Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study.

BACKGROUND: Depression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services. METHODS: We conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains. RESULTS: Reported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care. CONCLUSIONS: Depression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.

Exploring the contextual factors, behaviour change techniques, barriers and facilitators of interventions to improve oral health in people with severe mental illness: A qualitative study.

People with severe mental illness (SMI) have significantly poorer oral health compared to people without SMI and interventions targetted to improve oral health in this population failed to show any long-term improvement. Interventions are influenced by many contextual factors ranging from individual to systems level. This study aimed to understand the contextual factors, behaviour change techniques of the available oral health interventions and explore the barriers to and facilitators for engagement with these interventions from the perspectives of people with SMI (service users) and related service providers. Intervention details were extracted from 12 intervention studies identified from a previous systematic review using the template for intervention description and replication checklist (TIDieR) and behaviour change techniques (BCTs) were coded using the behaviour change technique taxonomy v1. Sixteen individual BCTs were identified and out of which "4.1 instructions on how to perform the behaviour" (n = 9) and "6.1 demonstration of behaviour" (n = 6) were most frequently used BCTs. Video vignettes prepared from the different intervention components identified from existing studies were shown to service users and service providers in dyadic or one-to-one interview format to elicit their views on barriers and facilitators for engagement with the intervention components. Interviews were analysed using Framework analysis and were guided by theoretical domains framework (TDF); and capability, opportunity and motivation (COM-B) model of behaviour change. Main facilitators identified to increase capability, opportunity and motivation of service users were the involvement of carers/care coordinators and integration of dental and mental health care, provision of oral health/hygiene information/products at an appropriate level and provision of tailored support according to individual needs and preferences. Barriers identified were related to lack of communication skills of the service providers, provision of coordinated care, lack of support in visiting a dentist and navigating the payment system and long follow up times. Appropriate training was considered as a facilitator, and staff turnovers and workload were considered as main barriers by the service providers. The findings suggest that comprehensive interventions that target barriers and enhance facilitators from individual to systems level are needed to improve oral health outcomes of people with SMI.

A Qualitative Study Exploring the Barriers and Facilitators for Maintaining Oral Health and Using Dental Service in People with Severe Mental Illness: Perspectives from Service Users and Service Providers.

People with severe mental illness suffer from a high burden of oral diseases, which can negatively impact their physical and mental well-being. Despite the high burden, they are less likely to engage in oral health care including accessing dental services. We aimed to identify both the service users' and service providers' perspective on the barriers and facilitators for maintaining oral health and dental service use in people with severe mental illness. Qualitative exploration was undertaken using dyadic or one-to-one in-depth interviews with service users in the UK with a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. Service providers, including mental health and dental health professionals, and informal carers (people identified as family or friend who are not paid carers) were also interviewed. Thematic analysis of the data revealed three main cross-cutting themes at the personal, inter-personal and systems level: amelioration of the problem, using a tailored approach and provision of comprehensive support. The main barriers identified were impact of mental ill-health, lack of patient involvement and tailored approach, and accessibility and availability of dental services including lack of integration of services. The main facilitators identified were service providers' effective communication skills and further support through the involvement of carers. The findings suggest that the integration of dental and mental health services to provide tailored support for overall health and well-being, including the oral health of the patient, can better support people with severe mental illness regarding their oral health needs.

The effectiveness of behaviour change interventions delivered by non-dental health workers in promoting children's oral health: A systematic review and meta-analysis.

OBJECTIVES: Dental caries is the most common preventable childhood condition. Non-dental professionals and health workers are often well placed to support parents in adopting positive oral health behaviours for their children. The aim of this study was to determine the effectiveness of behaviour change interventions and their individual component behaviour change techniques (BCTs), that were delivered by non-dental professionals and health workers. METHODS: A systematic search of Ovid MEDLINE, PubMed, CINAHL, Cochrane Library, Web of Science, TRoPHI and PROQUEST from inception until March 2021 was conducted. Randomised controlled trials and quasi-experimental studies for improving oral health outcomes in children were included. Quality assessment was carried out using Cochrane Risk of Bias tool and ROBINS-I tool. Publication bias was assessed using funnel plots and Egger's regression intercept. Effect sizes were estimated as standardised mean difference (SMD) and odds ratio/risk ratio for proportions. Meta-analyses were performed for studies reporting mean decayed, missing, filled surfaces (dmfs) and mean decayed, missing, filled, teeth (dmft) indices. Behaviour change technique coding was performed using behaviour change technique taxonomy v1 (BCTTv1). RESULTS: Out of the 9,101 records retrieved, 36 studies were included with 28 showing a significant effect either in clinical and/or behavioural/knowledge outcomes. Most studies (n = 21) were of poor methodological quality. The pooled SMD for caries experience showed statistically significant result for caries prevention at surface level -0.15 (95% CI -0.25, -0.04) and at the tooth level -0.24 (95% CI -0.42, -0.07). In 28 effective interventions, 27 individual BCTs were identified and the most frequently used were: "Instructions on how to perform the behaviour" and "Information about health consequences". CONCLUSION: There is low quality of evidence suggesting non-dental professionals and health workers may help improve oral health outcomes for children. To confirm these findings, further high-quality studies incorporating a variety of BCTs in their interventions for adoption of good oral health behaviours are needed.

