I. Introduction
Over the past two decades, Korea has transformed into a major migration destination in Asia. The foreign population has more than doubled in 2015, compared to that in 2005 [
1], and comprises approximately 1.81 million people. This sudden increase of resident foreigners in Korea may have resulted from Korea’s recent economic development and globalization.
Oral health is an important part of overall health and should not be neglected; furthermore, oral diseases should be recognized as a public health problem [
2]. When prioritizing overall medical services and health problems, oral health management is likely to be neglected compared to other systematic diseases. However, there is strong evidence that the general health status of young children directly influences their health, development and well-being throughout life. Severe dental caries in early childhood can disturb physical growth and cognitive development by interfering with sleep, appetite and eating patterns, and can lead to poor performance and behavioral problems school, and negative self-esteem [
3]. An inverse relationship between socioeconomic status and caries prevalence has been reported in studies of children aged less than six years. Children from immigrant backgrounds have been reported to have a three times higher rate of dental caries compared to those with non-immigrants backgrounds in the United States [
4].
According to statistics in 2013, the population of foreign children under the age of nine years comprised approximately 3.8% (59,584) of all foreigners living in Korea. With the acceleration of globalization, the number of foreign children in Korea will increase. Although there are some studies on the utilization of dental services by adult foreigners, no study has been conducted on the utilization of dental services by foreign children in Korea [
5].
The purpose of this study is to investigate the utilization status of pediatric dental services by foreign children living in Seoul, the capital of South Korea, as well as their level of satisfaction with the services provided. This study is designed to offer preliminary data for providing dental services and to establish health care policies for foreign children living in Korea.
II. Materials and Methods
1. Subjects
This study has been conducted to assess the utilization status of pediatric dental services by foreign children, between September 20 and December 5, 2014. Data were collected randomly from foreign children aged 6 months to 14 years, who are living in Seoul. We used a structured questionnaire with written information about the study, as well as dental recommendations for children. The total number of collected questionnaires was 411 and among them, 20 questionnaires with inadequate response were eliminated. In total, 391 were used for statistical analysis.
The participants who could read and understand English were from the embassies of Africa, Asia, Australia and Oceania, Europe, North America and South America. Foreigners encountered on the streets in Hannam-Dong and Itaewon also participated in this study; they were from Brazil, China, Philippines, Ghana, Italy, and Nigeria. We visited and surveyed other groups of people or institutions that participated in this study, including the military, the International Lutheran church, Youngsan-Gu office, International schools of South Korea, the Word of Faith Mission Center Program, Women`s Federation for World Peace-International Women in Korea, Seoul Children`s Dental Center, Soon-Chun-Hyang University Hospital-International Clinic (Depart. of Family Medicine), and Severance Hospital - International Clinic Care Center (Depart. of Pediatric).
2. Methods
Based on previous studies, we revised and supplemented various questionnaires according to our study purpose and subject. Additionally, two dental professionals, fluent in Korean and English, translated the English-language survey into Korean and compared each with the other to verify the conformance of the survey. Research items were 35 questions in total comprising of 14 questions relevant to demographic characteristics and 21 questions concerning the oral hygiene of the child (
Fig. 1,
Fig. 2).
3. Statistical analysis
The data for this study were analyzed using the SPSS (Statistical Package for the Social Science Version 12.0) program. Demographic characteristics and the utilization status of pediatric dental services by foreign children living in Seoul were analyzed by frequency and percentage. Other criteria were analyzed by descriptive statistics.
IV. Discussion
This study was performed to investigate the status of utilization of pediatric dental services by foreign children living in Seoul. All questionnaires were answered by parents. The participants in this study demonstrated minimal dental knowledge regarding oral hygiene and preventive dental care, with a majority reporting, average or above average levels of satisfaction regarding the quality of dental service they received. However, dental treatment fee and communication still appeared to be the most significant barriers for foreign patients.
Most respondents had basic knowledge about the importance of brushing twice a day and use of fluoridated tooth paste. The participants understood that the regular use of fluoride toothpaste is one of the most cost-effective methods for preventing dental caries [
6]. Approximately 70% of the respondents answered that their children brush their teeth at least twice a day and use fluoridated toothpaste. However, most respondents lacked knowledge about additional effective methods of preventing dental caries, such as tooth brushing under parental supervision, use of dental floss, periodic fluoride application, and regular dental check-ups. Preschool children are often too young to perform effective tooth-brushing on their own; therefore, tooth-brushing under parental supervision is recommended [
7]. About 40.4% of the participant’s children were brushing their teeth without adult supervision or assistance. Nearly 80% of the respondents reported that their children were neither using dental floss nor receiving any fluoride treatment; this was a surprising result considering that more than 80% of the respondents had high education level. According to a systemic review by Merrilyn
et al. [
8], parental oral health knowledge influences the children’s diet and dental hygiene, resulting in a decreased risk of caries. In another study, it was reported that children of parents with low education levels visited a dentist less frequently [
9]. Dental health knowledge did not correlate with the level of education of foreign parents included in this study. In this case, a high education level does not imply extensive dental knowledge. Therefore, education regarding oral hygiene is needed, for immigrants to reduce the development of dental caries in children, and improve their oral health.
In this study, correlation was observed, to some extent, between nationality and the use of fluoride toothpaste and additional fluoride treatment. It was determined that Africa had the highest percentage of children (53.3%), who had not used either fluoride toothpaste or any additional fluoride treatment, followed by Europe (39.1%), North America (21.0%) and Asia (18.0%). Availability and accessibility of oral health services is very limited in African countries, and little is known about the utilization status of oral health services in African countries [
3,
10,
11]. This study shows the lack of oral health knowledge in African parents with high levels of education, leading to the neglected of oral health care systems in many African countries.
