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Adaptation of child oral health education leaflets for Arabic migrants in Australia: a qualitative study Arora, Amit; Al-Salti, Ibrahim; Murad, Hussam; Tran, Quang; Itaoui, Rhonda; Bhole, Sameer; Ajwani, Shilpi; Jones, Charlotte; Manohar, Narendar Jan 10, 2018

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RESEARCH ARTICLE Open AccessAdaptation of child oral health educationleaflets for Arabic migrants in Australia: aqualitative studyAmit Arora1,2,3,4*, Ibrahim Al-Salti5, Hussam Murad5, Quang Tran5, Rhonda Itaoui6, Sameer Bhole2,5, Shilpi Ajwani2,5,Charlotte Jones7 and Narendar Manohar1AbstractBackground: The purpose of this study was to gain an in-depth understanding of Arabic-speaking mothers viewson the usefulness of existing oral health education leaflets aimed at young children and also to record their viewson the tailored versions of these leaflets.Methods: This qualitative study was nested within a large ongoing birth cohort study in South Western Sydney, Australia.Arabic-speaking mothers (n= 19) with young children were purposively selected and approached for a semi-structuredinterview. Two original English leaflets giving advice on young children’s oral health were sent to mother’s prior to theinterview. On the day of interview, mothers were given simplified-English and Arabic versions of both the leaflets andwere asked to compare the three versions. Interviews were audio-recorded, subsequently transcribed verbatim andanalysed by thematic analysis. Ethical approval was obtained from Human Research Ethics Committees of the formerSydney South West Area Health Service, University of Sydney and Western Sydney University.Results: Mothers reported that simplified English together with the Arabic version of the leaflets were useful sources ofinformation. Although many mothers favoured the simplified version over original English leaflets, the majority favouredthe leaflets in Arabic. Ideally, a “dual Arabic - simplified English leaflet” was preferred. The understanding of key healthmessages was optimised through a simple layout and visual images.Conclusions: There is a need to tailor oral health education leaflets for Arabic-speaking migrants. Producers of dental leafletsshould also consider a “dual Arabic – simplified English leaflet” to improve oral health knowledge of Arabic-speakingmigrants. The use of simple layout and pictures assists Arabic-speaking migrants to understand the content of dental leaflets.Keywords: Culturally and linguistically diverse, Arabic, Oral health, Migrant, AustraliaBackgroundEarly Childhood Caries (ECC) is a significant health prob-lem worldwide [1]. The prevalence of dental caries amongAustralian children has been on the rise since mid-1990s[2]. The most recent Australian Child Oral Health Survey(2012–2014) reported that nearly 25% of 5 to 10-year-oldchildren had untreated dental caries in the primary denti-tion, while one in ten children aged 6 to 14-years haduntreated caries in the permanent dentition [3]. Factorsassociated with the development and progression of dentalcaries are complex and may include an interplay betweengenetic inheritance, socio-demographics, lack of access todental care, poor dental care utilisation, low healthliteracy, beliefs; inappropriate health behaviours, culturalbeliefs and practices and bacterial infection (predomin-antly mutans streptococci) [4]. Despite of such complexcausal characteristics, dental caries in children can beprevented by providing health promotion to the families[5] to ensure early adoption of healthy behaviours.The health promotion messages to maintain good oralhealth are well documented [5, 6] and can be beneficial ifadopted early in life and become a part of routine life. Thekey oral health promotion messages include: brushing* Correspondence: a.arora@westernsydney.edu.au1School of Science and Health, Western Sydney University, 24.2.97Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751, Australia2Oral Health Services and Sydney Dental Hospital, Sydney Local HealthDistrict, Surry Hills, AustraliaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Arora et al. BMC Oral Health  (2018) 18:10 DOI 10.1186/s12903-017-0469-ztwice daily with fluoridated toothpaste, reducing the fre-quency of sugar consumption and seeking regular visits toan oral health professional. There is consensus that peoplewho have appropriate health knowledge and skills aremore likely to improve their quality of life [7, 8]. However,evidence suggests that health-related behaviours arestrongly influenced by social norms [9], which are relatedto education, social class, and ethnicity [10].Changing health behaviours is complex but is largelydependent on accessing, reading, understanding, andprocessing health information [11]. In developed coun-tries during the 1970s, health education initiatives wereaimed at behaviour change to prevent chronic diseases[12]. Most initiatives were heavily reliant on simple un-derstanding that the transmission of health informationwill lead to behaviour change [13]. Over time, it becameevident that health education may increase health know-ledge but was not enough for sustained behaviourchange [5]. This concept was strengthened in the 1980s,during which several theories were proposed on how so-cial and personal skills influence decisions related tohealth behaviours. This helped to explain the relation-ship between knowledge, beliefs and social norms; andprovided useful insights on the content of health promo-tion programmes [13].In dentistry, leaflets have been the traditional methodof conveying health information to consumers. However,there is overwhelming evidence that the value of thesehealth education resources will be compromised by anindividual’s literacy skills [7, 14–17]. The