Exploring the experiences of foster and kinship carers in Australia regarding the oral healthcare of children living in out-of-home care

Abstract

Foster and kinship carers play an integral part in establishing oral health promoting behaviours and managing the oral health issues of children in out-of-home care (OOHC). This study aimed to explore the knowledge, experiences and support needs of Australian foster and kinship carers in maintaining the oral health of children living in OOHC, using semi-structured interviews with eight purposively sampled carers. Results showed that the participants understood the importance of good oral health for general well-being and were motivated to implement good oral hygiene practices with the children in their care. The challenges encountered by foster and kinship carers included: a lack of information from foster care agencies regarding the oral health needs of children; difficulty in the pre-approval processes for dental treatment; and poor communication between carers and foster care agencies. Systemic challenges included: transience and frequent changes in the child’s foster placement; long waiting lists for dental treatment; and lack of dental professionals. We conclude that foster and kinship carers need support to promote the oral health of children in OOHC and that systemic barriers must be identified and addressed.

Keywords

Out-of-home care foster carers kinship carers oral health dental health

Introduction

In Australia, out-of-home care (OOHC) is a temporary, medium- or long-term living arrangement provided to children and young people up to 17 years old who are unable to live with their families (Australian Institute of Health and Welfare, 2021a). Recent statistics show that there are approximately 46,200 children in OOHC in Australia (Australian Institute of Health and Welfare, 2022), around 424,000 children in foster care in the USA (Child Welfare Information Gateway, 2021) and about 80,850 in England (Department for Education, 2021). Parental illness, drug use and incarceration, child abuse and neglect or a combination of these factors may lead to the placement of a child into OOHC, where their health and safety is to be prioritised and ensured (Australian Institute of Health and Welfare, 2021a; Barber, Delfabbro and Gilbertson, 2004).

There is consistent evidence that children living in OOHC experience increased physical, mental and developmental problems, as well as oral health issues, compared to children not living in OOHC (Berlin et al., 2018; Jurczyszyn and Easterbrook, 2018; Morón et al., 2019). Dental decay has been reported to be the most common form of childhood disease (Solis-Riggioni, Gallardo-Barquero and Chavarria-Bolaños, 2018), estimated to affect more than 520 million children globally (World Health Organization, 2021). In Australia, at least 40% of children suffer from dental decay (Centre for Oral Health Strategy, 2014) especially among those living in low socioeconomic areas (Peres et al., 2019), with a peak prevalence experienced by children under five years (Chen et al., 2019; Veale et al., 2016). Pain and swelling are common symptoms, which have negative consequences on children’s sleeping and eating behaviours and may also lead to poor school attendance (Abanto et al., 2011; Centre for Oral Health Strategy, 2014; Jackson et al., 2011). During 2017–18, at least 22,900 Australian children aged 0–9 years were hospitalised due to dental conditions, which could have been potentially preventable with early disease detection and treatment (Alshehri et al., 2021; Australian Institute of Health and Welfare, 2020; Peres et al., 2019). This is even more critical among children living in OOHC, with a study in Australia reporting that 61% of children in foster care suffer from dental caries (Rauter et al., 2018).

Dental decay is highly preventable and is directly linked to behaviours such as tooth brushing with fluoridated toothpaste, flossing, healthy eating and regular dental visits. Parents and carers are known to play a crucial role in establishing and maintaining children’s oral health behaviours early in life (Australian Institute of Health and Welfare, 2021b; Castilho et al., 2013; de Silva‐Sanigorski et al., 2013). When children are placed into OOHC, this role becomes the responsibility of the foster or kinship carer. However, there is a scarcity of evidence regarding the role of foster and kinship carers in relation to the oral health of children living in OOHC. The main objective of this study, therefore, was to understand foster/kinship carers’ experiences of addressing the oral health needs of the children in their care and, more specifically, to explore the challenges carers face and the supports they require to improve and maintain children’s oral health.

Methods

Study design

A qualitative design was chosen for this study to gain an insight into and understanding of foster and kinship carers’ experiences of managing the oral health of children living in OOHC.

Participants

A combination of convenience, purposive and snowball sampling was used to identify foster and kinship carers in Australia who were providing care to children aged 0–17 years at the time of the study. This combination of sampling techniques was used to recruit a hard-to-reach population (Abrams, 2010; Miles and Okamoto, 2008). Social media platforms such as Twitter, Facebook and LinkedIn were also used to advertise the study (King, O'Rourke and DeLongis, 2014). Interested individuals were invited to contact researchers and subsequently provided with information regarding the study’s aims, eligibility criteria, interview process and the voluntary nature of the research. Recruitment was undertaken until data saturation was reached; eight participants were interviewed before this was achieved.

