Barriers to oral health service access for rural and remote Australian children: a mixed-methods systematic review

INTRODUCTION: Children living in rural and remote communities experience challenges in dental care access. While several studies have reported barriers contributing to inequalities in services utilisation, a synthesis of evidence is lacking for those underserved children. In this review we explore the barriers and challenges to accessing oral health services among children and families living in rural and remote Australia. METHODS: This review followed the Joanna Briggs Institute methodology for mixed-methods systematic review. We structured our review question using the PICO framework (population: children and their families; phenomena of interest: barriers to oral health service access; context: rural and remote Australia). We conducted a comprehensive literature search across multiple databases, including Medline, Scopus, and Web of Science from December 2024 to January 2025 with no publication-date restrictions. We used the following keywords and Medical Subject Headings: 'children/paediatric', 'barriers', 'accessibility', 'oral/dental health', 'rural/remote areas', and 'Australia'. We complemented database searches with screening the reference lists of included studies and hand-searching in Google Scholar and relevant websites (Australian Institute of Health and Welfare, Australian Bureau of Statistics, and World Health Organization). We included qualitative, quantitative, and mixed-methods studies that reported barriers to children's oral health services in rural and remote Australia (including Indigenous and non-Indigenous populations). We excluded studies conducted outside Australia, letters to the editor, conference abstracts, opinion articles, and studies on medically compromised children. We imported articles into Covidence for de-duplication, screening, and data extraction by two independent authors. We assessed methodological quality using Joanna Briggs Institute critical appraisal tools and synthesised evidence using a convergent integrated mixed-methods approach. RESULTS: This review included 31 studies: 12 qualitative, 17 quantitative, and 2 mixed methods. Using the ecological model framework, we organised the barriers into four levels: system, policy, community, and individual. At the system level, geographic distance, limited service availability, and the cost of dental care emerged as significant barriers. At policy level, barriers were restricted access to water fluoridation and insufficient government financial support for oral health care, compared with other health services. At the community level, the impact of social determinants of health, along with the historical cultural oppression, colonisation, and loss of land, reduced both utilisation and confidence in oral health services. At the individual level, low oral health literacy, lack of dental insurance, fear, anxiety, and the presence of multiple competing priorities further discourage care-seeking. CONCLUSION: The findings of this review indicate that children in rural and remote communities have historically experienced limited access to dental services. This synthesis of multi-level barriers offers a comprehensive understanding of the complex factors influencing oral healthcare access. Hence, addressing these barriers in isolation is unlikely to be effective, highlighting the need for multi-level strategies.