inability toread, understand and act-upon health education mes-sages may contribute to health inequality, and this is cer-tainly true in dentistry aspect where children fromethnic minorities are more likely to have dental healthproblems due to lower levels of literacy, lack of under-standing on how to access and utilise dental services;and inappropriate culturally-specific norms and beliefs[18, 19]. Hence, all health education initiatives aimed forethnic minorities should take literacy and cultural ap-propriateness into account for raising oral health aware-ness. Despite the propensity to utilise leaflets as the keymedium for oral health education, there remains limitedempirical evidence on whether such medium addressesthe needs of migrants living in disadvantaged areas ofAustralia, such as Greater Western Sydney.The World Health Organization defines Health literacyas “the cognitive and social skills which determine the mo-tivation and ability of individuals to gain access to, under-stand and use information in ways which promote andmaintain good health” [20]. Lower levels of health literacyhave been associated with less focus on disease preventionand higher health care costs [21–23]. In an oral healthcontext, literacy skills are crucial for people to understandthe factors influencing oral health, to adopt oral healthpromoting behaviours, to communicate with oral healthprofessional team, or organise dental appointments, tofind their way to the dental clinics, to fill out the necessaryforms at the dental appointment, and to comply with anyrequired regimes, including follow-up appointments andprescribed medications [24]. Ethnic minority groups areparticularly susceptible to poor oral health literacy [15,17], which in part, may be implicated in the observed oralhealth disparities. There is a paucity of research andknowledge around this issue, including how to overcomethe barriers related to appropriate oral health literacy.Enhancing the oral health literacy of at-risk culturalminority groups living in multicultural countries such asAustralia is fundamental to the alleviation of healthdisparities and overall disadvantage.According to the Australian Bureau of Statistics (ABS),individuals residing in rural areas and from a lower socio-economic backgrounds (lower levels of income, educationand non-English-speaking) have lower levels of health lit-eracy [25]. Indeed, recent migrants to Australia, havingEnglish as a second language may also have limited liter-acy in their native language to some extent [8]. Hence, thisinability to access, engage-with and understand healtheducation messages in both their first and second lan-guage might lead to compromised health among ethnicminority groups living in Australia [18, 19]. Furthermore,migrants, among other groups residing in disadvantagedareas, experience additional drawbacks such as a higherprevalence of health risk factors and, difficulty accessingand utilising health services in comparison to the moreadvantaged counterparts [26, 27].To be specific, Arabic-speaking population is a fast grow-ing minority population in Australia. According to the ABSCensus in 2011, the Arabic-speaking population represents1.3% of the total Australian population [28]. The Arabic-speaking community in Greater Western Sydney forms6.6% of its total population; with Arabic being the top non-English language spoken at home [29]. Across Australia,there is a great diversity amongst the Arabic-speaking com-munity, as these families originate from over 22 countrieswhere Arabic is either an official language or spoken by asignificant portion of the population [30]. Furthermore, inthe last 10 years, some people from Arabic-speaking coun-tries have migrated to Australia as refugees or asylumseekers [8, 28, 31]. Due to this migration experience, a pro-portion of migrant Arabic-speaking population have signifi-cantly lower incomes, lower levels of English proficiency,and education compared to the local Australians or othermajor migrant populations [32]. As a result, they areparticularly susceptible to poor oral health literacy anddifficulty accessing the local health care services.Furthermore, the majority of Arabic-speaking communityin Greater Western Sydney resides within a socio-economically disadvantaged geographical location [33].Arora et al. BMC Oral Health  (2018) 18:10 Page 2 of 10Hence, based on the socio-economic and geographicdisadvantage faced by Arabic-speaking migrants inGreater Western Sydney, compounded by English lan-guage barriers, the need to assess the extent to whichexisting oral health leaflets address the oral health literacyneeds of Arabic migrants is exemplified. Thus, the aims ofthis study were two-fold: First, to explore the views ofArabic-speaking mothers (living in Greater WesternSydney) on readily available English-language oral healtheducation leaflets that provide advice on maintaining oralhealth of young children. Second, to evaluate the accept-ability of simplified-English and Arabic-translated versionsof the existing oral health education leaflets.MethodsAdapting the existing English oral health education leafletsNSW Health has several resources aimed at improving theoral health of young children. Of these, the two commonlyused leaflets include “NSW Messages for a Healthy Mouth”(L1) [34] and “Teach your baby to drink from a cup” (L2)[35]. Both leaflets (L1 and L2) use evidence-based messagesto educate parents about maintaining good oral health oftheir children, risk factors for ECC and prevention of ECC.These leaflets also consist of picture illustrations. The“NSW Messages for a Healthy Mouth” leaflet reinforces thenotion that oral health is an integral part of ‘general’ healthand comprises of five key messages namely: Eat Well, DrinkWell, Clean Well, Play Well and Stay Well. Every