Developing oral health services for people experiencing severe and multiple disadvantage: a case study from Southwest England.

People experiencing severe and multiple disadvantage (SMD) have disproportionately high levels of dental disease and tooth loss but have limited access to dental care. This paper presents an evidence-based case study of co-designing, implementing, evaluating and refining a community dental clinic for people experiencing SMD in the Southwest of England. It shares challenges, lessons, and solutions. Tailored interventions that coordinate flexible and responsive care are important for facilitating dental access for individuals experiencing SMD. Participatory approaches can deliver a range of impacts both on research and service development. No single fixed model of co-design can be applied in service development, and the choice will vary depending on local context, available resources and joint decision making. Through co-design, vulnerable populations such as those with SMD can shape dental services that are more acceptable, appropriate and responsive to their needs. This approach can also ensure long-term sustainability by bridging treatment pathway development and commissioning.

Barriers and facilitators to hepatitis C screening and treatment for people with lived experience of homelessness: A mixed-methods systematic review.

BACKGROUND: People experiencing homelessness have an increased risk of hepatitis C virus (HCV) infection, with rates higher than the general population. However, their access to HCV diagnosis is limited and treatment uptake is low. OBJECTIVES: To identify and describe the barriers and facilitators for HCV screening and treatment for adults with lived experience of homelessness in highly developed countries. METHODS: Bibliographic databases (Embase, MEDLINE, CINAHL and SocINDEX) and grey literature (Google, EThOS, the Health Foundation, Social Care Online, the World Health Organisation, Shelter, Crisis and Pathway) were searched. Two reviewers independently screened and appraised all studies. The Critical Appraisal Skills Programme tool and the Joanna Briggs Institute checklist were used. The analysis involved a three-stage process: coding, theme generation and theme mapping under Penchansky and Thomas's modified access model. RESULTS: Twelve papers/reports were included in the review. Several interacting factors influence access of people with lived experience of homelessness to HCV testing and treatment. Some mirror those identified for the general population. The precarious conditions associated with the lived experience of homelessness along with the rigidity of hospital settings and lack of awareness emerged as dominant barriers. Flexibility, outreach, effective communication, tailoring and integration of services were found to be important facilitators. Evidence from Black, Asian and minority ethnic groups is limited. CONCLUSIONS: People experiencing homelessness face multiple barriers in accessing and completing HCV treatment, relating to both their lived experience and characteristics of health systems. Although some barriers are readily amenable to change, others are more difficult to modify. The facilitators identified could inform future targeted measures to improve HCV diagnosis and treatment for people experiencing homelessness. Research is warranted into successful models to promote screening, diagnosis and treatment. PATIENT OR PUBLIC CONTRIBUTION: Our team includes a peer advocate, a hepatology nurse and a community volunteer, all with significant experience in promoting and engaging in HCV care and outreach for people experiencing homelessness. They contributed to the protocol, interpretation and reporting of the review findings.

Optimising the delivery of remediation programmes for doctors: A realist review.

CONTEXT: Medical underperformance puts patient safety at risk. Remediation, the process that seeks to 'remedy' underperformance and return a doctor to safe practice, is therefore a crucially important area of medical education. However, although remediation is used in health care systems globally, there is limited evidence for the particular models or strategies employed. The purpose of this study was to conduct a realist review to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety. METHOD: We conducted a realist literature review consistent with RAMESES standards. We developed a programme theory of remediation by carrying out a systematic search of the literature and through regular engagement with a stakeholder group. We searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, HMIC, CINAHL, ERIC, ASSIA and DARE) and conducted purposive supplementary searches. Relevant sections of text relating to the programme theory were extracted and synthesised using a realist logic of analysis to identify context-mechanism-outcome configurations (CMOcs). RESULTS: A 141 records were included. The majority of the studies were from North America (64%). 29 CMOcs were identified. Remediation programmes are effective when a doctor's insight and motivation are developed and behaviour change reinforced. Insight can be developed by providing safe spaces, using advocacy to promote trust and framing feedback sensitively. Motivation can be enhanced by involving the doctor in remediation planning, correcting causal attribution, goal setting and destigmatising remediation. Sustained change can be achieved by practising new behaviours and skills, and through guided reflection. CONCLUSION: Remediation can work when it creates environments that trigger behaviour change mechanisms. Our evidence synthesis provides detailed recommendations on tailoring implementation and design strategies to improve remediation interventions for doctors.

Perceived barriers and facilitators to accessing and utilising sexual and reproductive healthcare for people who experience homelessness: a systematic review.

