title: Enhancing Scotland’s Childsmile programme through Community Linking to address child oral health inequalities
Creators: name: Karamat, Aalia
Publisher: name: University of Glasgow
Year: 2023

description: Dental caries in primary teeth affects over 530 million children globally, and outcomes are significantly associated with social circumstances. Scotland’s national child oral health improvement programme Childsmile has in part been responsible for improvements in oral health over the past decade, but inequality based on socioeconomic factors persists. Community Linking/Social Prescribing aims to reduce inequality through addressing the social determinants of health by engaging patients with community services/third-sector support. The Childsmile programme employs Dental Health Support Workers who provide targeted and tailored interventions to families most in need. Part of the role of Dental Health Support Workers is to link families experiencing wider social and economic problems to external community services/resources where tailored support can be offered. This thesis describes research which aims to optimise Childsmile’s Community Linking/Social Prescribing pathway for families of young children to improve oral health and tackle the social determinants of health to reduce inequalities. Methodology: A mixed methods approach was employed, and three studies were conducted. Study one used secondary analysis of population-wide individuallevel linked routine administrative data and health data to investigate Community Linking practice within Childsmile. The second study was a Systematic Overview of systematic reviews and guidelines to assess best practices for Community Linking, drawing from literature across Primary Care health services and using the Consolidated Framework for Implementation Research (CFIR) model to guide analysis and reporting. The third study was an online national survey of Dental Health Support Workers to assess the feasibility and acceptability of Community Linking. The first and the second study informed the survey content, and again the CFIR guided survey design. IBM SPSS v26 was used to describe quantitative data, and QRS NVivo v12 was used for qualitative thematic analysis. Results: Secondary analysis of linked data showed just over a fifth of families were referred to a Dental Health Support Worker for additional support over the study years, reflecting the targeted nature of this Childsmile intervention. Among these families, the percentages who were linked to external community services/resources increased from 1.8% (219/12169) in 2011 to 21.0% (1227/5833) in 2015, with the main support services being related to nutrition/diet and parent/baby support groups. Families living in the most deprived areas of Scotland and those determined by their Health Visitor to have greater support needs were more likely to be linked to wider community services by Dental Health Support Workers; however, there was significant variation in linking rates. The Systematic Overview key findings highlight several programme delivery aspects associated with best practice, such as basing programmes on high-quality evidence, obtaining resources, and being flexible in approach, developing trust among partners and assessing participants' needs to provide a tailored pathway. An optimum level of training, mentoring, and feedback is required for Community Health Workers. The Community Health Workers' characteristics should be such that they are perceived as leaders in the community and are respected. The services should be accessible and perceived by the participants as beneficial. Inter-sectoral working is also key. Partners should have enough time to develop understanding, communicate, network, and implement and evaluate the Community Linking implementation. The Systematic Overview showed a need for a multilevel pragmatic approach. The Online Survey of Dental Health Support Workers had a response rate of 58% (59/102) from 13/14 geographical health boards. Results demonstrated high awareness of Community Linking: 88% (52/59) of respondents agreed that this is a good way to improve child oral health, and 72% (42/59) had some experience of Community Linking in their current role. Feedback from community services and families was lacking. More than three quarters, 85% (50/59), said they would be able to identify appropriate community organisations for Community Linking. Thematic illustrations of open-ended responses showed: workload and time barriers when working with families; the importance of collaborative working, for example, with social services and education; training of staff to overcome these barriers, such as local area knowledge; the importance of building trust with families; and the importance of actively facilitating and supporting access to services. Conclusion: Community Linking is a relatively new concept in dental public health. It is implemented within the Childsmile programme via Dental Health Support Workers and is considered a route to help families in need of support and address socio-economic inequalities in oral health. According to our findings, future implementation work in Childsmile is broadly supported by moderate quality evidence and perceptions on acceptability and feasibility. Programme theory is articulated in Chapter 7, which shows the need to tailor links to need and foster integrated working, with clear communication routes between referrers and community organisations, including those for monitoring and evaluation. Staff are supportive of this as a route to a range of positive health outcomes. Nevertheless, workload/resource barriers need to be considered, and support and training are required in terms of available community resources and building sustainable links.