messageis further explained in written text and pictorials. “Teachyour baby to drink from a cup” is a leaflet explaining howto choose the right training cup for a baby and how toteach the baby to drink from a cup at six-months and 6–12-months of age. It also explains what the baby can drinkat specified ages in terms of health benefits.The two original English leaflets were modified specificallyfor the Arabic-speaking mothers using standardised princi-ples for cultural, linguistic and literacy appropriateness ofeducation materials [36–38]. For example, pictures of trad-itional Arabic family and specific food-types were used tocomplement oral health education messages; medical jar-gons were removed and replaced by simple words, and mes-sages were translated into common Arabic terms (e.g.,“buzoogh-al-asnan”) so that a common Arabic-speaking per-son can understand. The original leaflets were reviewed by amulti-disciplinary team comprising of four project team-members (two English-speaking researchers and twoArabic-speaking researchers) and four lay individuals(mothers of young children) from an Arabic-speaking back-ground. The review team was asked to review the leaflet’scontent and identify potential barriers to Arabic communitymembers’ understanding of the health information alongwith making suggestions to simplify the language, reducemedical jargon and tailor them for cultural appropriateness.Afterwards, the simplified English version of both leaflets(SL1 and SL2) was translated into Arabic language by twoArabic-speaking researchers and two Arabic-speaking layindividuals. The Arabic version of the leaflets (AL1 andAL2) were then back-translated in English by two lay indi-viduals in order to ensure the quality and accuracy of keyoral health messages [38]. Revision of the materials was inaccordance with the findings at each step.Development of the evaluation toolsTwo separate semi-structured validated tools [39] were de-veloped by members of our research team to be used forevaluation of the leaflets. The overall purpose of the toolswas two fold: firstly, to assess the concept validity and ac-ceptability of oral health advices based on linguistic and lit-eracy skills of participants; and cultural norms. Secondly, toascertain and improve mismatches in the content, commu-nication and design of simplified English and translatedArabic versions of the leaflets. Each evaluation tool wasassessed by four volunteer Arabic community-memberswho had read the revised leaflets. They were advised to re-view the tools to ensure that concept validity, acceptability,and comprehension in the leaflets were clearly gauged.Additionally, the reviewers evaluated whether the questionsbeing asked would be understood by Arabic communitymembers. The evaluation tools were revised accordingly.Study backgroundThis study was nested within the Healthy Smiles HealthyKids (HSHK) birth cohort study (n = 1035), which com-menced in 2010 to explore the relationship between earlychildhood feeding practices and dental caries in preschoolchildren residing in South Western Sydney [1]. Child andFamily Health Nurses recruited mother-infant dyads at thefirst post-natal home visit at four to six weeks [40]. As part ofthe HSHK study, two leaflets giving oral health advice on tak-ing care of children’s teeth were sent by post to the parents.The two leaflets (L1 and L2) were: “Teach your baby to drinkfrom a cup” and “NSWMessages for a Healthy Mouth”.Research designA qualitative research design was utilised to get a deeperunderstanding of Arabic-speaking mothers’ perspectiveson oral health literacy needs and existing education leaf-lets. Such qualitative approach was used for two reasons[41]. First, it enabled us to collect in-depth data on thematernal perspectives of original and adapted leaflets.Second, the flexibility of research design provided an op-portunity for simultaneous data collection and analysis.SamplingWe used a purposive sampling strategy, that is, a samplingtechnique that enriches the data quality by selecting the sub-jects strategically and purposefully: a commonly used strat-egy in qualitative research [42]. The researchers adopted aArora et al. BMC Oral Health  (2018) 18:10 Page 3 of 10maximum variation sampling method to attain a variationon dimensions of interest and to identify important patternsto enrich our data quality [41, 43]. Previous studies haveshown that a sample of 12–15 interviews is sufficient toreach data saturation, defined as “the point at which add-itional data does not improve the understanding of thephenomenon under study” [43]. From HSHK birth cohortstudy, 19 Arabic-speaking mother-infant dyads were selectedfor a home interview from postcodes ranked as “disadvan-taged” according to the 2006 Australian Socio EconomicIndex for Areas (SEIFA) [44]. Furthermore, the followingcriteria’s were used to choose mothers thereby ensuring abroader perspective: either primiparous or multiparous; either married, or living with a partner, or were single; came from any Arabic-speaking county or origin; came from a range of education levels; either employed (skilled/unskilled) or unemployedand/or pensioners.The mothers fulfilling the selection criteria were invited toparticipate via a phone call and were then sent an informa-tion pack containing a participation information statementand a consent form for this nested study. Mothers who gaveconsent were selected and approached for the interview.In-depth semi-structured interviewsOn the day of the interview, mothers were given simplified-English (SL1 and SL2) and Arabic (AL1 and AL2) versionsof both the leaflets. Two bilingual researchers (HM andIAS) who had experience in population oral health andqualitative interviewing conducted in-depth interviews inArabic at the homes of study participants. During the