despite different political and socioeconomic systems. Until recently, people expressed less concerns about their health in China, possibly because of their strong social supports15,16. Adjustments to social values are underway in Asia with the large movements from rural to urban life and with improvements in affluence, although not necessarily in health and well-being17,18. For example, families in Asia generally feel social pressure to express their filial piety (xiao), yet this pressure is changing as urbanisation grows. It is not clear how these adjustments influence the cultural identity and behaviour of elders who have emigrated recently, especially when they move occasionally between their adopted and birth countries1. Consequently, there is interest in knowing how immigration and acculturation to the new society influences the traditional expectations of older peoples.

Asian immigrants use TCM, but many prefer Western medical care13,19,20; however, there are indications that older Chinese immigrants use general health services in British Columbia at a rate similar to non-immigrant elders21. In Western culture, body image, including dental appearance, has a strong influence on well-being even in old age22–26, whereas older adults in Hong Kong27 and Guangzhou7, and others who migrated to Australia12, Canada11 or the UK10 seem generally disinterested in the appearance of their teeth.

Dentistry in Australia and Canada

Dental services need to be accessible and culturally acceptable in Australia and Canada where there are large and growing immigrant populations from Hong Kong and mainland China28. Both Canada and Australia provide universal access to health care as a tax-based benefit regardless of ability to pay. Dentistry for the most part is excluded from this benefit, and is purchased mostly through private insurance or directly by the patient. Very few immigrants have dental insurance29,30, but some are entitled to limited dental services in both countries if they have little income, and if they can find a dentist who accepts the relatively low fees paid for these services31. Melbourne, in contrast to Vancouver, has a more extensive government-sponsored dental service through community health centres that enhance access to care for immigrant groups12.

Oral health care beliefs and behaviours of Chinese immigrants

Research in Leeds, England, found that many Chinese immigrants retain their traditional beliefs that gums bleed because of imbalanced body humours, and that, natural teeth in old age cause misfortune9. A more educated group of Chinese immigrants in Montreal accepted Western ideas on caries, but they managed gum problems with traditional herbs to quell the ‘internal fire’ along with antibiotics from China and vitamin C20. Nonetheless, they consulted Western dentists when problems resisted traditional medicine, but were concerned about ‘loosing face’ if they could not afford the treatment.

Theoretical framework for oral health

A theoretical framework or model for oral health based on views of the body, the person and society was constructed from interviews and, subsequently, expanded from focus groups that had previously been conducted among elderly people of European origins in Vancouver32,33. It presents beliefs and behaviours relating to oral health essentially as a combination of oral hygiene, general health and comfort (including eating, appearance and absence of discomfort), and it is supported by theories of personality, personal control, social learning and other affective phenomena dominated by the social environment34,35. Consequently, we used this framework to help interpret how acculturation in Australia and Canada influences the dental beliefs and behaviours of older Chinese immigrants.

Methods

Chinese elders have a cultural fear of personal confrontation that could disturb a direct one-on-one interview;9 therefore, we used focus groups to explore how Chinese immigrants interpret oral health and the significance of mouth care and dentistry. We focused on Chinese immigrants, because they are widely dispersed globally, and particularly to cities around the Pacific Rim. In addition, previous reports indicate that they have limited and frequently incorrect knowledge about oral health. We chose oral health–related beliefs and behaviours as the medium through which we would explore the acculturation of elders for several reasons. Firstly, we know relatively little about how Chinese elders perceive oral health and dentistry. Secondly, the mouth is a sensitive organ with all the usual mix of acute and chronic disorders and disabilities that are typically associated with ageing. Thirdly, dental pain and discomfort can be very disabling and distressing, so toothaches are likely to get attention, while chronic discomfort in the mouth can be managed without help from a dentist. And lastly, eating and digestion are very important personal and social features of Chinese culture. We selected the communities in Vancouver and Melbourne, because they are similar socially and politically, but have different social and health policies relating to oral health care, which offered possibilities for observing different behaviours and expanding our knowledge about acculturation of new immigrant communities.

