UK Dental Care for Disabled Patients

Introduction

One of the countries that have taken significant steps towards caring for the dental needs of individuals with learning disabilities is the United Kingdom. According to studies by Gallagher & Scambler (2012), the government of UK created a special dentistry unit in all hospitals within the Kingdom that provides oral health services for people with disability, which also includes those with difficulty in learning. The authors further suggest such action has drastically improved the health requirements of people with learning disabilities. In addition, this action taken by the UK government is cognizant of the fact that people who are physically or mentally handicapped are more predisposed to chronic oral healthcare issues compared to normal individuals. Moreover, poor oral health can have other effects on an individual like low self-worth, quality of life and one`s general health (Department of Health, 2007). In short, a wholesome approach towards improving the oral health of mentally challenged is a positive move towards improving the health and well-being of such a population.

Literature Review

Oral Health and Hospitalization among Learning Disability Patients

Oral hygiene as a routine medical practice has other benefits like confidence, improved self-esteem and general wellbeing in health. Thus, lack of or insufficient oral care may lead to discomfort a state. In cases where the illness is severe, high cost may be incurred in treating a condition that could be easily controlled or prevented through adherence to healthy oral health practices.

To properly serve patients with learning disabilities, the British Society of Disability and Oral Hygiene (BSDH) developed a guide on how to handle individuals with a learning disorder. The guide targets every stakeholder who is in support of the living with learning problems and it covers improvement of oral care and specialized care, factors that prevent learning disabled people from receiving sufficient oral care and oral care training given to parents and caregivers. The BSDH guidelines also targets dentist students in institutions of higher learning wby enhancing training for oral healthcare for the mentally challenged (Turner, Emerson, & Glover, 2013). However, there is a need for further initiatives addressing issues of knowledge and understanding of important oral healthcare procedures and practices among the mentally challenged (Canadian Institute of Health Research, 2012).

In most cases, health issues associated with oral care procedures are dealt with on an out-patient basis. According to Davis et al (2003), this poses a challenge to the mentally challenged because sometimes they might be required to conduct oral care procedures on their own. In 2008, out of 119,764 patients in hospitals under the NHS health records involving dental care revealed that 2,172 of the patients were diagnosed with a learning disability (Government of England, 2015). Further analysis of the records showed that 746 patients suffered from conditions like cerebral palsy and hydrocephalus which are diseases that are usually associated with a learning disorder. These statistics confirm that mentally disabled persons in the UK are facing a significant prevalence of oral health issues thus the need to address it.

But existing literature reveals that apart from other factors, lack of knowledge on oral health is one of the major barriers preventing the achievement of oral health and well-being among the mentally disabled. For instance, failure to understand the need for a regular dental check is not only a barrier to oral health well-being among people with mental illness but also among people without mental illness (Davis et al, 2012). Glasziou & Haynes (2005) also acknowledge that most personal barriers to oral health well-being are associated with lack of knowledge, and therefore there is a need for effective strategies to pass effective knowledge to the mentally challenged on oral health.

Recently, researchers have been interested in the best methods and tools for the delivery of health and well-being knowledge and education to the mentally challenged, and posters have emerged to be among the most preferred methods (Grimshaw & Eccles, 2004). But, whereas there is a paucity of research specifically evaluating the effectiveness of poster presentations in promoting oral health among the mentally disabled, there are several pieces of evidence evaluating the general effectiveness of poster presentation in transferring health knowledge. For instance, Rowe and Ilic (2015) conducted an art review study to explore the effectiveness of poster presentation in promoting knowledge transfer. Their study was based on an argument that whereas poster presentations have been a common technique used in conferences and seminars to transfer health knowledge, there is little evidence to show that health information can easily and effectively be transferred through posters. As a result, the researchers conducted secondary research on poster presentations and found that posters have great effectiveness in the transfer of knowledge, especially when integrated with other methods of knowledge transfer.

Knowledge Transfer

But before delving deeper into the literature on poster presentations, there is a need to establish the meaning of health knowledge transfer, and how it may relate to oral health knowledge among the mentally challenged. Also known as knowledge transition, the practice of knowledge transfer has been a subject of debate among researchers from various fields such as public health, health services, and medicine. Ideally, according to Lang et al (2007), knowledge transfer is considered as the process of transferring pieces of evidence into the discipline of medicine, public health or healthcare and may include the application, synthesis of exchange of knowledge within the context of a complex process between scholars and the end users (Canadian Institutes of Health Research, 2012).