one-hour interview, mothers were asked to compare all six leaf-lets (L1, L2, SL1, SL2, AL1 and AL2) and identify whichversion facilitated the best source of oral health informa-tion. A semi-structured interview guide (Table 1) derivedfrom our previous qualitative research investigation [45]was used to record their opinions and understanding aboutthe leaflets. Throughout these discussions, participants notonly justified their preference for a particular version of theleaflet, but also discussed any issues they had with the leaf-lets. All interviews were audio recorded, debriefed, andtranslated from Arabic to English and transcribed verbatim.Evaluation of the education materials and data analysisThe evaluation tools were administered by trained bilingualresearchers at the interview session in the participants’ lan-guage of choice. Data from closed-ended questions werepresented as percentages. Responses to open-ended ques-tions were translated by the interviewers and recorded inEnglish. If interviewers were not clear about the meaning ofwords or phrases used by participants, additional time wastaken to clarify.To improve the rigour and credibility, five researcherswere heavily involved in the data analysis, which includeddebriefing, transcript coding, and interpretation. Followingeach interview, the researchers reflected on data collec-tion, summarised the main findings and prepared for sub-sequent interviews. Thematic analysis was undertaken tointerpret the main findings of the interview transcripts.This process was conducted in three stages. First, tran-scripts were analysed line by line; and first-level of codingand common themes was performed by the principal re-searcher (AA) using NVivo 9 (QSR International, Cam-bridge, MA, USA). Second, four researchers (NT, IAS,HM, and RI) independently categorised, re-categorisedand condensed some of the first-level codes based onoverlap or similarity of some responses. They reviewedthe transcripts systematically and identified the conceptsprovided by the participants. The parent codes derivedfrom our analysis included topics such as literacy, compre-hension, translations, and culture. The sub-codes includedwords such as medical terms, native language, interpret-ation, tailor, target, simple, pictures, layout, and visual.Third, all five researchers reviewed the second-level cod-ing and their corresponding passages through an iterativeprocess, regrouping them into broader themes. All the re-searchers reached a consensus on any discrepant categor-isation through ongoing discussion.Ethical considerationsEthical approval for this study was acquired from theHuman Research Ethics Committees of the former SydneySouth West Area Health Service, University of Sydney andWestern Sydney University.ResultsAll 19 mothers participated in the interviews, a responserate of 100%. All women resided in South WesternSydney, and their children’s ages ranged from 6 monthsTable 1 Interview guide1. What are the key messages you got from the leaflet?2. What made the leaflet easy/difficult to read?3. Is there anything you were unable to read? If so,what is that you were unable to read?4. What made the leaflet easy/difficult to understand?Is there anything you were unable to understand?5. If so, what is that you are unable to understand?6. Did you need help from anyone?7. Did the leaflet had any missing information? If so, what was missing?8. What do you like the most/least about the leaflet?9. Would you recommend this leaflet for others? Why?10. Do you have any further suggestions?Arora et al. BMC Oral Health  (2018) 18:10 Page 4 of 10to 18 months. Sixteen out of total 19 mothers were agedbetween 20 and 40 years and 14 of them had year 12 orlower level of education. In general, mothers with lowerlevels of education reported that the original leaflets wereharder to read and understand compared to the tailoredversions of the leaflets. Additional socio-demographicdetails of participants (namely, number of children,country of birth) are described in Table 2.Evaluation of the simplified English education leaflets(Table 3)Eighteen participants read the simplified English leaflets.Seventeen of the 18 (94.4%) participants indicated that thesimplified English leaflets helped them better understandon how to look after children’s oral health compared tothe original English leaflets. Thirteen participants indi-cated that the original leaflets were more difficult tounderstand than the simplified leaflets. One participantfelt the simplified leaflets were missing information. Inter-estingly, all participants believed that the simplified leafletshelped them make better health choices for their chil-dren’s oral health.Evaluation of the translated Arabic education leaflets(Table 4)Of the 19 participants who read the Arabic leaflets, 16(84.2%) found it useful to receive the information in theirown language. Three participants indicated that they did notfind the translations useful particularly because Arabic hasdifferent dialects. Seventeen (89.5%) participants indicatedthat the Arabic leaflets helped them better understand onhow to look after children’s oral health. Eighteen of the 19(94.7%) participants indicated that the Arabic leaflets helpedthem make better health choices for their children’s oralhealth. One participant preferred the simplified English leaf-lets over the Arabic leaflets.Themes emerged from the qualitative dataThe following sections explain the three main themes thatemerged from the qualitative data: (1) Preference forArabic leaflets and Critique in translations, (2) Preferencefor simplified-English leaflets and its Complimentaryreading with Arabic leaflets (3) The importance of visualrepresentation: simple layout and use of pictures.Theme 1 - preference for Arabic leaflets and critique intranslationsA recurrent