Recruitment

With approval from research ethic boards at each university, we recruited elders for focus groups in Melbourne (5 groups) and Vancouver (4 groups). We included recruits who were aged 65 years or older and had emigrated from China, including Hong Kong, within the previous 15 years. We identified a facilitator or ‘champion’ within Chinese community centres in Melbourne and Vancouver36, and with their help, we displayed posters in Chinese and English to publicise the objectives of our study. Subsequently we helped the facilitator to present details of the study in Cantonese or Mandarin to groups of potential recruits. In this way, and with appropriate written consent, we recruited volunteers for the focus groups.

Focus groups

Each focus group in Vancouver or Melbourne contained 4–7 participants, usually friends from the same community centre. The Chinese-speaking facilitator reintroduced the participants to the protocol and focus of the discussion and obtained general demographic information along with a signed consent in Chinese from all participants. The discussions were recorded on audiotape with everyone assigned a confidential code name. The facilitator prompted the discussions of health-related beliefs and behaviours. In Melbourne, we used a clinical vignette developed to prompt similar discussions among white elders37. It presented a situation in which an immigrant couple argue about the social significance of teeth and dentures. In Vancouver, we began discussions more directly with the question ‘how difficult is it for you to get information about health, including dental health, in Canada compared with your experiences in China or Hong Kong?’ As the discussions progressed, we introduced other open-ended questions when needed, such as: ‘Is it difficult here to get oral or dental care’;How do you take care of your mouth?’; ‘Does oral health affect your general health?’; ‘Do your children provide financial support for you to see dentists?’; ‘How could government agencies help you to keep your mouth healthy?’ The recorded discussions were translated to English by the bilingual facilitator in each city and transcribed verbatim in English with allowances for idiomatic adjustments38.

Analysis

Consistent with grounded analysis theory as interpreted by Corbin and Strauss39, the PI and facilitator at each location analysed the transcripts after each group discussion by open coding to identify key themes (e.g. health and illness) relating to the concerns, beliefs and behaviours of the participants40. The facilitator in each location was born in Hong Kong, spoke English, Cantonese and Mandarin, but had no specialised knowledge of dentistry. The lead researchers at each site are dentists from European backgrounds. Codes were created from background information on acculturation and oral health of Chinese elders7,10,11,20,27,41,42, and expanded by iteration and interaction between the PI and the facilitator who read the transcript of each discussion group before proceeding to the next43. This iterative process of description, clarification and refinement allowed the analysis of one focus group to influence those that followed and continued until the discussions were repetitive or saturated44,45.

Results

Participants

A total of 51 older Chinese immigrants participated in one of eight focus groups. Over half of the participants were women, and most were aged 65–74 years (Table 1). More of the Vancouver participants had a college or university education. The majority of the Melbourne participants had immigrated between 10 and 15 years previously, whereas in Vancouver there was more range between recent and long-term immigrants46. In both cities, they arrived mostly from Guangzhou Province and Hong Kong, and nearly everyone had natural teeth.

Table 1.   Demographic and oral health characteristics of participants.
CharacteristicVancouver (n = 28)Melbourne (n = 23)
Gender (%)
 Men4145
 Women5955
Age in years (%)
 65–693431
 70–743435
 75–802226
 81+109
Education (%)
 Primary or less1439
 Secondary3444
 College140
 University3817
Time in host country (years; %)
 ≤5144
 6–10240
 11–156296
Country of origin (%)
 Mainland China5878
 Hong Kong4217
 Unknown04
Dentition (%)
 Natural teeth6491
 No natural teeth79
 Unknown290

Categories and themes

The focus group discussions addressed 10 themes, which we have arranged in three broad categories: health and illness; dentistry and accessing care.

Health and illness

Oral health and general health  Discussions about oral health and general health confirmed the strong belief that they ‘have a close relationshipV1F#9* that ‘seeing a dentist is related to healthV1F#1, and that, it ‘is not healthy when there is a problem with the teethM3F#2. The relationship is particularly significant to eating, because when teeth are ‘not good, your stomach and other parts of your body will be not [be] goodV1F#2. Even more specific were the beliefs that ‘seniors usually have bad breath because of a deteriorated digestive systemV4M#22, and ‘if I have a smell in my mouth, I know that my general health is not good and I have problems in my digestive systemV2M#13.

