HABITS, ATTITUDES AND BEHAVIOR OF REFUGEES AND MIGRANTS IN SERBIA IN RELATION TO ORAL HEALTH

Background/Aim: The aim of this study was to investigate: self-reported oral health, oral health related habits, nutrition and use of dental services among refugees and migrants in Serbia. Methods: Total of 226 migrants participated in the study. Participants were situated in the migrant centers Obrenovac and Krnjaca, in Belgrade, Serbia. All participants were given a questionnaire in order to examine oral health habits, attitudes and behavior among refugees and migrants. The questionnaire consists of 29 questions. SPSS 24 statistical software was used to analyze answers from the questionnaire. Results: Out of 226 examinees, 40 were female and 186 were male. Majority were adults (87.6%) and 12.4% were children. The results show that refugees and migrants who spend 200-300€ per month consume the most alcohol (33.3%) and tobacco (61.1%). Only 10.8% of men answered they have been to the dentist in Serbia, whereas 35% women had the same answer (p=0.000). The research also showed that most women (67.5%) brush their teeth 2-3 times a day and noticeably less men (37.1%) had the same habit. Fluoride supplements are used by 78.7% of examinees. Among most common reasons for the last visit to the dentist were pain (36.9%) and regular checkups (22.5%). Conclusion: Preservation of oral health of refugees and migrants in Serbia depends on various factors. Improving and preserving good general and oral health of refugees and migrants should be a public healthcare priority.


Introduction
Since the peak of the migration crisis in 2015, like many European countries, Serbia was struck with hundreds of thousands of refugees and migrants traveling through European borders 1 .
The United Nations High Commissioner for Refugees (UNHCR) stated that there were 30,216 newly arrived asylum seekers and migrants in Serbia in the year 2019. The same year, the number of arrivals of unaccompanied/separated children was almost twice higher than the year before, with a total of 3777 children. Majority of the asylum seekers and migrants were men (76%), and much less women (18%) and children (6%). When talking about nationalities, 51% of them came from Afghanistan, 13% Syria, 7% Pakistan, 6% Bangladesh, 6% Iran, 6% Iraq and 11% other 2 .
The effects of the migratory process can be noticed as changes in social determinants of health, lack of access to healthcare, interrupted care, poor living conditions, or other. This means general health could be at jeopardy. Healthcare systems and healthcare providers are the ones put to the test when this happens. Most common regional health policies recommend that emergency and urgent care should be available to all refugees and migrants, regardless of their legal status 3 . The Law on Healthcare of Serbia, specifically article 236. of this document, states that a person without a citizenship, refugees, people seeking asylum, registered foreigners seeking asylum, have the rights to healthcare in accordance with this law 4 .
Knowing that oral health is one of the key indicators of general health, well-being and quality of life, we should thoroughly examine the impact of oral health habits in order to preserve and improve oral health among migrants and refugees 5 . The aim of this paper is to provide information about oral health habits, attitudes and behavior towards oral health and indicate in which way public healthcare can contribute to oral health preservation and improvement among refugees and migrants in Serbia.

Participants
A total of 226 refugees and migrants took part in this exploratory cross-sectional study.
Criteria for inclusion of the respondents in the study were: signed consent form and the ability to understand and answer the questions independently or with the help of a qualified translator. Excluding criteria were: refusal to take part in the study and refusal of the parent or guardian to have their child participate in the study. Participation in this study was anonymous and voluntary. All participants were fully informed before giving consent or allowing their children to take part in the research. Parents answered questions on behalf of their children.