According to Davis et al (2003), the role of knowledge transfer is to establish continuing healthcare and medical education or to promote professional development among healthcare practitioners in different fields. Davis et al (1999) argue that the practice of knowledge transfer aims to close the gap between research and practice with different stages of the process faced with different barriers. Hence, in the context of oral health knowledge, it involves the transfer of oral health knowledge from researchers to end users (i.e. people with mental disability), their disability status being the main barrier to the process.

Poster as a Tool for Health Knowledge Transfer

The use of posters as tools for knowledge transfer has largely been popular with professional conferences, where researchers use posters to highlight their research findings before an actual publication of journal articles. According to Rndoph & Viswanath (2004), such conferences are usually events that provide an opportunity for practitioners to obtain current knowledge in a particular field of study. Berg (2005) also observes that during academic conferences and seminars, researchers usually complement posters with short presentations giving details of information that are often presented in the didactic form.

Existing literature shows several advantages of posters as tools for knowledge transfer. For instance, Berg (2005) claims that posters are generally cost-effective tools for delivering health knowledge because they present an opportunity to provide the audience with information that can be viewed by several other individuals at their own time and convenience. Moule et al (2004) also point out that posters are advantageous in the sense that they provide the audience with an overview of the topic addressed, and this may be supplemented with the author’s oral discussion during education sessions. When delivered alongside presentation, according to Taggert & Arslanian (2000), posters are able to generate an informed discussion between the author and the target audience hence promoting active learning.

Williams & Bethea (2011)

Williams & Bethea (2011) conducted a study to explore the effectiveness of poster integrated with leaflets to facilitate a campaign on oral cancer, the survey involved patients in the waiting room as they waited to consult with dentists. However, the study found that by the end of the study session, only 40% of the respondents had read the full information available on the leaflet, a phenomenon which led to a conclusion that the use of poster approach could have limited effectiveness in delivering oral health knowledge. This study raises important concerns over the usability of posters by the target audience as a source of health knowledge. Perhaps, the less than a half readership of the poster could be attributable to illiteracy, and this highlights the limitation of posters among illiterate patients – a phenomenon that could be more complicated in the case of mentally challenged.

Jung et al (2010)

In another study conducted on patient waiting room, Jung et al (2010) used posters to promote health awareness on sun protective behaviors and worryingly, two-thirds of the participants were drawn to the imagery on the posters while only a half of the participants notice the posters, and only 5% of the respondents asked further information base on the information presented in the posture.

Rowe & Ilic (2009)

In a study by Rowe & Ilic (2009) a survey was conducted among academics to get their perceptions and views on the effectiveness of poster presentations in the transfer of knowledge. Most of the study participants acknowledged the importance of posters as a medium of conveying medical information, while 90% of the participants were of the opinion that the imagery used in posters can easily attract the reader’s or target population’s attention to the content. However, a majority of the respondents were of the opinion that posters need to be accompanied by oral presentations to be more effective.

Lieger et al (2009)

Lieger et al (2009) conducted a project that involved stand-alone posters distributed schools to educate teachers on dental knowledge. After conducting a post-intervention evaluation, the study found that there were significant improvements in knowledge among the participants. This study is therefore material in informing the current study on the effectiveness of posters in promoting oral health knowledge. However, it is still unclear as to how effective the intervention might be with the mentally challenged target audience.

Gilaberte et al (2008)

Gilaberte et al (2008) integrated poster presentation with a multi-modal educational workshop aiming to educate participants on skin cancer in school children. The study, after a post-interventional evaluation, found that the participants had increased knowledge on skin cancer and there was a significant positive modification of behavior.

Marx et al (2008)

In a similar study design that integrated poster with other modes of knowledge transfer, Marx et al (2008) was determined to deliver education on the risks of using antibiotics to treat flu in school children and adults. After conducting a post-interventional evaluation, the researchers found that there was an increase of knowledge on the topic, characterized by a behavior change whereby participants stopped using antibiotics as their preferred medication for flu.

Pless et al (2007)

However, a study by Pless et al (2007) used stand-alone posters in waiting rooms to educate patients on injuries. When a post-interventional evaluation was conducted for the study, it was found that only 16% of the participants could remember viewing the posters, while no participant cited the poster as the main source of information on the injury. Ultimately, the researchers concluded that whereas posters could be effective in knowledge transfer, their effectiveness may reduce in certain contexts to modify knowledge, attitude, and behavior.