Improving oral health in people with severe mental illness (SMI): A systematic review.

BACKGROUND: Those with severe mental illness (SMI) are at greater risk of having poor oral health, which can have an impact on daily activities such as eating, socialising and working. There is currently a lack of evidence to suggest which oral health interventions are effective for improving oral health outcomes for people with SMI. AIMS: This systematic review aims to examine the effectiveness of oral health interventions in improving oral health outcomes for those with SMI. METHODS: The review protocol was registered with PROSPERO (ID CRD42020187663). Medline, EMBASE, PsycINFO, AMED, HMIC, CINAHL, Scopus and the Cochrane Library were searched for studies, along with conference proceedings and grey literature sources. Titles and abstracts were dual screened by two reviewers. Two reviewers also independently performed full text screening, data extraction and risk of bias assessments. Due to heterogeneity between studies, a narrative synthesis was undertaken. RESULTS: In total, 1462 abstracts from the database search and three abstracts from grey literature sources were identified. Following screening, 12 studies were included in the review. Five broad categories of intervention were identified: dental education, motivational interviewing, dental checklist, dietary change and incentives. Despite statistically significant changes in plaque indices and oral health behaviours as a result of interventions using dental education, motivational interviewing and incentives, it is unclear if these changes are clinically significant. CONCLUSION: Although some positive results in this review demonstrate that dental education shows promise as an intervention for those with SMI, the quality of evidence was graded as very low to moderate quality. Further research is in this area is required to provide more conclusive evidence.

Clinical consequences of untreated dental caries assessed using PUFA index and its covariates in children residing in orphanages of Pakistan.

BACKGROUND: The purpose of this study was to determine the prevalence and clinical effects of untreated dental caries in Pakistani children residing in orphanages using the DMFT and PUFA index; association of decay and untreated dental caries with demographics including type of orphanage; behavioural and dental visiting pattern; and association of dental pain experience and type of orphanage with dental visiting. METHODS: A cross-sectional survey was conducted on a total of 753 orphan children belonging to 4-17 years of age group residing in twin cities of Rawalpindi and Islamabad, Pakistan. Clinical examination of children was performed using the DMFT and PUFA index for the assessment of dental caries and untreated decay, followed by questionnaire enquiring about eating and oral hygiene habits, dental visiting pattern and dental pain and swelling experience. Association between dental decay, child's dental visiting and pain as a consequence of untreated decay was carried out using chi square test and logistic regression analysis. RESULTS: The overall caries prevalence was 34.8% and overall prevalence of PUFA/pufa was 15.9%. The mean score of DMFT and dmft was 1.18 (SD 0.39) and 1.04 (SD 0.23), and mean PUFA was 1.18 (SD 0.57) and mean pufa score 1.14 (SD 0.35). Untreated caries ratio was found to be 49.1% indicating half the decay had progressed to involve the pulp. No significant association of gender was found with DMFT, dmft, PUFA and pufa (p > 0.05), however, when analysed individually, the 'D' component of DMFT was significantly associated with male gender (p = 0.05). Furthermore, no significant association of DMFT/dmft or PUFA/pufa in either dentition was found with behavioural characteristics such as dietary and oral hygiene habits. Also, 66.2% children who experienced pain had not been to the dentist in the past year (p = 0.013) and 52.6% children who mentioned experiencing pain at night had not been to the dentist in the past year (p = 0.009). Children with decay were more likely to have visited the dentist (OR 3.3, 95% CI 1.42-7.6, p = 0.006). However, children who reported to have experienced pain were less likely to have visited the dentist in the past year (OR 0.53, 95% CI 0.32-0.88, p = 0.014). CONCLUSIONS: Moderate levels of decay were found in the sample with 'd' component majorly responsible for the cumulative DMFT index. However, alarmingly almost half of the decay component (49.1%) had progressed to involve the pulp. Experiencing pain in teeth prompted dental visits. Initiation of preventive services for children residing in orphanages in Pakistan would help greatly towards reducing the burden of untreated decay.