Data collection
The survey was carried out in migrant centers Obrenovac and Krnjača. To ensure equality, all questions were asked oraly. Parents answered questions for children involved in the study. One certified dentist (Zoran Mandinić) conducted the interviews and one dental student (Aleksandra Prokić) noted and saved the data. The interviews were carried out in Serbian, English, Pashto and Farsi, with the help of certified translators in the migrant centers. Each interview took approximately 20min.
The survey included both closed and open ended questions. Participants were asked if they had any bad oral health habits (teeth grinding/thumb sucking/mouth breathing/chewing on one side of the mouth/no), if they consume tobacco (yes/no) or alcohol (yes/no).
Furthermore, we asked participants concerning their food regimen, such as the frequency of consuming sweetened drinks/juices (daily/several times per week/several times per month/rarely/never), sweets (daily/several times per week/several times per month/rarely/never) and fruits (daily/several times per week/several times per month/rarely/never).
Questions about the frequency of tooth brushing (never/2-3 times per month/once per day/two or more times per day), the use of fluoride supplements (toothpaste/mouthwash/fluoride tablets/fluoride varnish/tooth gel/no) and oral hygiene utensils (tooth brush/interdental brush/oral irrigator/toothpick/dental floss/no) were asked in order to investigate oral hygiene habits of migrants and refugees.
Oral health problems (yes/no/I do not know) and the number of dental visits (once/twice/three or more times/ I have not been to the dentist in the last year) in the year prior to the research were questions of great value for this research. We also inquired the reason for the last visit to the dentist (pain/trauma/swelling/gum bleeding/regular checkup/none of the above). Questions about the satisfaction of overall health (very dissatisfied/dissatisfied/ neither satisfied nor dissatisfied/satisfied/very satisfied) and oral health (very dissatisfied/dissatisfied/ neither satisfied nor dissatisfied/satisfied/very satisfied) were also incorporated in this study.
Specific part of this research was the attitude of migrants and refugees towards dental healthcare in Serbia. We inquired if the participants knew if they were provided free dental care in Serbia (yes/no/I do not know), as well as their thoughts if there is a language barrier that would endanger their dental treatment (yes/no). Participants were asked if they have been to a dentist in Serbia (yes/no) or have ever been denied dental treatment (yes/no).
Those who had dental treatment in Serbia were asked if they were satisfied with the service (very dissatisfied/dissatisfied/ neither satisfied nor dissatisfied/satisfied/very satisfied).
The participants were also asked about their age, gender (male/female), marital status (single/married/divorced/widowed), country of origin, time spent in Serbia (under 10 days/10-30 days/1-2 months/more than 2 months), migrant and refugee center they are situated at (Obrenovac/Krnjača) and the amount of money at their disposal per month (less than 100€/100-200€/200-300€/more than 300€). In addition to these questions, participants answered questions about their education level (primary school or less/high school/bachelor's degree/master's degree/Ph.D./unknown), level of education of their mother (primary school or less/high school/bachelor's degree/master's degree/Ph.D./unknown) and father (primary school or less/high school/bachelor's degree/master's degree/Ph.D./unknown).

Statistical analysis
All statistical analyses were performed using of Statistical Package for the Social Sciences IBM Corp.) Chi-square test was used to determine the significance of differences between two independent groups. In the process of examining the relationship between variables ANOVA test was used. The level of significance was set at 5% (p<0.05).

Socio-demographic characteristics
In this study participated 226 refugees and migrants staying in migrant centers in Serbia.
Single male refugees and migrants were situated in Obrenovac, whereas in Krnjaca were families, children and female refugees and migrants.

Food regimen
In both migrant centers, Krnjaca and Obrenovac, food is provided. In addition to the provided food, refugees and migrants can buy and consume other foods. A majority of respondents eat sweets on a daily basis or a few times a week (Table 2). Male population drinks sweetened juices more often than female (p=0.008). Statistical analysis showed that the duration of the stay of refugees and migrants in Serbia affects consumption of fruits (p=0.008). According to the results 50% of migrants who stay in Serbia for a longer period of time, longer than 1 month, eat fruits daily and 28.4% of them eat fruits a few times a week.

Oral hygiene
Good oral hygiene is a mandatory for good oral health. The results show that 42.5% of participants brush teeth two or more times per day and 19% of refugees and migrants mentioned they brush teeth once a day. There was a statistical significance between men and women concerning the frequency of brushing teeth.

Dental healthcare
Majority of respondents ranked their general health as satisfactory (64.6%). Twice as many men answered that their oral health is dissatisfactory (22%), whereas 10% women had the same answer (p=0.002). Out of the total number of participants, 36.7% refugees and migrants mentioned to have had problems with oral health in the past year. Although there is a widespread need for dental treatment, 57.1% of the participants have not been to the dentist in the past year. The most common reason for their last visit to the dentist was pain (39.2%). Refugees and migrants that have between 200 and 300€ per month at their disposal had the highest percent (50%) of last visits to the dentist caused by pain.

Dental healthcare in Serbia
Majority of the participants answered that they do not know if dental treatment in Serbia is for free (45.5%), the rest were divided, 27.5% stating it is free and 27% stating it is not.
Most of the single participants (60%) believe there is not a language barrier that would endanger their dental treatment. However, married participants weren't as sure with a total of 47.9% answering there is a language barrier. The results show that women have been to a dentist in Serbia more often than men (Table 3). Based on the results obtained, a total of 38 refugees and migrants were in a situation where a dentist refused to give them dental treatment. Most participants are satisfied with dental treatment in Serbia (44.1%).

