Barriers to orthodontic treatment among rural children in Guangxi, China: a mixed-methods study

BACKGROUND: Malocclusion represents a major global oral health burden, impairing function, aesthetics, and psychosocial well-being. The rates of treatment of rural children are significantly lower than for urban children. The objective of this study is to find core barriers to orthodontic treatment for these children and analyze how these factors vary by malocclusion severity. METHODS: In this mixed-methods study, we recruited 42 pairs of 11-12-year-old children with malocclusion and their parents by purposive sampling in 10 rural primary schools in Guangxi, China. Data came from semi-structured interviews; after coding, network analysis was used to find the key barriers to orthodontic treatment and to assess if these barriers varied by malocclusion severity. RESULTS: Financial pressure and low orthodontic health literacy were primary barriers to orthodontic treatment. Financial pressure was consistent across all malocclusion groups, but other factors differed. For the definite group, primary barriers were the difficulty of regular follow-up, limited individual awareness of adverse effects, and personal concerns about daily impacts. For the severe group, primary factors were the parental lack of orthodontic knowledge, poor treatment timing awareness, and doubts about efficacy and safety. For the handicapping group, primary barriers were the poor awareness of the treatment time, parental concerns about children's daily life, and doubts about efficacy and safety. With the malocclusion severity increasing, primary factors shifted from child-centered concerns to parent-centered knowledge and trust issues, as individual-level barriers became less and the family-concerned environment factors became more. CONCLUSIONS: Financial pressure and low orthodontic health literacy were the primary barriers to orthodontic treatment among rural children, with differences across malocclusion severity subgroups. From a public health view, future efforts should be focused on improving orthodontic health literacy with targeted education and awareness campaigns, especially tackling subgroup-specific barriers. Furthermore, training primary care dentists in orthodontics can help spread the related knowledge and handle simpler cases locally. Also, cost-effective treatment strategies should be explored and advanced. These could improve the treatment uptake among the rural children.