title: Optimising delivery of the Childsmile nursery supervised toothbrushing programme in Scotland
Creators: name: Eaves, Jennifer Lillian
Publisher: name: University of Glasgow
Year: 2023

description: Background. Supervised toothbrushing in nurseries, delivered as a component of Childsmile, Scotland’s national oral health improvement programme for children, is associated with reduced caries experience and cost savings in prevented dental treatments. There is also evidence that it is effective in reducing oral health inequalities, with greater improvements in oral health observed among children living in the most deprived areas. However Childsmile process evaluation data indicate that the nursery supervised toothbrushing programme does not take place as intended in all nursery settings. This highlighted the need to undertake further research to optimise its delivery, to maximise the gains for children’s oral health and contribute to reducing oral health inequalities. Aims: The overarching aim of the research is to optimise delivery of the nursery supervised toothbrushing programme, which is achieved by: further developing its Theory of Change; assessing the fidelity of its implementation compared with the Theory of Change; identifying the barriers and facilitators to its implementation; and identifying implementation strategies to overcome those barriers. It is intended that findings will be fed back into the Childsmile programme to inform ongoing improvement of the nursery supervised toothbrushing programme component. Methods: The research was framed within the paradigm of pragmatism and utilised a mixed-methods approach, informed by a programme theory approach and implementation science methods, making it the first study of its kind to utilise this approach to investigate the implementation of a complex toothbrushing intervention delivered in educational settings. The researcher explicated the programme’s Theory of Change via documentary review, to identify its key components (the inputs, activities and outcomes); and qualitative interviews and focus groups with programme stakeholders, to discuss and agree the Theory of Change, which was depicted in a logic model. Using a mixed methods approach, the researcher undertook national, crosssectional surveys of nurseries, qualitative interviews with programme stakeholders and extracted data from ongoing Childsmile process evaluation, to assess fidelity of implementation and identify barriers and facilitators to delivery. Delivery-in-reality was assessed in comparison with the intended model (per the logic model developed in the previous stage of the research). The researcher used the Consolidated Framework for Implementation Research to categorise the barriers and facilitators identified and mapped these to the Expert Recommendations for Implementing Change compilation of implementation strategies to identify potential methods and techniques to overcome barriers to programme delivery. Results: This novel study identified that optimising the Childsmile nursery supervised toothbrushing programme requires a shared vision to be developed and strengthened among partners involved in its implementation, supported by developing a formal implementation blueprint and further work to increase nursery staff’s buy-in, such as local champions and enhanced training. The fidelity of programme delivery should continue to be monitored and evaluated using the methodology and logic model developed via this research. The inputs, activities and outcomes comprising the Theory of Change of the nursery supervised toothbrushing programme were specified, with consensus on those reached among programme stakeholders. This included stating the primary aim of the programme: 100% of children brush their teeth in nursery, every day they attend. However, national survey results showed that this target was not met, with 92% of eligible children brushing in nurseries on the day of the survey and variation in percentages of children brushing across geographical health boards. Nurseries with 100% toothbrushing rates were more likely to have fewer children attending, only have a single age group attending and were situated in certain geographical health board areas and not others. Using a mixed methods approach highlighted inconsistencies between these quantitative data on nurseries’ participation and qualitative findings on stakeholders’ perceptions about nurseries’ participation. There were variations between health boards in the extent to which delivery-in-reality matched what was intended. This included the content and frequency of training provided to nursery staff to support their delivery of the programme, with no standardised training package available nationally. Relationships between Childsmile teams and local authorities’ education departments were identified as important although these required careful management and communication. Barriers and facilitators influencing programme implementation before and during the Covid19 pandemic were identified and the Consolidated Framework for Implementation Research provided good coverage of these (encompassing all five domains and 14 out of 26 constructs associated with intervention implementation). Relevant constructs included: ‘Complexity’, in relation to fitting toothbrushing in to nursery routines and perceptions about it being too time-consuming; ‘Patient Needs and Resources’, in terms of children’s ability to perform the required actions as well as their reluctance to participate in toothbrushing instead of other available activities; and ‘External Policies and Incentives’, which related to the interpretation of early years policies which conflicted with directing children to participate in activities, including toothbrushing. An overarching theme related to the prioritisation of the nursery supervised toothbrushing programme by nursery staff, including the extent to which other activities were given precedence over it; and nursery staff’s willingness to accommodate toothbrushing flexibly within nursery schedules. The Covid-19 pandemic disrupted delivery of the programme due to nursery closures in 2020 and 2021, as well as creating additional pressures for nursery staff once establishments reopened. This affected the extent to which they engaged with efforts to restart the toothbrushing programme. Conclusions: This research has explicated the Theory of Change for Childsmile’s nursery supervised toothbrushing programme, from the perspective of programme stakeholders. There is scope for further specification of core, ‘essential’ programme components and adaptable, peripheral components, to identify an acceptable level of delivery which will allow progress towards outcomes. There are also opportunities to work with stakeholders from other organisations, aside from Childsmile, to identify changes to the Theory of Change to enhance its fit with their needs and priorities. In assessing the fidelity of programme implementation, it was found that aspects were delivered as intended; however, most logic model activities had components that were not being delivered with fidelity, including that less than 100% of children brushed their teeth every day they attended nursery. It was identified that the nursery context in which the programme is delivered was complex and fluctuating, with competing demands on nursery staff’s time. This indicated a need to accept that the programme has to fit within overall nursery provision, to ensure it is given enough priority. This requires identifying implementation strategies to find ways to help it fit alongside other priorities, including strategies to enhance engagement among nursery staff while taking their perspectives into account. A number of recommendations are made to support and optimise programme delivery going forward. These include supplementing the programme’s ongoing work in fostering relationships with partners with a focused communications campaign, targeted at stakeholders in individual nurseries and local authority education departments, which demonstrates how the programme fits within the wider nursery curriculum and its contribution to children’s health and wellbeing alongside information (tailored to stakeholders’ roles) that clarifies what is involved in programme delivery. It is also recommended that a knowledge exchange and support network should be established among nurseries, led by champions (invited to undertake this role among nursery staff with an interest in oral health working in nurseries identified to deliver the programme well) who support and mentor their peers to overcome challenges to delivering the toothbrushing programme. This could include enhanced training, tailored to individual nurseries’ needs, to provide practical solutions to overcome challenges encountered. To encourage participation among local authorities’ education departments and individual establishments’ head teachers and managers, it is recommended that further, supportive dialogue takes place between the Childsmile programme, the Scottish Government and local authority education departments.