theme was a sense that oral health promotionmaterials written in Arabic language were the preferredchoice for oral health information. Majority of participantsindicated that the leaflets in Arabic language (AL1 and AL2)were the most useful medium of oral health education; andTable 2 Socio-demographic characteristics of the studyparticipants (n = 19)Characteristic NParityPrimiparous 8Multiparous 11Mother’s age (in years)20–29 730–39 9≥ 40 3Mother’s country of birthEgypt 3Iraq 4Lebanon 4Saudi Arabia 2Syria 3United Arab Emirates 3Mother’s level of education≤ year 12 14College or university 5Mother’s occupationUnemployed 11Unskilled workers 6Skilled workers 2Marital statusMarried 15Single 4Table 3 Simplified English leaflets questionnaire and responsesDid you read the leaflets?Yes n = 18 No n = 1Did you find the simplified leaflets helped you to understand howto look after children's oral health?Yes n =17 (94.4%)a No n =1 (5.6%)What helped you to understand the simplified leaflets?This is easier to understandI like the picturesVery simplified and attractiveDid you find the original leaflets were more difficult to understandcompared to the simplified English version?Yes n = 13 (72.2%) No n = 5 (27.8%)Please tell us what part was difficult?I didn"t understand fizzy drinksThe part where the leaflet talks about leaving the kids with a bottle at nightDid you find the simplified leaflets had any missing informationcompared to the original leaflets?Yes n = 1 (5.6%) No n = 17 (94.4%)What information is specifically missing?It has dot points but is not very detailed, it may be useful only fornon-fluent English speakersDo the simplified leaflets help you to make better health choicesfor your child's oral health?Yes n = 18 (100%) No n = 0 (0%)aPercents are based on the numbers of participants that read the pamphlet (n = 18)Arora et al. BMC Oral Health  (2018) 18:10 Page 5 of 10are easier to read and understand compared to the ones inEnglish (L1, L2, SL1 and SL2).“It’s always easier reading it in Arabic so I’ll be lesspicky about the Arabic version than the English one be-cause I can understand it better”.“…I can read Arabic more fluently than English so I getto pick up the information quicker and understand it well.When I read it in English, it took me longer to read and ofcourse there were words that I didn’t understand…”Despite an overall preference for the Arabic leaflets,some participants felt that the Arabic translations wereinaccurate or confusing, particularly the use of ‘formalArabic terms’, or Arabic terms used exclusively by thosefrom a small number of Arabic speaking countries.“[Translation of ‘sealants’ to ‘protective tooth paint’]this makes it sound like nail polish (laughs). I thinkmaybe just translate it to “protective filling” and thenwith the help of a picture show it on a tooth.”Despite a consensus on the usefulness of leaflets in theirnative language, interviewees provided valuable critique onthe usefulness of Arabic translations. The risks of homoge-nising cultural groups through certain translation termin-ologies were highlighted. As suggested by participants, thiscan be overcome by utilising simple terminology that tran-scends across all groups, rather than incorporation of cul-turally specific ‘slang’ or use of formal language.“…change “buzoogh al-asnan” (eruption of teeth) to“thuhoor al-asnan” (appearance of teeth). I don’t thinkthe word “buzoogh” (eruption) is that commonly used.”“Word “bozoog” if you can change it to “zohoor”. We areused to the simple language rather than formal Arabic”.Theme 2 – Preference for simplified-English leaflets andits complimentary reading with Arabic leaflets (dualArabic-English leaflet)A consensus in participant preference for the simplifiedEnglish version, rather the original English leaflet wasalso expressed. The participants expressed difficulty inunderstanding the medical jargon and technical languageused in the original leaflet, which was explained in layterms in the simplified English leaflets.“I think it’s [original English] packed with writing andit may be too much for some mothers to read, especiallyif they are slow English readers”.“I guess ‘less is more’. If you were at a doctor’s surgeryand pick this up to read then you are more likely to fin-ish reading it and get the important bits of informationbefore let’s say the doctor calls you in”.The informant perspectives shed light on how thecomplimentary reading of the Arabic leaflets alongside thesimplified English versions facilitated the improvement ofthe mothers’ English literacy skills. This was due to thesimplified English version providing a clearer under-standing of the messages depicted in the leaflets.Furthermore, it also enabled mothers to understandmedical terminology used in dental clinics and health-care environments in Australia.“If I see a pamphlet in English and Arabic written nextto it then I’d definitely pick it up to see what certain wordsare in English. This would help in improving my English.”“Personally I’d pick up both because for me I’d want tolearn more English words and improve my English thatway. So this is why I’d do it this way.”As reflected in the above testimonials, certain termin-ologies were more understandable when Arabic to Englishsynonyms were used. Many terms and phrases were notnew, but more difficult to understand in the originalEnglish version. As asserted by the participants, the sim-plified English and Arabic versions of the leaflet werecomplimentary assets to aid the comprehension of keyterminology. A very interesting finding emerging from thisstudy was the need of a ‘dual Arabic-English leaflet’, whichwould assist Arabic mothers to read and interpret the keyhealth messages (written in English) by matching themwith Arabic words. They believed that such leaflets wouldalso improve their English vocabulary and reading skills.