We have learned that ECOH in FN and Metis communities is impacted by a mutually reinforcing mix of personal and social determinates of health brought on by long standing socio-economic exclusions and political inequities . Prevalence and persistence of ECC rates and experiences, is consistent with other indigenous populations within Canada and elsewhere [6, 8, 33, 34].
Attempts to reduce ECC must therefore understand and address root causes as well as parental and familial agency. One of the dynamics although not expressly discussed by participants but glaringly evident, is one parenting roles and health decisions making. More females attended the focus groups. This was not intentional as everyone interested had been invited, but the poor male attendance is likely indicative of usual caregiving roles of females being responsible for children under 72 months. However, the actions or inactions of males can and do influence health behaviors in the home. ECOH promotion is needed, targeting males who may or may not be caregivers, but who could influence children or female health decision making in the household. The males in this study were knowledgeable and insightful, their viewpoints could be further explored. Other challenges and problems that must be tackled to promote ECOH, include firstly, the well-known fact that restricted access to dental care is associated with poor ECOH [11, 35]. While the concept of access has no universally accepted definition, the FN and Metis participants in this study revealed important insight into factors that currently limit access for their children and act as barriers from attaining and maintaining optimal oral health including absent social determinants of health, limited transportation, lack of adequate oral health information available and dentists’ behaviors. It appears that a three pronged approach may be necessary to address current access and equity disparities – policies, education and action. All three are suited to work together, with policy and education driving direct action to change current ECOH realities of Indigenous peoples and communities.
Inadequate access to oral hygiene instruction, oral health supporting nutrition, and information on how to access oral healthcare could result in continued inequities and disparities . It has been suggested that involving non-dental professionals and Indigenous dental care workers could be effective in delivering quick access and culturally informed care [34, 37]. Culturally grounded models have been used and recommended as effective engagement and chronic disease prevention tools among American Indians . Alaska Natives , and Australian Indigenous peoples .
Policies and actions could be geared toward better access to dental clinics, affordable transportation to access dental services, access to appropriate, and accurate oral health information to guide oral hygiene practices at home. Such policies and actions could also work to combat poverty that creates food insecurity and poor nutrition compromising the overall health of FN and Metis peoples. Campaigns encouraging families and other caregivers to reduce children’s intake of sugary foods and beverages could also be useful in promoting ECOH. We also learned from participants in the study, that dentists’ behaviors and seeming to suggest a lack of transparency, can harm parents and their children’s trust. Thus dentists and other dental professionals must strive to maintain transparency and build trust with parents and their children, which may encourage long term compliance of families and result in better ECOH .
Some participants have said, in light of rural living, that it could be easier for a dental provider to go to the community so families are not scrambling to look for a dentist and/or missing appointments due to logistical and transportation difficulties. Commuting to care and not having transportation to get there is a challenge faced by FN and Metis parents in both rural and urban communities. Limited access to transportation is known to affect access to care and impact health of people living with chronic conditions  and more so for remote populations . Not only do some people living in rural and remote locations not have publicly funded or private transportation, but the transportation that is available might be atrociously expensive. This creates additional strain on scarce resources and causes parents to refrain from seeking dental care. Although some FN participants in this study said that they have some transportation coverage through the NIHB program, reported complications with Treaty status identification is also said to often exclude parents or their children from utilizing covered transportation services for medical appointments.
Registration with the NIHB dental program is one particularly problematic barrier for registered FN people to get their infants dental care. Currently, some young children are unable to access first dental visits by the first birthday in keeping with professional dental recommendations, because they do not have a Treaty number to confirm their FN status. The PI of this study [RJS] sees this every few months, where parents who have not been able to get their child registered, are often delayed in getting their infant in for the checkup by age 12 months.
Some participants believe that the Department of Indigenous Services Canada policies is limit access to dental care by paring down the procedures that can be covered for FN patients. Federal and provincial health policies, while well intentioned, can and do limit access to care for Indigenous populations [43,44,45,46].
Contextualized and tailored care may be the answer to policy and systemically induced inequities in healthcare systems [15, 47]. For example, Treaty status, which is a ticket to NIHB for FN, is determined by the Federal Indian Act . FN people who are without status for various reasons are excluded from accessing available resources. An infant not being registered with NIHB right away, and lacking a number, can be a barrier to getting a dental appointment as the dental office cannot bill NIHB for the early preventive dental visits by 12 months of age. Delays in getting paperwork completed and processed also means that many never get seen by their first birthday, as is recommended by dental providers. Perhaps community determined Treaty status may make it easier for more community members to quickly access health benefits offered through the NIHB, including transportation. Considering the high prevalence of ECC in FN and Metis populations, this would be an important step in promoting equity in ECC prevention and access to dental care. While NIHB has observably enhanced its programs over the years to remove the need for predetermination for many procedures, many registered FN peoples may not be aware of the enhancements or that it may be easier to access care. Perhaps, NIHB also needs to undertake an education campaign with its beneficiaries so that parents and practitioners alike can truly understand their dental benefits.
