Title: Identifying effective and sustainable interventions to improve the oral health and related behaviours of adults with severe and multiple disadvantage: evidence synthesis and qualitative stakeholder research
Funder: Department of Health and Social Care

Abstract: Increasing numbers of people in England are homeless, substance users and repeated offenders &ndash; these issues co-occur and are referred to as severe and multiple disadvantage (SMD). SMD groups have poor physical and mental health, and considerable health and social care costs. Oral health problems, including tooth loss, tooth decay and gum disease, are the most common physical health conditions amongst SMD groups, and are closely interlinked with health behaviours, particularly drug and alcohol use, smoking and poor diet. Poor oral health results in pain, infections, under-nutrition, and wider impacts on mental health, self-esteem, isolation and employment. Our research aims to identify interventions that are effective and sustainable in improving the oral health and related behaviours of adults facing SMD. The goal of our research is to provide insights and evidence to improve the health and well-being of SMD groups. Our research objectives are to: Evaluate interventions to improve oral health and related behaviours (drug and alcohol misuse, smoking, diet) in adults with SMD in terms of their (i) effectiveness; and (ii) resource use. Assess factors that influence sustainability, including implementation, settings, acceptability and potential adverse effects, of interventions to improve the oral health and related behaviours of adults with SMD. Explore the role of oral health interventions in identifying other health issues and supporting individuals from SMD groups to access health, social and voluntary sector services. Develop a conceptual framework (including components, pathways, outcomes) to underpin interventions by iteratively refining our logic model. Collate findings from the above strands to formulate recommendations for policy and an evidence for practice briefing guide for interventions to improve the oral health and related behaviours of SMD groups. This project was developed in partnership with people with lived experience of SMD, who contributed to the initial logic model, qualitative study and dissemination plans. Fulfilling Lives, a charity that supports SMD groups, are project partners. We will refine our initial logic model iteratively and takes a whole-systems approach recognising wider determinants underlying SMD (e.g. economic structures, housing, psychosocial factors). We will conduct systematic reviews of effectiveness, and implementation and acceptability of interventions. In-depth primary research will include a qualitative study and data collection on resource implications of services, led by our &ldquo;Expert by Experience&rdquo; Co-applicant and peer researchers. Fieldwork will include interviews with individuals from SMD groups, and focus groups (Newcastle, London, Plymouth) with other stakeholders (Local Authority, charities, policy makers). A cost consequence analysis, based on data from the systematic review and primary data collected, will explore and synthesize average costs of interventions. Finally, we will collate findings from the logic model, evidence synthesis, qualitative study and economic analysis. We will conduct a dissemination workshop with SMD groups, Local Authorities, charities and Public Health England (PHE) to develop recommendations and an evidence for practice briefing to aid commissioning and policy related to SMD groups. Having team members representing SMD groups, and embedded in Local Authorities, charities and PHE, will ensure that our research is translated into policy and practice.

Lay abstract: An increasing number of people in England are homeless, have drug or alcohol problems, or repeat offending &ndash; these problems, referred to as severe and multiple disadvantage (SMD), often occur together. SMD is associated with stigma, physical and mental ill-health, and contributes to &pound;10 billion/year in public spending. People in SMD groups have very high levels of dental problems, such as tooth loss, tooth decay and gum disease. These problems in SMD groups remain untreated, leading to pain, infections, poor nutrition, and have profound negative impacts on self-esteem, employment opportunities, and mental health. Dental problems in SMD groups are also associated with high levels of poor health behaviours, particularly, smoking, drug and alcohol use and poor diet. We have developed this project in partnership with Fulfilling Lives, an organisation that supports SMD groups. We have spoken directly to people who are experiencing SMD, and other partners such as Local Authorities, and those who develop health policies and their input has guided this project. These partners have highlighted the urgent need to tackle dental problems and related health behaviours in SMD groups. In this research, we will find solutions that are most effective in improving the oral health and health behaviours of adults facing SMD (homelessness, substance misuse, repeat offending). We will also understand how these solutions work and how best to implement them. We will do this by working with people who have experienced SMD and organisations that support them. Our project consists of four strands of work: 1) We will review existing research studies to understand which solutions are most effective in improving the oral health and related behaviours among SMD groups. 2) We will find out what solutions are appropriate, acceptable and feasible in improving the oral health and related behaviours in SMD groups. We will do this by gathering the views of SMD groups, and other partners, including charities and Local Authorities who support SMD groups. 3) We will assess possible costs of services to improve the oral health and related behaviours of SMD groups. 4) Finally, we will bring together results from above strands and discuss these with SMD groups, Local Authorities, Public Health England, and charities &ndash; together with them, we will draw recommendations for effective ways to improve oral health and behaviours. These recommendations will act as a guide for Local Authorities, charities and for health policies, which are necessary to reduce the negative impacts of oral health on the lives of SMD groups. The ultimate goal of this project is to improve the physical and mental health, self-esteem and employability of SMD groups. The insights and evidence from this project will be valuable exemplars to help tackle other health-related issues in SMD groups.

Research activity codes: 2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS;3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH;ORAL AND GASTROINTESTINAL;GENERIC HEALTH RELEVANCE