“Can’t you make a dual Arabic-English pamphlet,where each line is translated for those who know a littlebit of English but want to learn new English words to im-prove their vocabulary for when they visit the dentist?”Together these results highlighted the importance oftailoring oral health messages to the literacy needs of thetarget populations. Further, it points to the benefits ofthis ‘targeted’ approach in not only enhancing the healthliteracy of disadvantaged communities, but also improv-ing overall English language competency – an essentialskill for navigating the vast and complex health systemin an English-speaking nation like Australia.“English is useful. If you give me both I learn any wordI’m missing in the English version… we want to learnthese words because we get exposed to it in hospitals”.Table 4 Translated Arabic leaflets questionnaire and responsesDid you read the leaflets?Yes n = 19 No n = 0Was it useful to receive information on child's oral health in Arabic?Yes n = 16 (84.2%)a No n = 3 (15.8%)If No, please explain why?Arabic has different dialects, so the translations did not helpDid you find the Arabic leaflets helped you to understand how tolook after children's teeth?Yes n =17 (89.5%) No n = 2 (10.5%)What helped you to understand the Arabic leaflets?All of itDot points and the size of the textDo the leaflets help you to make better health choices for yourchild's oral health?Yes n= 18 (94.7%) No n = 1 (5.3%)aPercents are based on the numbers of participants that read the pamphlet (n = 19)Arora et al. BMC Oral Health  (2018) 18:10 Page 6 of 10Theme 3 - the importance of visual representation:Simple layout and use of picturesA preference for using a ‘dot point’ structure, rather thanparagraphs in the leaflets was expressed by mothers.This was attributed to enhanced comprehensibility ofkey messages and issues covered in the leaflets.“I think for non-fluent English speakers it may be easiestto read summarised points rather than full sentences. Thisis because they will get the message quickly rather than hav-ing to read through more text to get the same messages”.Additionally, most informants mentioned that oralhealth education material must include visual imagesthat complement the messages provided in the text inthe form of pictures, photos, diagrams or labelling.“The colours would also capture the mother’s attention.Adding pictures will definitely help because we can thenput “picture to word””.Mothers preferred the simple layout of written content tobe accompanied by visual images such as diagrams, graphsand pictures that relay the key oral health messages.“The pictures let us know that this pamphlet would betalking about things like food (points to food image), car-ing for children’s teeth. The colours are also bright andgive the impression that the pamphlet is about children’shealth. The font is also like chalk making it appear to bedirected at young children’s health”.The perspectives provided by the Arabic-speakingmothers in this study indicate the benefits of simplifiedinformation along with visual design of oral health pro-motion materials. Indeed, the integration of high qualityvisual material in a simple layout may enhance the un-derstanding of key health messages, and possibly im-prove the health literacy of disadvantaged groups suchas non-English speaking communities.“Pictures are always understood by people without hav-ing to read much….The pictures are clear and expressive,even if the person didn’t read all the writing they canstill get the message clearly by looking at the picture”.DiscussionOral health literacy is the “degree to which individuals havethe capacity to obtain, process and understand basic oralhealth information and services to make appropriate healthdecisions” [46]. This study provides insight into the accept-ability and need for simplified English and translated ver-sions of commonly available oral health education leafletsto fit the needs of Arabic-speaking mothers with youngchildren in Greater Western Sydney, Australia. In terms ofsocio-demographic characteristics, mothers with lowerlevels of education reported that the original leaflets wereharder to read and understand compared to the tailoredversions of the leaflets. While mothers favoured reading thesimplified version over the original English leaflets, the ma-jority favoured the leaflets in their native language. A morepreferable choice was having the simplified English version(SL1 and SL2) compliment the Arabic version (AL1 andAL2) in the same document. The understanding of key oralhealth promotion messages was optimised through the useof a simple layout, simple language and incorporatingcomplimentary visual images. The current findings reaffirmthe need to actively engage the target audience in the devel-opment process of oral health promotion material in orderto enhance the value of the educational materials amongethnic minority groups [15, 16, 47–50].Input from the nineteen Arabic-speaking mothers inthis study stresses that the oral health literacy of ethnicminorities is more likely to be enhanced by presentinghealth information in a simplified format when accom-panied by an informal/conversational writing style and vis-ual images that complement the content. As highlightedby the empirical data in this study, the need to provideleaflets, in the native language, and ‘simplified English’ notonly is more likely to enhance oral health literacy, but alsohas the ability to improve English proficiency and literacyskills overall. This reaffirms the findings of Jones et al. [39]who highlighted the overall value of the simplified educa-tional materials for a Canadian South Asian community.Mothers preferred reading the simplified English leafletcompared to the original English leaflet. This