According to this study, there were no significant barriers that hindered the respondents from visiting dental clinics in Korea. Their frequency of dental treatment was similar before and after their migration to Korea, as were the types of dental institutions they visited. When asked to explain why they did not avail dental treatment in Korea, only 13% of them referred to the expensive dental treatment fee as the main reason, while others answered that there was ‘no need’ (21%), their children were ‘too young’ (11.3%), or due to the ‘language problem’ (3.8%). The remaining 33% of the respondents did not specify a reason. On the basis of these results, it may be concluded that the low utilization rate of dental health services by foreign children in Korea is not influenced by inaccessibility to dental clinics, language/communication problems, or financial burden, but rather deficient dental health knowledge and insufficient interests in oral health. Most of the respondents took their children to dental clinics when dental problem occurred, such as cavitation, pain, or mobility of teeth. This observation is supported by the finding that the most frequently received dental treatment, both before and after migration to Korea, was the ‘filling’ of dental cavitation.
The foreign children who had received dental treatment in Seoul showed overall satisfaction of about 95% regarding quality of treatment, pleasant environment, speed of treatment, and friendliness of staff. However, reduction of the treatment fee and improvement in communication were pointed out as strategies to improve their utilization of dental services in Seoul. Approximately 60% of the respondents answered that they pay the treatment fee either fully or partially. Only 60% of the respondents were receiving benefits from either private insurance or company coverage. Although foreign employees are eligible for Korean worker health insurance since 2004, many foreigners decline to apply due to the unfavorable application system and requirements [
12]. For these reasons and due to expensive insurance coverage, many foreigners seem to defer joining Korean health insurance. Without insurance coverage or support from a company, health care fee will remain a burden to most foreigners living in Korea. Regarding communication, only 20% of the respondents had the ability to speak fluent Korean language, with more than 60% admitting to having poor to very poor Korean language skills. In this study, the respondents showed similar rates of utilization of dental health services before and after their migration Korea, which indicates that dental treatment fee and communication hindrance were not the most significant barriers. However, in another study regarding foreigners in Korea, lack of time and excessive treatment fee were main reasons for not using dental health services in Korea [
12]. Therefore, the result of this study should not be generalized to the entire foreign population living in Korea.
Immediate systemic changes and improvements regarding national health insurance, reduction of dental treatment fee, or communication support for foreigners are hard to achieve in a short term; moreover, owing to the steady growth of foreign population, long-term governmental considerations are necessary. Meanwhile, educating the parents of foreign children can be a cost-effective and practicable modality for preventing dental caries and maintaining good oral health. In this study, 86% of the group, that reported the frequency of tooth brushing as zero times per day, was comprised of infants and young children aged 0 - 5 years old. This demonstrates a lack of knowledge regarding the importance of oral health and hygiene in infants and young children. Educating foreign patients about the importance of good oral hygiene practices, such as tooth brushing under parental supervision, use of dental floss, and fluoridated tooth-paste, will be a valuable preventive approach. They should be also educated about the importance of different preventive measures, such as regular dental examination and additional fluoride application, e.g., fluoride varnish, which has been proven effective in preventing dental caries by robust scientific evidence from clinical trials [
13]. Oral health education can be provided at international schools, embassies, or as a part of the Korean immigration and integration program. In addition, inclusion of foreign infants and children in the infant and child dental check-up programs will be a meaningful step for maintenance and improvement of dental health of foreign children living in Korea. If the Korean government takes the initiative to promote the importance of oral health of foreigners as well as their employment and integration into Korean society, their quality of life in Korea will definitely improve.
Though not included in this study, the children of North Korean refugees and internationally married couples should also be considered as foreigners in Korea. According to AAPD guidelines, children with immigrant backgrounds have a three times higher rate of tooth decay than those with non-immigrants backgrounds [
4]. According to data regarding the oral health status, North Koreans in South Korea show a higher dft index (6.35) and DMFT index (3.67) compared to South Koreans (3.15 and 2.27, respectively). Young North Koreans adolescents in South Korea, showed 0% experience with sealant or topical fluoride application [
12]. Further, the children of internationally married couples are another easily neglected population of children in Korea. According to the National Statistical Office, the ratio of international marriages to all marriages is increasing from 3.5 percent in 2000 to 10.8 percent in 2009 [
5]. Therefore, studies evaluating the oral health status of children of internationally married couples and North Koreans in Korea are necessary to determine the need for special dental care for these two groups of children.
This study has several limitations in regard to the participants, as they were selected by convenient sampling. The participants of this study did not reflect the actual demographic characteristics of foreigners in Korea, in regards to nationality distribution and socioeconomic status. According to the Immigration Policy Headquarters in 2015, majority (50.6%) of the foreigners in Korea are from China, followed by the United States (7.8%), Vietnam (7.2%), Thailand (4.9%), and others [
1]. However, the nationality distribution of the participants in this study consists of a particularly high percentage of countries in Africa (23.6%), as well as North America (24.1%). Furthermore, most of the respondents had high education levels and lived in Seoul; eighty percent of the respondents were either college graduates or had attained higher education level. Although this study was not a randomized controlled study, it provides some meaningful information about the dental health knowledge and status of pediatric dental services utilization by foreign children with relatively high socioeconomic status living in Seoul. In addition, the questionnaires were written in English; the participants who do not have English as a native language were more than 50%, even if the object of this study is who can read and understand English. Therefore, inadequate understanding of the questionnaires may have resulted in misleading answers. In spite of these limitations, this study still provides valuable data that may improve the Korean governmental approach to educating foreign parents and children about the importance of dental care and utilization of preventive measures for improving their quality of life in Korea.