Title: An intervention using mental health support workers as link workers to improve dental visiting in people with severe mental illness: A feasibility study.
Funder: Department of Health and Social Care

Abstract: Severe mental illness (SMI) affects around 1% of the population. It includes depression, psychosis, and bipolar disorder. People with SMI often have problems with their teeth and gums. They are more likely to have missing, filled, and decayed teeth than people without SMI. Having poor oral health impacts a lot of everyday activities like eating, speaking and smiling. It can affect how patients see themselves and their mental health._x000D_ _x000D_ Dentists can treat many early teeth and gum problems. However, very few people with SMI attend regular dental appointments. Instead, they are more likely to seek help when in crisis and invasive treatments are the only option. Accessing a dentist for people with SMI can be difficult for lots of reasons. People can feel helpless, fearful, or demotivated about attending. They can have difficulty booking, planning, and getting to appointments. They may struggle to pay for or access free dental care. Unfortunately, existing dental initiatives have not addressed the barriers facing this group. They do not help people with SMI to attend the dentist._x000D_ _x000D_ We want to help people with SMI to access dental care. We will use mental health support workers who are already working in the NHS. They will link people receiving care from mental health teams with dental services. The support workers will help people to book, plan, and attend regular dental appointments. They will support patients to apply for financial support. People call this type of support link work. Research has indicated that link work can increase dental visits in people who might not normally attend. Mental health support workers already do link work for other appointments. Link work has been used to help other vulnerable groups of people (e.g. children) around dental care. However, this will be the first use of link work to help people with SMI to attend the dentist._x000D_ _x000D_ There are four work packages (WP)._x000D_ _x000D_ WP1: We will complete six workshops with patients, staff, and carers. We will use this to refine the link work intervention. It will help to design training materials for use by support workers. _x000D_ _x000D_ WP2: We will do a review of how link work has been used in the past. We will look at why it might work. We will explore what might make it more or less effective. _x000D_ _x000D_ WP3: We will test whether the intervention is feasible. We will do this in a clinical study with 84 people recruited from Lancashire, Manchester, and the Pennines. Half will get the link work intervention. The other half will receive their usual NHS services. This will be decided by chance. We will measure how often people in both groups visit the dentist. We will also assess the state of their teeth and gums. We will collect this data when people come into the study and after nine months. _x000D_ _x000D_ WP4: We will interview patients and staff. We will also listen to recordings of appointments and read field notes. This will tell us whether or not patients and staff find the link work intervention is acceptable to people. It will tell us whether or not we should test this further in a larger trial. It will also help us to make changes to its design.

Lay abstract: Research question: What is the feasibility and acceptability of a link work intervention using support workers to increase planned dental care visits for patients with severe mental ill health (SMI)?_x000D_ _x000D_ Background: The term SMI refers to complex and enduring mental health difficulties (e.g. psychosis, bipolar disorder). People with SMI experience poorer oral health compared to the general population. They are more likely to have decayed, missing or filled teeth, and are three times more likely to experience total tooth loss. This can then affect their self-esteem, quality of life and mental health. Dentists can prevent and treat oral health problems. However, often patients with SMI only attend their dentist at times of crisis, where more intrusive treatments (e.g. extractions) are needed. Barriers to dental attendance are likely multifactorial including practical issues, costs, and motivation. Unfortunately, existing dental interventions have not addressed these issues. They have not enabled people with SMI to attend the dentist. This is particularly important given the widening inequalities around dental access. This study aims to explore whether a link work intervention, delivered by mental health support workers, can promote dental visiting in people with SMI. Link work aims to afford vulnerable populations with the capacity, opportunity and motivation to make meaningful behavioural changes. Here, it may help people to attend the dentist. _x000D_ _x000D_ Aims and objectives: i) To understand what constitutes best practice when delivering link work; ii) To identify what training needs exist around link work; iii) To determine whether patients with SMI are willing to be randomised to a trial targeting dental visiting; iv) To understand whether it is feasible to collect clinical outcome and planned dental appointment data in this population; v) To explore if, and how, patients with SMI engage with a link work intervention; and vi) To understand the potential factors impacting to acceptability and delivery._x000D_ _x000D_ Method: There are four work packages (WP): WP1 involves up to six coproduction patient and public involvement workshops with patients, staff, and carers. We will use this information to refine the link work intervention and co-design training materials. WP2 is a systematic review of how link work interventions have been used to facilitate service use, their mechanisms of action, and facilitators and barriers to implementation. WP3 is a feasibility trial of the link work intervention in 84 people with SMI recruited from three participating NHS Trusts. 42 people will be randomised to receiving the link work intervention. The other 42 people will receive their usual care. We will record dental attendance and clinical outcomes in both groups at baseline and after nine months. WP4 is a qualitative evaluation of the trial and intervention involving 20 patients, 10 stakeholders and six staff interviews, which will be analysed using thematic framework analysis._x000D_ _x000D_ Timelines for delivery: 24 months._x000D_ _x000D_ Anticipated impact and dissemination: This project will provide data on the feasibility and acceptability on a refined link-work intervention for people with SMI. The eventual aim is to produce a link-work intervention that is cost and clinically effective, and can be readily implemented in mental health services. We will disseminate widely to academics, clinicians, commissioners, patients, and carers, ensuring accessibility to all groups.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH;ORAL AND GASTROINTESTINAL