Eating and digestion  We heard that ‘Cantonese like to eat the right food to be healthy… as food therapyM1M#2. There is apprehension that the Cantonese ‘traditional way of eating affect[s] the health of our teeth, [by being] too hard, too sour, too hot’M5F#2, and that, people with painful teeth or uncomfortable dentures ‘when they have to eat hard food, are not able to chew properly, their digestion is affected, and their health is affected negatively’V2M#13. They explained that fruits and vegetables rather than ‘digestive pillsV2F#15 are better for preventing digestive problems, and that, if ‘you have strong teeth, your digestion system is goodV2F#12. We heard from one person in Vancouver that ‘there is no fun without teeth, such as you do not know the taste of food without teeth’V3F#16 and from another in Melbourne that ‘when you are in pain, you could not do anything, you definitely could not eat, [and] even [if] you could eat, you could not digest properlyM2F#2. Discussions in both locations confirmed the dominant role of comfortable teeth and dentures for healthy eating and digestion: ‘Chinese love food, and without teeth [to chew] it will affect the quality of lifeM3F#1.

Beliefs about the effects of age on teeth were confusing. Some participants had strong beliefs about keeping themselves healthy, but a different belief emerged where deterioration of the teeth and mouth was associated directly with age:

‘My teeth are worse than before since I am old now… I had cavities in my teeth when I was young because I ate sweets too much. I seldom had mouth-problems in Hong Kong. It might be because I was younger in Hong Kong. I am old now. My teeth [are] getting worse’ V2F#12.

In general, participants in Melbourne and Vancouver shared this lament.

Personal and dental appearance  There was agreement that ‘without dentures one will look oldM1F#5 when teeth are extracted, or that ‘good looks give people confidence and health, [and] society needs people with confidenceM1F#1. These opinions were supported by the observation that ‘youth has natural beauty’M1F#1, and that, ‘older people need man-made beautyM1F#1, although the form of artificial beauty was questioned by the critical comment that Chinese unlike Westerners ‘traditionally do not have a tidy set of teeth- they are not straight and the sizes vary’M5F#1. For example, Mrs. T, Mr. and Mrs. H all explained that they changed their beliefs to comply with how they feel they should appear in Melbourne in contrast to Hong Kong:

Mrs. T.: ‘I like to be tidy and good looking’M4F#8.

Mrs. H.: ‘Appearance is important, it means politeness. Tidy appearance means you are respectful to other people. Therefore tidiness is importantM4F#10.

Mr. H.: ‘I agree. Besides tidiness, personal comfort is also important. In Hong Kong, I do not care too much. People there don’t bother too much on that. I don’t shave for days without a problem. In [Melbourne], I find people care a lot about their appearance. Especially senior citizens are tidy and respectful. The custom here is… to be clean and tidy’M4M#9.

Mrs. H: ‘Beauty is more important for me than for my husband. He did not shave when he first came to Australia, but later he changed his view’M4F#10.

Another woman in Melbourne explained why she and her husband care about their appearance out of respect for others:

There is no such thing as image. The old traditional Chinese way was the wife had to follow the husband’s wish. This is changed now. To me ethically, the good or bad of a person is not on their appearance. Ethical conduct means… respect for each other… Dentally, good appearance is fine but personal health is more important than teeth…. Communist China educated people not to bother with exterior appearance. That was in 1960’s. Capitalism… encourages exterior beauty’M5F#4.

This comment was supported further in the same groups by the statement that:

I could not accept that my husband does not care about his appearance… When we go outside, he has to dress up smartly, because this is showing respect to other people’M5F#2.

The role of personal and dental appearance obviously worries older immigrants as they make efforts to acculturate and to respect others in the host country.

Preventing mouth diseases  One participant explained oral health care as: ‘I see my dentist regularly. If I have tooth cavities, I will have them filled. I use dental floss in Canada, but I did not use dental floss in Hong Kong. I did not see a dentist regularly in Hong KongV3M#17; whereas another goes ‘to a dentist… if I have a toothache… [but] I can treat other things myselfV3F#21. Knowledge about preventing disease is quite sophisticated as we gathered from this complaint in Vancouver:

‘I think that my oral health is worse in Canada than in Hong Kong. It may be due to water quality in Canada… in Hong Kong, the government adds fluoride to the drinking water; therefore my teeth [were] more healthy in Hong Kong… when I came to Canada, I had canker sores, swollen gums and cavities; I did not have those mouth-problems in Hong Kong’ V4F#29.