Data collection

This study used in-depth, semi-structured interviews to gain insights into foster/kinship carers’ experiences in relation to the oral healthcare of children in OOHC. Interviews were conducted and recorded online via Zoom, lasting between 20–30 minutes each.

Data analysis

The Zoom-derived transcripts were reviewed to ensure accuracy then subjected to content analysis as described by Miles and Huberman (1994) using NVivo software. The research team held iterative discussions to generate codes and sequentially identify themes.

Ethics

Ethical approval was obtained from the Human Research Ethics Committee at Western Sydney University in Australia prior to the start of the study. Informed consent was gained prior to data collection. Pseudonyms have been used to present the findings and ensure the confidentiality of both the participants and the children in their care.

Findings

Sample description

A total of eight carers (n = 7 foster carers and n = 1 kinship carer) from three Australian States – New South Wales (n = 6), South Australia (n = 1) and the Australian Capital Territory (n = 1) – participated in the study. Of these, seven identified as female and one male. The majority were married (n = 5), with ages ranging from 32 to 57 years (M = 40.8 years), and had at least four years’ experience of providing care to children in OOHC (n = 7). The types of care provided included short-term, long-term, and emergency care.

Three key themes were identified from the data:

foster carers’ knowledge of the oral health of children in OOHC;

the challenges of caring for the oral health of children in OOHC;

the roles, current practices and support needs of foster and kinship carers.

Foster carers’ knowledge of the oral health of children in OOHC

Overall, participants were aware of the importance of good oral health among children and the need for preventative oral hygiene practices, such as regular brushing and flossing, as well as routine dental visits. All participants were also aware of the adverse effects of a high sugar intake on children’s oral health, recognising that a healthy diet was a key factor in determining the oral health outcomes in children: ‘[we] need to include healthy, wholesome foods and plenty of water while minimising sugary foods’ (Sophie). In addition, most participants acknowledged that it was important to take care of children’s teeth as dental decay can adversely impact on the children’s overall health and well-being. Specifically, they understood that dental pain may result in behavioural changes:

If they’re in pain, then it’s going to affect their moods, and their behaviour. If they’re little, they don’t understand how to tell [you that] their teeth hurt them, they are just going to cry, and you’re not going to know what’s going on. So [it] definitely will affect, like, the[ir] day-to-day life. (Astha)

Carers also seemed to understand that oral health could impact upon and be impacted by a variety of factors. For example, one carer articulated the link between poor oral health and cardiovascular disease: ‘it affects your heart and all that sort of stuff if you don’t have good teeth’ (Sophie). Other carers (n = 3) were concerned about the impact of poor maternal health on children’s teeth during pregnancy. One participant indicated that she was told by the dentist that the child in her care ‘had weak and fragile teeth as a result of the biological mother’s alcohol intake’ (Mary). Another participant explained that the child in her care had a mental health condition which impacted her ability to perform daily tasks, including brushing her teeth:

One of things she got a big aversion to was brushing her teeth. So, there was a long period where, essentially, she would probably brush her teeth, maybe once every two to three days. (Julie)

Challenges of caring for the oral health of children in OOHC

Despite the participating foster and kinship carers’ sound knowledge of good oral health practices, the interviews revealed that there were several factors affecting the oral health of the children living in their care.

While half of the participants indicated that the children in their care did not have any significant issues with their teeth, three reported that the children in their care had serious dental problems requiring intensive treatment or had other health issues affecting their teeth. When describing the oral health of a little girl in her care, Mary indicated that there may be a need for significant orthodontic work: ‘Her teeth are terrible and, obviously, her baby teeth still have to come out, but the positioning, and jaw alignment [are] terrible.’

Carers reported receiving minimal information from their foster care agencies when the children were initially placed into their care, making them feel unprepared to deal with the children’s oral health issues. In addition, the transient stays of children also affected their healthcare. Rita reported that she was not advised by the agency to take the children who came into her care for a short duration to the dentist. She reflected on ‘how things might have been different’ if the agency had informed her of the child’s oral health needs, explaining that the brief stays of children had changed her priorities: ‘Having children for a shorter duration meant that making them feel safe and comfortable was more important over dental assessment and treatment’. Another carer, Julie, seconded this by saying that there was no continuity of care when children were placed with different carers or managed by different social workers. Moreover, remaining with the same carer was seen to have the benefit of generating trust in the child, thus facilitating the care process:

Her having known us her whole life and having us as her very safe space made her trust us and [know] that we’re going to help her, whereas if you had a child who’s been through four or five homes and may not have that same safety, they’re not gonna listen to the social workers or to carers as much if they don’t trust them. (Julie)

There was a consensus among participants that working with foster care agencies to access oral health services for children living in OOHC was difficult. Participants emphasised getting pre-approval from foster care agencies for children’s dental visits was a lengthy and arduous process. Once approved, some carers reported long waiting periods to see a dental clinician. Those living in rural areas struggled due to the lack of dental professionals or the long distances required to travel to dental services. However, it was an advantage that all participants were aware of the dental benefits scheme of the government and were therefore able to access free dental treatment from public dental services.

