Oral health promotion and homelessness: A theory-based approach to understanding processes of implementation and adoption

Abstract

Objective: To use the Theory of Diffusion of Innovations as a framework to explore the qualitative data gleaned from a process evaluation of the Smile4life intervention across Scottish National Health Service (NHS) Boards and to inform future oral health promotion and homelessness. Design: A qualitative exploration. Setting: In 2012, the Smile4life programme to promote the oral health of homeless people was launched in Scotland. Practitioners received training to ensure its successful implementation and adoption. A process evaluation began in February 2013. Method: A total of 20 oral health officers from the 11 participating NHS Boards took part in the process evaluation. They were interviewed each month for a 17-month period. Boards were placed into adoption categories based on the time taken to adoption. The data were analysed using a framework approach. Results: The Theory of Diffusion of Innovations was used to define 'time to adoption' and to classify participating NHS Boards' adoption categories. It was also used to identify diffusion variables that underpinned Smile4life adoption. For Boards that more readily adopted Smile4life, the diffusion variables of familiarity and good social exchanges appeared to promote implementation. Numerous conflicts emerged, however, in late adoption Boards. These included a lack of resources and practitioner ambivalence, which slowed up implementation. Conclusion: The Theory of Diffusion of Innovations provided a useful theoretical framework for understanding the processes in the implementation and adoption of the Smile4life programme. It allowed specific training requirements for the practitioners to emerge to facilitate diffusion of the programme in their Boards.

Barriers and enablers to accessing dental services for people experiencing homelessness: A systematic review

“…Dental professionals may fear aggression and have cross infection concerns with regard to their homeless patients . Limited or no training in dealing with socially excluded groups can affect the confidence of staff in dealing with homeless people …”

“…Homeless people are sometimes refused ongoing care at dental practices and some clinics, or dentists are hesitant to accept homeless people for treatment . Reasons reported for precluding homeless people from “registering” or attending included lack of a fixed address (ie, having a hostel address), the practice being full, or existence of a waiting list, the practice taking only private patients and patients being on welfare benefits .…”

“…For people who experience homelessness and chaotic lifestyles, current priorities such as securing accommodation and managing their daily living expenses are more pressing issues to deal with than oral health. 3,4,[33][34][35][36][37] Mental health issues and psychosocial factors can exacerbate the prevalent dental anxiety/fear and further inhibit dental attendance. 3,15 Furthermore, dependency issues (ie, drugs, alcohol) lead to self-neglect and further decrease the priority placed upon oral health.…”

“…Homeless people are sometimes refused ongoing care at dental practices and some clinics, or dentists are hesitant to accept homeless people for treatment. 11,[33][34][35][41][42][43]48 Reasons reported for precluding homeless people from "registering" or attending included lack of a fixed address (ie, having a hostel address), the practice being full, or existence of a waiting list, the practice taking only private patients and patients being on welfare benefits. 10,33,35,[41][42][43] From the healthcare provision side, some reasons for the hesitation to take on people who experience homelessness include the belief that they should be accessing care through dedicated services, that they are likely to have drinking problems, that the practice list is full, and that homeless people have poor compliance or rate of attendance resulting in dental services losing money (ie, are 'not practice builders').…”

Implementing an Oral Health Intervention for People Experiencing Homelessness in Scotland: A Participant Observation Study

“…The evaluation found that it took NHS Boards an average of 16 months to implement the Smile4life intervention following the launch of the Guide for Trainers training package. The results of this evaluation highlighted various barriers to successful implementation, particularly a lack of resources (staffing, time constraints), and poor engagement between the NHS and the Third Sector [17]. Factors that facilitated implementation included motivated practitioners and a willingness to engage with other organisations [17].…”