Additional sophisticated insights to preventing caries were heard in Melbourne:

‘I know the genetic factor is as important as what you eat. I know if children do not eat much sweet foods, when they get old their teeth will be better. Especially eating sugar cane a lot will have a great effect on the health of teeth… it is better for a poor family not to have sweet snacks… In the poor rural area of China, people could not afford snacks other than their three meals. They set a good healthy foundation in their childhood. They have far less problems than the wealthier families’ M5F#4.

Dentistry

Knowledge of dentistry  Participants in Vancouver obtain their dental information from a Cantonese television station, but they complained that this information in Chinese is not available in public libraries. Consequently, we heard recommendations that: ‘government should provide oral health information… [because] education to the community is important[because with] good health, medical costs can be reducedV1F#1.1 We were told in both countries that interpreter services are available to immigrants when seeking health care in community clinics, although not when attending dentists in private practice. There was a complaint in Melbourne that ‘propaganda has a problem’ and that it is difficult ‘to get information… [and to] know what’s going on in the communityM4M#7. Concerns overall were expressed in both locations about how little emphasis governments place on dental services, and how difficult it is to find dentists who are culturally sensitive. The best strategy to promote oral health, according to several participants, is ‘free oral examinations from the government. It is the most useful way of informing older Chinese people about oral health’V4F#24. Yet, despite difficulties accessing oral health-related advice, at least one participant proclaimed ‘I have more [general] health knowledge in Canada than I had in Hong KongV3F#16.

Quality of dentistry  There is widespread belief that dentists in Canada and Australia are technically better than in China, although the participants qualified this view by statements, such as ‘[t]here are good and bad dentists in Canada, Hong Kong and China, [so] it depends on your experiences… the quality of dentists in China is quite good now’V4F#23. Regardless of beliefs about the quality of care, many participants prefer shorter waiting times, easier communications and the relatively low cost of dentistry in Hong Kong and China.

Traditional Chinese dentistry  Everyone seemed familiar with preventive strategies for managing chronic rather than acute oral and dental diseases. Herbal teas are used as mouthrinses to prevent disease ‘after eating hot and deep fried foodV1F#1, or to prevent cavities after drinking milk, juice or sweet drinks. Salt water rinses, antibiotics and other unidentified ‘medications’ from China are popular also. Some TCM strategies are derived from family traditions, such as ‘our grandmother taught the whole family to use salt to rub on our teethM5F#2, but participants seemed to know also about ‘dental floss… gum bleeding and bad breath’V4F#29. They drink water after eating sweets, and avoid ‘Western-style cakes, which are sweeter than Chinese-style cakes’V2M#10. They believe that ‘calcium is also important for the teeth’M5F#10, and that, they should ‘take [dentures] out… and clean them during night timeM4F#4.

Herbs and specific diets based on TCM are consumed in the immigrant communities to prevent and remedy various mouth problems. Swollen and infected gums, for example, are treated with ‘Xia Sang Ju (inline image) or ‘24 tastes (inline image) and with rice porridge, such as ‘salty egg and pork congee’V4F#28. One participant explained how he ‘usually steams a sliced banana for 10 hours… [to relieve a toothache] within 1 or 2 hours after eating the minced banana’V3M#18. Others listed ‘traditional herbal teas (Liang Cha) of honeysuckle flower (Lonicerace japonica), chrysanthemum (Chrysanthemi Morifolii), and tarragon (Artemisia capillaries) to decrease heat’, and ‘five flower tea (inline image)’, ‘Chinese Yam (Dioscoria Oppositae) and Fox nut (Euryale Ferox) (inline image)’, ‘Huang Lian Pian (inline image)’, and dried lotus seed soup with pork for the digestive system, which includes gums and teeth. Nonetheless, most of the participants preferred Western dentists and medications to treat toothaches, and occasionally acupuncture for relief of pain.

Accessing care

Financial burden  The most recurrent theme in both locations was the cost of dental treatment, which is perceived generally by the participants in both locations as a burdensome, if necessary, out-of-pocket expense. The effect, explained a participant in Vancouver, is that ‘the elderly lose all their teeth; they do not have money to get a denture; [so] they just give up and don’t take care of their mouthsV2M#13. The feeling was that at least some public benefits should be available to reduce this financial burden and health risk, ‘if the government does not cover the costs of meals in hospitals and uses that money to cover dental care [it would be] much betterV1F#9. Other suggestions were that the government:

does not need to cover crowning [of teeth because]… it is hard to do crowning… [but] seniors should be covered for cleanings, check-ups and fillings’V2M#10;

and ‘the government should give financial assistance for dentures for seniors based on their income’V2M#13.

