Abstract
Childsmile, the national oral health improvement programme for children in Scotland, aims to reduce oral health inequalities and improve access to dental services. Childsmile is delivered, in part, by a new category of lay or community-based worker known as a Dental Health Support Worker (DHSW). DHSWs support families to improve oral health behaviours and attend dental practice.
Aims: To compare delivery of the DHSW role between NHS boards in Scotland, in order to gain an in-depth understanding of which variants impact on effectiveness of the DHSW role and establish what works, for whom and under what circumstances. Findings will be fed back to the programme to improve delivery of the role.
Methods: Explanatory case studies explored causal links between context, delivery and outcomes. Case study units comprised one DHSW and key stakeholders involved in delivery of the role from three NHS boards. Case studies and participants were selected using theoretical sampling based on characteristics integral to delivery of the role. Twenty six interviews and ten observations involving sixteen stakeholders explored factors impacting on delivery of DHSW role. Sessions were recorded and transcribed. Realistinspired analysis, whereby mid-range theories and context, mechanism and outcome configurations were identified within cases, and cross case analysis was conducted (Pawson et al 2005). University and NHS ethical approval was granted and consent obtained for each participant.
Results: Key mid-range theories include: (1) Wider Context: Embedding of Childsmile within existing healthcare policy and delivery over an extended period of time has improved stakeholder buy-in. There is reluctance among some dental practices to engage with Childsmile due to the perception of costs outweighing benefits. This increases DHSW workload and contributes to a lack of continuity of care. (2) Nature of DHSW Support: Delivery of the DHSW role involves information provision and linking families with a dental practice. To address programme aims, oral health attitudes and parenting behaviours of high risk families must be addressed (Ajzen 1988, 1991). This requires additional DHSW training and a greater focus on those families at highest risk. (3) Parenting Behaviours: DHSWs typically receive referrals for low-risk families already engaging in oral health parenting behaviours who are motivated and receptive to oral health advice. Thus the role concentrates on reinforcing existing positive behaviours rather than behaviour change of high risk families. Supporting low risk families is not an effective use of DHSW time and shifts resources from those who need it most.
Conclusions: A “onee size fits all” approach is not suitable for the DHSW role and variation can be facilitative. Programme theory requires further development to ensure targeted referrals for high risk families, implementation of behaviour change theory in the DHSW role, and partnership working with dental practices to address programme aims of reducing inequalities in oral health and improve access to dental services.
The project is funded by the Scottish Government.
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