Stigmatization and discrimination of beneficiaries of public funding is also unfortunately a common occurrence as some people face discrimination when they have social insurance and as when they do not [48, 49]. Some face difficulties because of presumptions made of them drawing on public funds undeservingly. On the flip side, others may not receive the best service if they are not seen to have adequate insurance. As reported by participants in this study, some healthcare providers appear less interested in the patients’ wellbeing when they find that the patient has little or no money. Education for dental professionals to promote better understanding of micro aggressions, lack of transparency and outright racism directed at Indigenous populations which erodes trust and impacts compliance is needed. This could be useful in reducing predatory behaviours as reported to be the case in some dental offices. The result could be the promotion of proactively respectful and accommodating behaviors.
Facilitated pathways to supporting access to dental care could help in the form of direct information sharing between the NIHB and dental offices so the offices are frequently made aware of any changes to the program. Better information sharing could also mean that dental offices would be more flexible in accommodating patients and making changes to appointments without penalties when families are not able to make scheduled days and/or times due to administrative challenges with NIHB. Better information sharing may also help prevent ECC by clarifying what resources are available to parents and caregivers to enhance access to dental care in general. The persistent lack of information, lack of clarity overall and sheer difficulty of navigating systems, prevents utilization. An example of how accurate information could help prevent ECC, is that some parents in this study seemed to think that costlier oral hygiene products would do a better job of cleaning their child’s teeth. Not only is this not the case but it also shows how a paucity of evidence-based, professional driven information flow to parents and caregivers can expose children to ECC when parents assume they are not able to do anything about their child’s oral health. Parents may be waiting to purchase expensive oral hygiene products when more affordable products are just as effective.
Sometimes, families with NIHB or private insurance coverage pay some fees upfront before receiving care at dental offices. Some families become discouraged by this realization and stop attending dental clinics. They need to know the expectations for out-of-pocket costs so they can plan appropriately. Once again, facilitated pathways  coordinated by community-based primary healthcare workers may help FN navigate available resources and help Metis patients access affordable options planned and executed with the communities.
Participants in this study mentioned that other adults make poor food and beverage choices for their children. Mass awareness of practices, products and nutritional impacts on ECOH could change the attitudes and adult oral health related behaviors around children and possibly reduce risky behaviors such as the tendency to offer sugary substances when brushing afterwards cannot be implemented (Blinded Reference). Mass awareness must also be supported by practical opportunities to make actual changes. For example, a recent study highlighted the association between quality nutrition and reducing early childhood caries  and others the role vitamin D could play in supporting ECOH [52, 53]. However, parents living in poverty may bypass such information if they are not able to afford healthy food options. A real opportunity is presented when such awareness is followed by a listing of essential vitamins supporting ECOH that could be easily obtained from consuming traditional foods available on Indigenous lands and territories . Such information could be amply circulated in community-based settings and also to policy makers, social planners and local leadership who could provide support maternal and early childhood access to such nutrition.
While raising awareness among the communities of the availability of opportunities, such as the free dental visit for children up to 1 year in Manitoba is required, policies will also need to address the lack of capacity to meet the increased demand for visits that will be generated, and which may result in general dissatisfaction of patients to lengthy wait-times. Also, having to wait for more than 6 months for an appointment, as currently happens, is unacceptable, especially if a child already has early stages of caries which may progress to a more severe stage in that length of time. Policies that will create or facilitate care pathways may enable a faster establishment of a dental home for priority populations at higher risk of ECC.
One way to help keep parents and caregivers aware of ECOH and prevent ECC could be working in collaboration with non-dental healthcare providers [54, 55]. Families tend to interface with primary care providers more often than with dental providers, therefore, involving primary healthcare practitioners in caries assessments could increase and fast track access to dental professionals and dental care overall. Moreover, integration of oral care into primary care practice is gaining increasing appreciation and could be successfully implemented in community-based contexts with some management of information and roles . Integration in this way, is important for holistic health and is often advocated for by Indigenous peoples [57, 58] Thus in partnership with Public Health Agency of Canada, our team developed the Canadian Caries Risk Assessment Tool for use by non-dental healthcare professionals or dental professionals in non-dental settings (https://umanitoba.ca/CRA_Tool_ENG_Version.pdf). This tool can be used to identify children at high risk for caries, provide anticipatory guidance for parents, and establish a pathway of referral for those who may need additional dental care. Perhaps the use of technology to perform dental screenings remotely using the tool could be considered, especially now given a new propensity for conducting healthcare via use of technology.
Our research team includes Indigenous community members, Indigenous community leadership, (including FNHSSM and MMF), health professionals, local, provincial and national decision-makers and academics. This team structure promoted the sharing of recommendations with stakeholders as data became available. Results have also been shared with FN and Metis organizations and communities in formats that can promote further discussions and implementation plans. We however note that a stronger distinction could be made of the experiences and factors affecting ECOH among urban versus rural FN and Metis peoples. Our analysis did not explicitly consider these differences. Those differences will be considered in future analyses. The results may also not necessarily be generalizable to every FN and Metis community in Canada, thus the recommended strategies can be expanded by conducting additional studies with more communities and with increased sample size.