There was also a further concession that a ‘denture for appearance can be self-financed’V1F#9.

Concern about the expense of dentistry was eased in Melbourne because, unlike Vancouver, there are several government-sponsored community health centres where dentists on salary provide comprehensive dental treatments at reduced fees. Consequently, we heard in Melbourne that ‘if you are entitled to have a pension card, you are all right, because you could access most service[s] free or at low costM3F#4. Elders with this card are eligible for services through dental clinics in community health services, rural hospitals and the Royal Dental Hospital of Melbourne,§ but ‘otherwise it is expensive and difficultM3F#4. Participants in Vancouver overall were more sensitive to costs because ‘the dentist fees in Canada are 20 to 30% higher than those in Hong Kong’V3F# 16, and an oral implant ‘costs… seven times the cost in ChinaV1F#4. In Melbourne, we heard that ‘you could pay your dentist by instalmentsM2M#9, but that estimated costs are very unreliable. Confusion arises also from differences in professional fees because in Melbourne ‘for same disease, one doctor charges $200, another charges $2000M4M#2. Another participant explained how even with ‘a cheque of $200 [from the local council in Melbourne] to see the dentist, at the end, it cost $800 for the treatment [and] I still have to find ways to pay the $600M1F#2.

There were recurrent recommendations during all of the discussions in Vancouver and Melbourne to include dentistry, at least for elderly people, as an integral component of a government-sponsored health care plan. They were based on the argument presented in Vancouver that

teeth are important for digestion. If teeth are not good, digestion will be affected. Then, stomach and other parts of your organs are affected. Oral health and general health have a close relationship; therefore, the government should cover dental care for seniors. It is a chronic disease for seniorsV1F#9.

Concerns about the cost of dentistry led to comments in both locations about not being a burden, such as: ‘I don’t want my children to support my dental fee and… to deal with many chronic diseases… as a senior here, I don’t want to give extra burden to my childrenV1F#2.

Returning to China for dentistry  Benefits of dental insurance continue on retiring from the civil service in Hong Kong and China to provide annual dental examinations along with preventive and restorative care by dentists. Consequently, many participants in both locations return ‘home’ for treatment because ‘dental treatment in China is cheaper… [and] there is no language barrier when seeing dentists in China [and] the quality of dentists in China is quite good now’V4F#23. One participant who anticipated the cost of dentistry in Canada ‘filled-up cavities and fixed all dental problems in Hong Kong before coming to Canada’V3M#18. Nonetheless, the benefits of dentistry in China were challenged by two participants who returned to Shanghai for dental treatment that needed retreatment in Canada.

Social isolation and access to dentists  When asked how to remain healthy, we heard in Melbourne that it is important to ‘avoid isolation [by going]… out to see your friends more often, and talk to them more often’M4F#1. A woman in Vancouver told us that good social interactions help to compensate for language difficulties because:

Western people are helpful. They give us helping hands as we communicate with limited English… using body language… in Canada, people help each otherI feel that we are living in a big family in the society… there are many enthusiastic people helping me, such as people from the church… people help me to make appointments for specialists…. there are translators and Chinese-speaking social workers helping me… the human relationship is very good, and we don’t feel isolated’V4F#28.

Melbourne offers discount travel with concession cards for elders, and we heard that public transportation is good in both cities ‘if you don’t mind walking far and you have plenty of time’M5F#2. It can be ‘quite inconvenient to get aboutM5F#6, especially for elders with arthritis, and in suburbs with infrequent bus services and long distances between stops. Therefore, some of the participants are more dependent than they wish on spouses or family members for transportation.