Finally, how dental health professionals interact with children in OOHC was also recognised to play a key role in accessing oral health services. One of the carers, Whitney, identified that the poor chairside manner of the dental professionals impacted negatively on the behaviour of the children especially those who were traumatised by past experiences:

So, the dental team at the hospital were really rushed and not very patient with her, she would revert to the baby behaviours and wouldn’t let them look in her mouth. She would let them put a mirror in her mouth and air but wouldn’t let other instruments in her mouth.

Roles, current practices and support needs of carers

All participants were committed to their role in motivating children in their care to value oral health and develop good oral hygiene practices. Most of the carers in this study reported implementing good oral health practices for children living in their care and accessed oral health services for children’s preventative and treatment needs when required.

Participants described a variety of preventative strategies for improving and maintaining the oral health of children living in their care. These included motivating the children to brush their teeth and assisting them to do so. Three participants used daily reminders to ensure their children developed the habit of oral hygiene. Having good communication with children was an important strategy used by participants (n = 3) in promoting oral health, emphasising that talking with children was important to help them understand the value of good oral health practices. Some participants recommended modelling behaviour by brushing their teeth with the children. Others tried more innovative methods such as singing and making the activity fun: ‘We have two-minute song and dance in the bathroom every morning … I sing it, she brushes, and she’s got to keep brushing for that whole two minutes’ (Sophie).

While many of the participants developed their own strategies to improve the oral health of the children in their care, they agreed that education and training programmes on diet and nutrition could benefit foster and kinship carers and assist in promoting children’s oral health. Some also felt this information should be provided to birth parents as they had witnessed poor dietary habits when the children visited with their parents. This holistic approach would ensure that children received consistent messaging about oral health both while in care and when returning home.

As stated above, participants reported that more information from the agency regarding the child’s oral health status would help carers plan for their oral healthcare and dental visits: ‘Sometimes they [agencies] just come and drop them off and they say, all right, this is his name, this is how old he is. And that’s it’ (Astha).

Being given more information by the agency would have allowed carers to re-organise priorities for the child’s welfare. As Rita stated: ‘[Oral health] might not be my top priority. But if I was told this needs to happen then I would have’. Support in making the process easier for foster and kinship carers to access oral health services would be beneficial and expedite addressing the oral healthcare needs of children living in OOHC.

Discussion

To our knowledge, this is the first Australian study to explore the experiences of foster and kinship carers regarding the oral healthcare of children living in OOHC. Our findings show that the participating foster and kinship carers possessed sound knowledge in relation to the importance of oral health and preventative behaviours such as regular tooth brushing and routine dental visits for the children living in their care. This mirrors the results of research conducted in the UK, which found that foster carers had positive oral health attitudes and a good knowledge of the risk factors and health impacts of poor oral health among the children living in their care (Muirhead et al., 2017). The findings of the current study also illustrate that foster and kinship carers influence the oral health behaviours of the children in their care as positive role models. Despite this, as research conducted overseas has similarly shown (Morón et al., 2019; Solis-Riggioni, Gallardo-Barquero and Chavarria-Bolaños, 2018), children living in OOHC in this study still experience poor oral health and high rates of unmet oral health needs. This suggests that the efforts of foster and kinship carers alone are not sufficient to promote and maintain the oral health of children living in OOHC. Some of the major barriers highlighted in this study were systemic challenges which included difficulty in seeking approval for dental care for children in OOHC from the Australian foster care agencies and the lack of authority of foster carers to initiate dental visitations for their children without pre-approval from their agency. This resonates with another Australian study (McLean et al., 2020), which identified foster and kinship carers’ lack of decision-making authority as a major factor in not accessing healthcare for children living in OOHC, in contrast to carers who obtained permanent care or guardianship by court orders and so have a legal right to make health-related decisions. Those lacking legal rights rely on the agencies for health-related decision-making, which can have an impact on the timely receipt of healthcare among children in OOHC (McLean et al., 2020). Another major systemic barrier identified in this study was the transience of children living in OOHC, which resulted in carers prioritising more urgent mental health issues over oral health. Similar to our findings, studies have also identified short-term stays and frequent transfers of children living in OOHC as prime factors affecting their oral healthcare (Hillen and Gafson, 2015; Szilagyi et al., 2015). An understanding of these systemic barriers is therefore warranted to identify and develop supportive strategies and policies in Australia.

