1. School of Dentistry Website: http://dentistry.dundee.ac.uk/ The University of Dundee is a Scottish Registered Charity, No. SC015096 Smile4life: Background and Future Plans Laura Beaton and Dr Andrea Rodriguez 31 st March 2015

2. School of Dentistry What is Smile4life? A preventive oral health intervention for people experiencing homelessness in Scotland Promoting oral health, health, and psycho-social wellbeing

3. School of Dentistry 2005 – Health and Homelessness Standards Outlined the framework, performance requirements and role of NHS Boards in the planning and provision of health services for homeless people 2005 – Dental Action Plan NHS Boards advised to develop and implement oral health care promotion for priority groups of ‘adults most in need’ 2007 - A successful proposal was put to the Chief Dental Officer to develop oral health improvement programmes for homeless people. The proposal was called ‘Smile4life’, and was submitted by a consortium of seven NHS Boards, co-ordinated by NHS Highland. The Smile4life steering group was convened in November 2007. Background to Smile4life

4. 2007 Smile4life proposal submitted and accepted 2008-2009 Smile4life survey data collection 2012 Smile4life report launched Smile4life Guide for Trainers launched 2013 March: Telephone interviews started September: Hopscotch data collection begins 2014 September: Hopscotch data collection ends 2015 February-March: Training events with NHS Education for Scotland

6. 2007 Smile4life proposal submitted and accepted 2008-2009 Smile4life survey data collection 2012 Smile4life report launched Smile4life Guide for Trainers launched 2013 March: Telephone interviews started September: Hopscotch data collection begins 2014 September: Hopscotch data collection ends 2015 February-March: Training events with NHS Education for Scotland

7. School of Dentistry Smile4life Oral Health Survey The aim: to conduct an oral health and general needs assessment as the first stage of the programme Produced data on: -Demographic profile; -Health and health behaviours; -Degree of patient management complexity; -Psychosocial health

8. School of Dentistry Smile4life: Oral Health Survey

15. Results

16. School of Dentistry Smile4life Report: Results 853 homeless people took part Demography  age range 16 to 78 years  largest age groups 16-24 years (29%) and 25-34 years (30%)  75% male  78% single Living status  32% living in hostels  20% in short-term temporary accommodation  7% in longer-term supported accommodation  2% rough sleepers Reasons for homelessness included relationship breakdown, substance misuse, eviction/loss of tenancy The group presented a diverse range of social exclusion and marginalisation: chaotic lifestyles

18. School of Dentistry Smile4life Report: Results Health Status 54% of people stated that they were receiving medical treatment in primary or secondary care

19. School of Dentistry Smile4life Report: Results

20. School of Dentistry Smile4life Report: Results Health Behaviours The majority of the sample (85%) reported being smokers The average number of cigarettes smoked daily was about 20 with a range of 1 to 120: men stated that they smoked on average 20 cigarettes per day women reported to smoke on average 15 cigarettes per day 30% drank alcohol daily 29% used drugs (81% of drug users IVDU)

21. School of Dentistry Smile4life Report: Results

22. School of Dentistry Smile4life Report: Results Oral health status: 27% of decay experience was due to decayed teeth 52% by missing teeth and 22% by filled teeth. This suggested that people had their decayed teeth extracted rather than filled.

23. School of Dentistry Smile4life Report: Results Dental Attendance Dental attendanceYes Registered for dental care 31% Dental attendance in last 12 months 15% Last dental visit more than 10 years previously 54% Reason for last visit Pain/trouble with teeth68% Check-up21%

24. School of Dentistry Smile4life Report: Results Dental Anxiety Mean score for dental anxiety = 11.70 Mean score for a GDP population is 10.79 20 % of homeless sample scored 19 or above, compared to 12% of UK representative sample (ADHS 2009) 20% of this sample of homeless people experienced extreme dental fear

25. School of Dentistry Smile4life Report: Qualitative Results Stories of becoming homeless Health concerns Oral health Dental registration and attendance Oral health status Lifestyle choices Moving on from homelessness Re-establishing family relationships Addressing health and oral health

26. 2007 Smile4life proposal submitted and accepted 2008-2009 Smile4life survey data collection 2012 Smile4life report launched Smile4life Guide for Trainers launched 2013 March: Telephone interviews started September: Hopscotch data collection begins 2014 September: Hopscotch data collection ends 2015 February-March: Training events with NHS Education for Scotland

27. Smile4life: Guide for Trainers

28. School of Dentistry Smile4life: Guide for Trainers

29. School of Dentistry Training Units

30. School of Dentistry Learning Outcomes UnitLearning outcome 1LO1To have knowledge of the oral health issues and barriers to accessing care as experienced by homeless people 2LO2To know the main oral health care messages and be competent in providing tailored oral health information to clients 2LO3To be familiar with the risk factors that contribute to the oral health status of homeless people 2LO4To be aware of how and where homeless people can access dental care 3LO5To be competent in giving basic health advice on diet, smoking, alcohol consumption and methadone use 4LO6To know the structure and application of the Smile4life intervention 4L07To know how to assess client readiness to change using the assessment tool 4LO8To know the basic motivational interviewing techniques when interacting with clients