Discussion occurred from several perspectives on the opinion that ‘it is better to live separatelyM4M#6 from your children. Participants fear differences in lifestyle, like food and taste, along with suspicions that their children only want maids and babysitters. They explained that ‘in China, you have no choice but to live with a son or daughter, because there is no housing for old peopleM5F#4, but not so in Melbourne or Vancouver. There are good features of living with their children, because ‘life with them is livelier, [and] they could support me in case of illnessM5F#2. Different preferences for food can be settled when ‘my son has spaghetti and I have my riceM2F#8. However, the benefits of shared accommodation are more than balanced by a wish not to burden children with the transport and related expenses for visits to dentists, or with ‘an old person’s cough and fluM5F#4 that might infect grandchildren. They appreciate the welfare systems in Australia and Canada permitting them independence from their children when ‘the old Chinese happiness of five generations under one roof is a thing of the pastM1F#3. They were not disrespectful of their children and explained further how ‘my children can support my dental fee in Canada, [but] I do not want to give them extra financial burden since we can get free treatment in Hong KongV2F#11. Even more importantly, they agreed fervently with the belief of one woman who stated: ‘my children have already paid for my living expenses. In Chinese culture, children respect and take care of their parents. This belief has not changed in Canada’V1M#8.

Discussion

This study contributes to our knowledge about oral health care and acculturation of elderly Chinese immigrants in Australia and Canada. In this section, we will discuss the implications of the study for understanding the beliefs and behaviours of this immigrant population, relating specifically to health literacy, significance of the mouth, TCM and financial burdens. Additionally, we will discuss the theoretical implications and limitations of the study.

Beliefs, concerns and behaviours

Health literacy  Local differences between the social services and health care policies of the two cities had no obvious influence on the oral health care of participants in this study. The health beliefs and behaviours of the immigrants support the concept of acculturation as a combination of Western and Chinese concerns and practices, where Western dentistry is sought for acute problems, such as toothaches and TCM for chronic problems, such as periodontal diseases. In both cities, the participants knew how to prevent common diseases of the mouth and teeth, and their opinions about oral health care probably formed before they emigrated to Australia or Canada. Nonetheless, they complained about a lack of ‘propaganda’ or information on dental services, which might reflect their general interest in health rather than a serious ignorance of dental services. The facilitators we employed from the local Chinese community in each city were similar to the Latino ‘peer health advocate, or a lay-person health promoter’ employed by Watson et al.47 for a Latino community in the United States. Perhaps health care workers with backgrounds and approaches similar to the target population could promote health in communities that differ culturally and linguistically from the mainstream and help to provide an oral health service sensitive to the culture and needs of immigrants48.

Significance of the mouth  The significance of the teeth and mouth expressed by our participants is similar to explanations offered by other elderly groups22,23,25,49. The function and appearance of the mouth and teeth are described typically in the context of hygiene, health and comfort, where comfort includes eating, acceptance of appearance and overall well-being with natural or artificial teeth. Cleanliness and appearance of the mouth and teeth are influenced by a sense of social responsibility, which seems to increase after immigrating to the West, and is unlike other communities of older Chinese immigrants7,10–12. Concerns about chronic diseases of the mouth and teeth were associated with their impact on general health, especially digestion. Investigations of immigrant groups with a greater range of age and socioeconomic status might find that these concerns about dental appearance are useful indicators of acculturation.

Traditional health care  Traditional health practices continue actively among older Chinese immigrants, suggesting that enculturation is an important component of acculturation. They use teas, soups and porridges to prevent or manage chronic disease by rebalancing the body and reducing digestive disorders, which include mucosal ulceration and gingival swelling. TCM is combined with Western dental techniques and medications to treat acute toothaches and swellings. It is a complement rather than a substitute for Western dentistry to prevent or manage chronic diseases. Typically, a toothache is managed with traditional remedies for only a short time, and a dentist is consulted if the problem persists.

Overall, the participants expressed general admiration for the technical sophistication of Western dentistry, although participants in both cities were surprised by the separation of dentistry from medicine. TCM changed significantly in China during the 1950s following state-directed efforts to integrate it with Western biomedicine into a larger health care system18,50. This probably explains in part why separation of dentistry from medicine seemed so anachronistic to them. Boundaries between Western medicine and TCM are similarly permeable in China today, which is a trend that Jin18 attributes to general changes in cultural values. Consequently, the participants were probably reporting beliefs and behaviours formed before they emigrated rather than as a result of immigration.