was largelyattributed to the simplification of medical jargon and tech-nical terminology in the original format. This key findingmirrors the main opinions expressed by English-speaking,Chinese-speaking and Vietnamese-speaking mothers liv-ing in South-Western Sydney [15, 17, 47].Most notably, a preference for reading the Arabic trans-lated leaflet, alongside the simplified English version pro-vides valuable insight into the role that health educationcan have in enhancing English literacy. It also highlightsthe positive effects that well-developed health promotionmaterials can have in educating the ethnic minoritygroups regarding Australia’s health system and processes.The Arabic-speaking mothers interviewed in this studyfavoured the educational leaflets written in their nativelanguage. This was mainly due to greater readability andunderstanding of the material than what was attained inreading both versions of English leaflets. Although partici-pants preferred the Arabic version, they were also open toreceiving oral health education in English, as long as thiswas provided in simplified, colourful and ‘visually robust’mediums. Many participants also expressed a preferenceto read the Arabic in conjunction with simplified Englishversions to assist with their English literacy skills. Thepreference for the simplified English version was mainlydue to concerns that the medical jargon, lengthy text andcomplex words made the original English version difficultto read whereas when the language was simplified, or par-ticipants substituted their own words, the readability andtheir understanding of the messages improved. As KwanArora et al. BMC Oral Health  (2018) 18:10 Page 7 of 10[51] suggests, this may occur due to the differences in lan-guage structure and grammar, whereby very literal transla-tions from one language to English may lead to confusion,change the intended meaning and even impede under-standing. Further, the need to consider different variationsand ‘slang’ of certain languages, such as Arabic when pro-ducing translational material was highlighted. These find-ings provide valuable insight on how to produce moreappropriate leaflets based on colloquial Arabic idioms,whilst also enhancing the English literacy skills of ethnicminorities concurrently.In this study, mothers critiqued the English to Arabictranslations and suggested using simple terminologies thattranscends across all Arabic groups, rather than use ofculturally specific ‘slang’ or use of formal language. This isa common finding in research conducted in an Arabiccontext since Arabic is a diglossic language, i.e. it consistsof two different varieties – one High variety that is formaland is mainly written while the Low variety is spoken andis used in daily life [52]. This Low variety of Arabic lan-guage differs across all Arabic-speaking countries makinga wide array of Arabic dialects. This is of particular signifi-cance to public health researchers working with differentArabic-speaking migrants since every region and countryrepresents unique culture and people [53].The mothers in this study preferred pictures and a simpli-fied layout, suggesting that such format helped them to morerapidly understand the main concepts being communicated.This has also been reported elsewhere [39, 54, 55]. Thesefindings are supported by research in psychology, indicatingthat humans have a preference for picture-based informa-tion, rather than text-based information [56]. Furthermore,the health communication literature [54, 55] suggests thatadding pictures to leaflets can significantly improve patientinterest, recall, comprehension, and behaviours. This findingis particularly important in English-speaking countries asvisual support is commonly used in Teachers of English toSpeakers of Other Languages (TESOL) and Teaching Englishas a Foreign Language (TEFL) classes worldwide [57].Strengths of the studyThis study had a number of strengths that are worth report-ing. Firstly, we used a qualitative approach to get an in-depthunderstanding of the Arabic-speaking migrants in GreaterWestern Sydney. The flexibility of the research design givesan opportunity for further investigation if required and fosterssimultaneous data collection and analysis [41]. Secondly, weapproached 19 Arabic-speaking mothers from the ongoingHSHK study and all agreed to be a part of this nested study,thus achieving a 100% response rate. A sample of 19 researchparticipants was enough to reach data saturation, that is allthe dimensions of interest were explored and no new infor-mation would have been collected from interviewing moreparticipants [43]. Third, the strong community partnershipthat our team has established with ethnic minorities throughthe HSHK study is crucial for the ongoing development oftailored oral health education leaflets. Fourth, some membersof the research team in this study were from an Arabic-speaking background that provided a cultural insider aspectto the development of leaflets, interview process and dataanalysis. Finally, in our research, male researchers interviewedyoung Arabic mothers; this entails cross-gender research interms of research positionality. In most instances, men’s sta-tus in feminism is still marginalised no matter how muchthey are committed to women’s problems and concerns [58].Limitations of the studyThere are several limitations of this study. Firstly, we werenot able to assess whether the simplified English andArabic-translated leaflets were actually able to improvethe oral health practices of mothers and children. Sec-ondly, we were not able to record the participatingmother’s period of residence in Australia and what impactdid that have on their health literacy level. Third, the sta-tus and influence of fathers’ oral health literacy on chil-dren’s oral health were not