31. Smile4life evaluation

32. 2007 Smile4life proposal submitted and accepted 2008-2009 Smile4life survey data collection 2012 Smile4life report launched Smile4life Guide for Trainers launched 2013 March: Telephone interviews started September: Hopscotch data collection begins 2014 September: Hopscotch data collection ends 2015 February-March: Training events with NHS Education for Scotland

33. School of Dentistry Smile4life evaluation Aim: to evaluate the implementation of Smile4life in Scottish NHS Boards Data Collection Method: Monthly telephone interviews with (mostly) NHS practitioners 20 oral health staff and 1 tenancy support worker Semi-structured interviews Digitally recorded then transcribed

34. School of Dentistry Smile4life evaluation Results Beaton and Freeman (2015) Oral health promotion and homelessness: A theory- based approach to understanding processes of implementation and adoption Beaton and Freeman Interview data analysed using Theory of Diffusion of Innovations Classified Boards into adoption categories Identified variables that underpinned adoption Average time to adoption: 16 months after Smile4life launch Intervention by the research team acted as a change agent Many Boards struggled with implementation

35. School of Dentistry Smile4life evaluation

36. School of Dentistry Smile4life evaluation BarriersFacilitators Geography of NHS Board Not enough time Other priorities Heavy workload Staffing Bad previous experiences Complexity of intervention Enthusiastic and motivated staff Positive social interactions Good previous experiences

37. School of Dentistry Smile4life evaluation Conclusions To encourage the implementation of Smile4life, it is necessary to overcome the conflicts experienced at the individual staff, NHS Board and Third Sector levels There is a need to continue to promote Smile4life and highlight the needs of people experiencing homelessness There is a need for specific training in the implementation, adoption and consolidation of interventions, to be tailored to the needs of practitioners

38. HoPSCOTCH Homeless People in Scotland: a process evaluation of a Community-Based Oral Health Intervention

39. 2007 Smile4life proposal submitted and accepted 2008-2009 Smile4life survey data collection 2012 Smile4life report launched Smile4life Guide for Trainers launched 2013 March: Telephone interviews started September: Hopscotch data collection begins 2014 September: Hopscotch data collection ends 2015 February-March: Training events with NHS Education for Scotland

40. School of Dentistry Hopscotch evaluation Aim To conduct a process evaluation of Smile4life enhanced training for practitioners and the Smile4life oral health intervention for homeless clients In 4 Scottish NHS Boards Two control Boards Basic training Two intervention Boards Additional training in communication, and in motivational interviewing Data collection Baseline and Follow-up questionnaires with NHS staff, Third Sector staff, and service users Staff: oral health knowledge, homelessness knowledge, service provision, attitudes Service users: dental attendance, oral health knowledge and attitudes, oral health behaviours, dental anxiety, depression, oral health-related quality of life, self-esteem, social support

41. School of Dentistry Hopscotch evaluation Results – a work in progress Low numbers of service user participants Difficult to maintain links with service users – low follow-up numbers Practitioners saw value in intervention Some changes were observed between baseline and follow-up Improved self-reported oral health status and oral health behaviours for service users Increase in oral health-related quality of life for service users Increase in practitioner knowledge and improved understanding of oral health and homelessness Increase in Third Sector practitioners’ likelihood of providing oral health education, helping access dental care and using motivational interviewing with homeless service users Increase in all practitioners’ confidence at providing oral health information and using motivational interviewing Issues emerged re: staff roles, staffing, priorities, support from NHS Board/employer

42. 2007 Smile4life proposal submitted and accepted 2008-2009 Smile4life survey data collection 2012 Smile4life report launched Smile4life Guide for Trainers launched 2013 March: Telephone interviews started September: Hopscotch data collection begins 2014 September: Hopscotch data collection ends 2015 February-March: Training events with NHS Education for Scotland

43. School of Dentistry Current Actions 1 - Partnership with NHS Education for Scotland: -Developing Training resources -Third Sector Links -Training days 2 - Partnership with Third Sector Organisations Mapping of key organisations from Third Sector working with Homelessness across Scotland Informal visits to know about their activities, outcomes and challenges in order to build integrated actions

44. School of Dentistry Future Actions Increase the participation in networks of diverse organisations from Government, Third Sector and NHS Boards Survey from professionals working with people experiencing homelessness in the Third Sector to identify perceptions on health/oral health associated with their field of intervention and also to identify gaps and needs in their practices Systematization and dissemination of good practices and team work strategies to face homelessness from Third Sector Organisations and NHS Boards Identify and train oral health champions/peer educators from professional teams and user groups Provide training activities of Third Sector practitioners on issues that meet their needs Provide training and supervision of service users to improve users’ participation; health literacy; communication and life skills

45. School of Dentistry Problems… …and solutions

46. School of Dentistry Email: l.z.beaton@dundee.ac.uk a.rodriguez@dundee.ac.uk Thank you!