Financial burden of dentistry  Dentistry in Hong Kong and China is paid mostly from private funds, and our participants were familiar with paying directly for dentistry. Yet, in both cities, and despite salaried dentists in Melbourne’s community health centres, participants complained about the cost of dentistry and a lack of government support for dental services. Many of them found it less expensive and generally more accessible linguistically and culturally to obtain dental treatment in Hong Kong or China occasionally for all but emergency treatment. This preference was even more appealing for immigrants who retired from government service in Hong Kong or China, where free dentistry is a benefit of retirement.

Inconvenient transport and various cultural barriers to accessing dentistry highlighted the traditional role of the family rather than the state in health care. It was very clear that the participants sought only emotional comfort and support from their children, without burdening them with the costs of dental or other health services.

Theoretical implications

The framework of oral health developed and refined from groups of elders from a European culture in Vancouver supports our findings. As the earlier theoretical framework indicates31,32, concerns and behaviours relevant to oral health care were dominated by hygiene, general health and comfort (incl. appearance). The immigrants discussed specific ways of adapting and coping with disorders of the mouth. Apart from the use of traditional remedies and visits to China, they seemed influenced by personal and social environments similar to elderly people from a European culture in Vancouver47. They also expressed significant concerns about the cost of dentistry, which Brondani et al.25 found also among European elders. Therefore, the theoretical framework helps to interpret how acculturation in Australia and Canada influences the dental beliefs and behaviours of older Chinese immigrants, and especially, if we consider the comfort of eating not only as nourishment but also as a remedy for illness.

Limitations

Our attempt to recruit on the principle of theoretical sampling was only partially successful. The participants were moderately affluent, well educated and well acculturated to life and health services in Canada or Australia. Ethnic minorities in general are prone to poverty and social isolation4, both of which inhibits recruitment for research among this population35,51. We recruited in community centres with diverse socioeconomic profiles, yet we failed to recruit immigrants with low incomes and little education, or those who felt socially isolated, despite our snowball sampling techniques52. We did not solicit information directly about personal income, because we felt that it probably would have deterred recruitment, and is often unreliable. Nonetheless, our recruits, when compared with Chinese immigrants of low socioeconomic status surveyed in the UK10, seemed affluent, well educated, knowledgeable about oral health care and unbothered by the potential misfortune from natural teeth in old age. Instead, they were socially engaged in the community centres. They value the emotional support of their children, but prefer to live independently of them. Clearly, we need different recruitment strategies to involve immigrants who are socially disengaged and others who experience financial problems49.

In general, our findings reflect the beliefs and behaviours of people in ordinary, albeit immigrant, circumstances, and much of what we heard were ordinary discussions of everyday concerns and activities. Nonetheless, we contend that the discussions did reveal quite credibly the state of acculturation that the participants had attained within the two societies that are still dominated by European culture.

Conclusions

The theoretical framework of oral health developed and refined from groups of elders in Vancouver is relevant to the acculturation of elderly Chinese immigrants in Vancouver and Melbourne, but with an elaboration of eating as a therapeutic remedy to illness. The similarity of concerns among the immigrant populations in Melbourne and Vancouver suggests that dissemination of information and availability of services are the important themes influencing experiences and perceptions of oral health. Likewise, beliefs developed over a lifetime play an important role in interpreting oral health. Apparently, knowledge about oral health and related practices in this group of elderly immigrants is influenced continuously by traditional Chinese culture interacting with the realities of life and access to dental services in the adopted country.

Footnotes

  • *

    Confidentiality Code – for example: V1 = 1st focus group in Vancouver; F#9 = female participant number 9.

  • Xia Sang Ju (inline image) is a herbal tea or soup made with a mixture of selfheal (Prunella vulgaris), mulberry leaves (Morus alba L.), and wild chrysanthemum (Chrysanthemi Indici) used commonly to prevent the common cold.

  • 24 tastes (inline image) is a hot tea made with a mixture of 24 herbs.

  • §

    http://www.health.vic.gov.au/dentistry/clients/dental_system.htm

Acknowledgements

This research was funded by a grant from the Canadian Institutes of Health Research (Grant #84561). The authors are grateful to Stella Kwan (University of Keeds, Leeds Dental Institute, UK); and Malcolm Williamson (Ministry of Health, Government of British Columbia, Canada) for their contributions to the grant application. Asuman Kiyak who was an active member of our research team died in 2011.

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