The findings from our study also revealed that these systemic factors were further complicated by a lack of sufficient information regarding individual children’s oral health needs. The national framework for protecting Australia’s children (Australian Institute of Health and Welfare, 2021a) recommends that each child should have an initial health assessment when entering the OOHC system and a comprehensive assessment, inclusive of oral health, conducted within three months of initial placement. Carers in our study remarked on the lack of information regarding prior health screenings and assessments and the existing oral health needs of the children living in their care.

Participants did not articulate a clear understanding of their specific roles and responsibilities in relation to the oral health of the children in their care, nor did they provide a clear description of the case worker’s role. Some carers described being proactive, accessing dental services from their clinicians, while others waited for foster care agency direction and approval to seek dental treatment. This inconsistency requires attention, and the responsibilities of both foster/kinship carers and case workers need to be clearly delineated if the oral health of children living in OOHC is to be promoted and maintained.

Limitations and recommendations

The small sample size of this study may not have reflected the views of culturally and linguistically diverse carers, Aboriginal and Torres Strait Islander carers and those residing in same sex relationships. Future research should consider these perspectives. Such research can aid in providing unique and valuable insights into the influence of an individual’s cultural and social framework on their oral health knowledge and practices.

The knowledge, attitudes and practices of other key stakeholders involved in the care of children living in OOHC, such as case workers and relevant health care professionals, should be explored to provide additional perspectives on how, when and what other strategies are needed to improve the oral health of children in OOHC.

Recommendations for policy

While Australia’s National Oral Health Plan 2015–24 provides a framework for collaborative action in relation to oral health, this does not explicitly identify children living in OOHC as a priority group and lacks guiding principles specific to the oral health promotion of these children (Council of Australian Governments Health Council, 2015). Similarly, planning in the state of Victoria has also missed the opportunity to highlight children in OOHC as a higher risk population in their 2020–30 action plan to prevent oral disease (Department of Health and Human Services, 2020). On the other hand, the government of New South Wales has identified children in OOHC as a priority population and provides a strategic framework to improve oral health by increasing access to oral health services and promoting primary prevention through water fluoridation, health promotion and disease prevention (Centre for Oral Health Strategy, 2013). This illustrates the inconsistency in the oral health policies between states across the country which predisposes children in some jurisdictions to poorer oral health. There is a need to make sure that the policies of all states and territories align with the national framework to ensure equitable access to dental services for all children living in OOHC in Australia. Similar efforts could be followed in other countries that have foster care systems to guarantee a consistent approach to improving the oral health of children in OOHC worldwide. Increasing the funding for public dental health resources for children in OOHC is another important strategy for reducing waiting times and improving this vulnerable population’s access to oral healthcare.

Recommendations for practice

This study highlights numerous areas that require the attention of policymakers, social and healthcare professionals and those involved in the care of children in OOHC. Better collaboration, information-sharing and communication are needed between foster/kinship carers and foster care agencies to simplify the oral healthcare approval processes, provide autonomy to carers for making decisions and facilitate access to healthcare. The continuity of oral healthcare must be taken into consideration in decisions involving children in OOHC who have been transferred or provided with short-term care.

People with a better understanding of the importance of oral health have lower rates of missing teeth and gum disease and are more likely to adopt beneficial oral health behaviours (Baskaradoss, 2018). Increasing awareness and knowledge through educational oral health refresher courses targeted at foster carers (and indeed, birth parents) would benefit the oral health of the children in their care.

Conclusion

The major challenges that need to be addressed to improve the oral health of children in OOHC are systemic barriers. Strong collaboration and open channels of communication among child social welfare and other healthcare professionals, such as paediatricians and dentists, must be established to promote oral health among children living in OOHC. Including the voice of foster and kinship carers in the planning and design of oral health interventions for children in OOHC is an important strategy to ensure that these interventions are tailored and fit for purpose.

Footnotes

Acknowledgements

We would like to thank the participants in this study who shared their experiences related to the oral healthcare of children living in OOHC, despite the challenges of the Covid-19 pandemic.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

These notes were prepared by Reecha Acharya, Western Sydney University, Professor Ajesh George, the Australian Centre for Integration of Oral Health at Western Sydney University, the Ingham Institute for Applied Medical Research and the School of Dentistry at the University of Sydney, Harrison Ng Chok, Western Sydney University, Dr Della Maneze, the Australian Centre for Integration of Oral Health at Western Sydney University and the School of Nursing at the University of Wollongong and Associate Professor Stacy Blythe, the School of Nursing and Midwifery at Western Sydney University and the Ingham Institute for Applied Medical Research, New South Wales, Australia.

Health Notes are edited by Ellie Johnson, Health Consultant, CoramBAAF.

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