Discussion
In the year 2019, 14 reception centers and 6 centers for asylum were at disposal for refugees and migrants across Serbia.  16 . Most common effect of a high consumption of added sugars on oral health is a greater prevalence of dental caries, but also of periodontal disease. Both dental caries and periodontal disease are a major public health problem globally and are a widespread non-communicable disease. Addressing these health issues and preventing them is of high importance. With a significance of male participants drinking sweetened juices, the findings obtained in this research concur with a study from Udaipur 17 . Our study shows that almost half of the participants consume fruits daily. These results are higher than in a study conducted in Lithuania, but lower than the European Union average fruit intake 18,19 . Malnutrition can intensify the severity of oral infections and may lead to their evolution into life threatening diseases 20 . Public healthcare should address refugees and migrants suffering either from malnutrition and being overweight/obese, but also educate refugees and migrants on a balanced and healthy diet.
Findings from our study showed less than half of migrants brush their teeth two or more time times per day. A study conducted in United Kingdom showed a higher percent (71.5%) of Pakistani/Bangladeshi brushing teeth twice a day 21 . Asylum seekers and immigrants that participated in a research in Finland had similar habit of brushing teeth.
Women (75%) brushed teeth more often than men (56%). The same study showed that 57,5% of the participants used toothpastes, whereas 79% of participants in our study used some kind of fluoride supplements 22 . The findings show a large percent of children brushing teeth more than once a day (more than 80%) 23 . These findings are much higher than the ones in this study. Recognizing the need for early dental treatment, providing migrants with adequate oral hygiene utensils and promoting good oral hygiene could highly impact oral and therefore general health.
Oral health affects general health by causing considerable pain and suffering and by changing what people eat, their speech and their quality of life and well-being 24 . This is why there is an undeniable connection between general health and oral health. A comparative study found approximately one third of refugees from the Middle East and Africa that participated in the study had regular oral pain 25 . Oral pain is the most common reason for a visit to the dentist and our research concurs 22,26 . Postponing dental treatment may lead to higher risk of complications occurring and more difficult treatment procedures.
Public healthcare systems should strive to promote early dental treatment and emphasize the importance of prevention.
Some of the principles healthcare in Serbia is based on are solidarity, efficiency and protection of the rights of a patient. Free healthcare is provided to all children under 18 years of age and students till the age of 26 years, as well as people over 65 years of age and people with disabilities. Refugees and migrants in Serbia have the same rights and are included in the public healthcare system. The law concerning free dental treatment applies to trauma, swelling, etc. only at public dental clinics 4 . A low percentage of refugees and migrants going to the dentist in Serbia might as well be due to financial issues, language barriers, fear of the dentist and many more. Conclusions from other studies indicate that financial aspect and the lack of adequate dental insurance is one of the leading issues for not seeking dental treatment 27,28 . As for language barriers, it is mandatory that refugees and migrants are able to communicate whit healthcare workers. Specialized translators should be at disposal at all times when refugees and migrants seek medical treatment.
This study was among the first attempts to tackle habits, attitudes and behavior of refugees and migrants in Serbia in relation to oral health. The study had however certain limitations.
The sample size can be considered as a limitation of this study. Since special permissions were necessary to be obtained prior to every visit to the migrant centers, we limited the sample group to two migrant centers situated in Belgrade. In addition to the excluding factors, element that also impacted the sample size was that not all residents of the migrant centers were at the premises at the time of conducting the interview.
The number of male participants was dominant in comparison to the number of female participants which could be seen as a limitation. However, majority of migrants and refugees in Serbia in the year 2019. were male, and our study concurs 2 .
The lack of clinical examinations is one of the shortcomings of this study. Oral status with DMFT and CPITN were not registered and this study did not include radiographs.
Obtaining this information about migrants and refugees would further explain how habits, attitudes and behavior impact oral health of migrants and refugees. Clinical examinations should be investigated in future studies.

Conclusion
Based on the findings of the study we can understand that in order to provide a safer and healthier environment, attempts should be made to educate and motivate refugees and migrants to maintain oral health. Public healthcare system should focus on refugees and migrants as an at risk population and make a specialized strategy for them. With a large number of refugees and migrants coming every day to Serbia and other European countries, this public health care issue should be prioritized and further analyzed. Early identification of oral health issues may mean less costly procedures which would be in the best interest of patients in need of dental treatment. Health care providers should have in mind the specifics of the migrant population and adjust procedures and treatment to their needs. The ultimate goal is to preserve and improve oral health among refugees and migrants in Serbia.  Table 3 Dental healthcare in Serbia for migrants and refugees