explored although they alsoshare the responsibility of maintaining children’s oralhealth. Fourth, the participants’ level of understandingwas measured only by their need for help and their per-sonal description of the difficulty to read the leaflet. Fifth,the original leaflets ((L1 and L2) are readily available inNSW and are used as part of the ongoing HSHK study.Therefore, mothers had access to these leaflets before theinterview and they may have taken help to understand thecontent of the original leaflets. Nonetheless, the simplifiedand translated versions of the leaflets, which were givenon the day of the interview, were deemed more appropri-ate by the Arabic-speaking mothers. Finally, the use of asmall sample of Arabic-speaking mothers living in SouthWestern Sydney limits the generalisation of our findingsto the broad range of literacy skills shared amongst otherdisadvantaged and culturally diverse families.ConclusionThe empirical findings of this study brings our attentionto the need for ongoing development and distribution ofhealth education material in formats that are readable anduseful to potential user groups whose first language is notEnglish. The Arabic mothers felt that existing oral healtheducation leaflets were too complex and they had diffi-culty understanding the key messages; whereas they wereparticularly receptive to the Arabic-translated leaflet. Alsoof interest was the finding that many Arabic motherswould prefer a ‘dual Arabic-English leaflet’ for better un-derstanding and improving their English literacy skills.This study suggests the need to tailor information to thelanguage and literacy level of the target audience, alongwith the need for a more visual and simple layout toArora et al. BMC Oral Health  (2018) 18:10 Page 8 of 10optimise readability and understanding. Proactive engage-ment of the target community during the process of de-signing oral health promotion material is critical to ensurecultural and linguistic appropriateness of health educationmaterials. The process of simplifying the content of healtheducation leaflets may be useful to other researchers andpolicy makers who wish to develop leaflets for people withlimited literacy skills.AbbreviationsABS: Australian bureau of statistics; AIHW: Australian institute of health andwelfare; ECC: Early childhood caries; NHMRC: National health and medicalresearch council; NSW: New South Wales; SEIFA: Socio economic index forareas; TEFL: Teaching english as a foreign language; TESOL: Teachers ofenglish to speakers of other languagesAcknowledgementsWe would like to thank Sydney and South West Sydney Local HealthDistricts and the families for their ongoing support with the cohort study.FundingThis study was supported by Australian NHMRC Project Grant (1033213),Australian Dental Research Foundation, Western Sydney University, OralHealth Foundation and NSW Health. Dr. Amit Arora is supported byAustralian NHMRC Early Career Fellowship (1069861). Dr. NarendarManohar is supported by Australian NHMRC Postgraduate Scholarship(1134075).Availability of data and materialsThe data that support the findings of this study officially belongs to Sydneyand South Western Sydney Local Health Districts and Western SydneyUniversity. The authors do not have permission to release the data, asparticipants did not consent to make their personal information and fullinterview transcripts publicly available. The simplified English and Arabicversions of the leaflets were developed for this study. We do not havepermission to publish these leaflets.Authors’ contributionsAA, SB, SA, NM and CJ conceptualised the study. IAS and HM were involvedin the data collection. IAS, NM, HM, QT, AA, RI were involved in the dataanalysis. All authors were involved in the writing of the manuscript. AA andNM were involved in revising the manuscript, and all authors approved thefinal version.Ethics approval and consent to participateEthical approval for this study was obtained from the Human Research EthicsCommittees of former Sydney South West Area Health Service (nowclassified as Sydney Local Health District and South Western Sydney LocalHealth District), University of Sydney, and Western Sydney University. The“NSW Messages for a Healthy Mouth” and “Teach your baby to drink from acup” leaflets are freely available in all hospitals in NSW. Approval to use theleaflets in the study was granted by the Centre for Oral Health Strategy, NSWHealth. A written informed consent was taken from all participants. A writteninformed consent was also taken from the people who reviewed the originalleaflets, modified leaflets and the evaluation tool.Consent for publicationAll participants consented to publishing the de-identified excerpts of thetranscripts.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Science and Health, Western Sydney University, 24.2.97Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751, Australia. 2OralHealth Services and Sydney Dental Hospital, Sydney Local Health District,Surry Hills, Australia. 3Discipline of Paediatrics and Child Health, SydneyMedical School, Westmead, Australia. 4Collaboration for Oral HealthOutcomes Research, Translation, and Evaluation (COHORTE) Research Group,Ingham Institute for Applied Medical Research, Liverpool, Australia. 5Facultyof Dentistry, The University of Sydney, Westmead, Australia. 6School of SocialSciences and Psychology, Western Sydney University, Penrith, Australia.7Faculty of Medicine, University of British Columbia, Vancouver, Canada.Received: 26 January 2017 Accepted: 18 December 2017References1. 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London:SAGE Publications; 2004.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Arora et al. BMC Oral Health  (2018) 18:10 Page 10 of 10

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