INTRODUCTION: People who experience homelessness face disproportionately poor reproductive health and adverse pregnancy outcomes, including but not limited to unintended pregnancy, abortion, low birth weight and preterm birth, as well as a higher risk of sexually transmitted infections (STIs). Precarious living conditions are known to contribute to poor uptake and engagement with sexual and reproductive healthcare (SRH) for this population. AIM: To identify and understand the perceived barriers and facilitators for accessing and utilising SRH for people who experience homelessness from their perspective, and the perspective of support staff/volunteers and healthcare professionals. METHODS: Electronic databases and online sources were searched. Two reviewers independently carried out the screening, data extraction, critical appraisal, data synthesis and thematic analysis of findings. RESULTS: Following deduplication and screening, 23 papers/reports were considered eligible for the review. Barriers for people experiencing homelessness to accessing and utilising SRH were identified within the themes of complexity, feelings and knowledge (ie, individual-level factors), as well as patient/provider interaction and healthcare system (ie, organisational factors). Facilitators were identified within all of the above themes except for complexity. CONCLUSIONS: Both population characteristics and attributes of the healthcare system influence access and utilisation of SRH by people experiencing homelessness. Given the complexity of living conditions associated with homelessness, greater efforts to improve access should be placed on healthcare systems and aspects of care delivery. This systematic review highlights current gaps in the literature and provides recommendations for enhancing future research and practice to meet the needs of this vulnerable group more effectively.

Strategies to improve oral health behaviours and dental access for people experiencing homelessness: a qualitative study.

Objectives The present study aimed to identify strategies to improve oral health behaviours as well as access to and provision of dental care for people experiencing homelessness.Method We conducted focus groups with people living in a residential homeless centre and semi-structured interviews with other stakeholders working with or supporting people experiencing homelessness. Following an inductive approach, thematic analysis was used to synthesise the findings on NVivo software.Results Participants included 11 British males experiencing homelessness and 12 other stakeholders from various professional backgrounds. Themes identified included: awareness and empowerment; supportive environment and dental health system; flexible and holistic care; outreach and community engagement; collaboration with other health and social services; and effective communication.Conclusions Efforts to improve oral health among people experiencing homelessness via improved oral health habits and engagement with services need to be directed at both the recipients of care and the healthcare teams. Well-powered empirical studies are needed to evaluate whether the strategies identified can improve engagement and care provision for this population.

Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach.

BACKGROUND: People who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not-for-profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population. OBJECTIVES: To evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service. METHODS: The evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi-structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted. RESULTS: By 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health-care team attitudes as key factors influencing service utilization and continuity of care. CONCLUSIONS: This study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels.

'Teeth Matter': engaging people experiencing homelessness with oral health promotion efforts.

People with experience of homelessness commonly suffer from poor oral health and are likely to have low-level engagement with dental services. 'Teeth Matter' was a pilot study developed to examine whether peer education could result in improved plaque management among people who are experiencing homelessness. Based on the experience gained from developing and implementing the study, and taking into consideration the views of everyone involved, this paper provides a list of suggestions and resources that can be used to improve engagement of this population with oral health promotion activities. Some of the learning points are also applicable in the clinical setting.

A dental student view on learning gained through Inter-Professional Engagement with people experiencing homelessness.

Community engagement is an important element of the undergraduate programme at the Faculty of Medicine and Dentistry, University of Plymouth, United Kingdom. This report presents a project that a group of second year dental students undertook with people experiencing homelessness, and provides an in-depth reflective account of its impact on the students' learning. The project formed part of the students' inter-professional engagement module and delivered an intervention to enable residents at a temporary accommodation centre to access dental treatment. As a result of the project, 14 residents received dental treatment. The groups' confidence in engaging with people experiencing homelessness and their understanding of the complex needs of this group also significantly improved. Community engagement modules can be an important learning tool for students' future practice and can help promote access to dental care for vulnerable populations.

Management of plaque in people experiencing homelessness using 'peer education': a pilot study.

Introduction People who experience homelessness have poor oral health and limited access to dental services.Aim To examine whether 'peer education' could yield improved plaque management among people experiencing homelessness.Methods A quasi-experimental, one-group pre-test-post-test study was conducted, with follow-up at one and two months. Participants were living in temporary accommodation in Plymouth, UK. Plaque levels were assessed using the simplified oral hygiene index. A questionnaire and the oral health impact profile (OHIP-14) were administered. Patient satisfaction and barriers to dental care were explored by interviews.Results The baseline sample included 24 people with a mean age of 36.88 ± 10.26 years. The mean OHIP-14 score was 25.08 ± 19.56; finding it uncomfortable to eat and being embarrassed attracted the highest values (2.46 ± 1.53 and 2.33 ± 1.63, respectively). Plaque levels decreased by month one and month two, though the changes were not statistically significant. Positive changes in confidence in toothbrushing at month two were identified (p = 0.01).Conclusion Experiencing pain and the opportunity to access treatment were key drivers of study participation. The study indicated that it is feasible to conduct oral health promotion projects for people in temporary accommodation. Adequately powered studies examining the impact of peer education on improving homeless people's oral health are warranted.

Remediating doctors' performance to restore patient safety: a realist review protocol.

INTRODUCTION: Underperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor's practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety. METHODS AND ANALYSIS: Realist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). ETHICS AND DISSEMINATION: Ethical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics. PROSPERO REGISTRATION NUMBER: CRD42018088779.