Whereas there is a mixture of results from the reviewed literature on posters as effective tools of knowledge transfer, a further review of literature reveal that there are several barriers encountered by posters when used for knowledge transfer. An evaluation of such barriers is especially important for the current project because they inform out the need to ‘proceed with caution’ when implementing the project.

First Glasziou & Hynes (2005) say that a common barrier faced by posters in transferring knowledge is that the recipients may not be aware of the evidence base behind the information they are in contact with. This is because posters are majorly meant to give a visual representation of the knowledge being transferred in a manner that attracts attention, a phenomenon that may help overcome the perceived barriers. Moreover, according to Taggert (2000), the design of the poster, including the information readability, the framing, and the color schemes have an influence on how the information can effectively be conveyed. Keely (2004) and Butz et al (2004) also argue that poster presentations may not effectively accommodate alternative learning styles. Whereas an audience may be able to effectively learn by reading the information, there is a need for the researcher to clearly indicate the navigation planes so as to deliver the information in sequential logic.

Keely (2004) argues that posters are passive in nature and therefore it is more difficult to achieve effective results when it is not complemented with a more active intervention such as physical interaction or oral presentations so as to facilitate an effective exchange of knowledge through verbal learning. Nonetheless, Butz et al (2004) acknowledge that a traditional poster can only reach a percentage of its intended audience. Clearly, this underscores the importance of embedding poster intervention with interaction to create a reciprocal dialogue for an effective transfer of knowledge. In the same regard, Glasziou & Hynes (2005) argues that administering poster intervention together with a reciprocal dialogue process creates an environment for socialization that further allows for a mutual understanding between the researcher and the target audience thus easier knowledge transfer.

Nonetheless, the reviewed literatures indicate that poster intervention is an effective tool for transferring health knowledge to participants and therefore can be used to implement the oral health hygiene targeting the mentally challenged. We have established that with the help of technology, poster interventions have moved from didactic forms to learner-center forms Pless et al (2007), thus creating the ability to be used even with the mentally challenged. Ideally, it is possible to extrapolate that in their learner-interactive form; posters allow educators to address their learner’s needs through interactive communication formats thereby enabling an effective achievement of knowledge transfer. Based on the reviewed literature, we intend to implement the poster intervention to educate mentally ill patients on effective oral health practices. However, we intend to figure out the use of poster intervention in the absence of evidence on its effectiveness in changing behavior, knowledge, and attitude.

Project Management Plan

Having settled on poster project complemented by an interactive education session as the best intervention from promoting oral health awareness among the selected participants, the current we acknowledge that implementing the intervention as a form of change in the mental health care setting may not be as easy as expected, because several barriers are expected to be encountered while implementing the program (Langley et al, 2009).

Against this backdrop, it is monumental to note that an oral health education for the mentally challenged will have to be based on an elaborate theory of change as well as effective planning, thus justifying the use of various change models such as the PDSA change model, the Kotter’s step change model, and the Kurt Lewin’s change management model. Particularly, our project will adopt the PDSA model of change.

The main reason why we have selected the PDSA is that through its fours steps of Plan, Do, Study and Act, it provides opportunity for health practitioners to identify their strengths and weaknesses beforehand so that the implementation process takes account of such strengths and weaknesses so that the implementation yields more effective results (Moen et al, 2009). Besides, according to Dubberly (2008), PDSA is more preferable than Kurt Lewin’s change management model because the latter only implements change based on people’s preferences hence being a complex model to deal with.

Ideally, the PDSA is implementable in a cycle to enable health practitioners to transitionally identify issues affecting the quality of care in order to effectively implement change (Dubickis, 2017). Hence, this cycle can be implemented and re-implemented to enhance the process and each step of the cycle depends on each other, so much so that if one strep fails, the cycle must be restarted until all the stages are passed.

Plan

In the current project, the change lead agent will be the head of the nursing department for the mentally challenged in a conveniently nominated hospital. Other key stakeholders to the project will include the mentally ill patients (target audience), nurses in the mental health ward, family members of the patients, and the hospital management. The first step will be to develop a plan to identify the cause of poor oral health practices among mentally disabled patients and develop effective strategies for solving them. However, having established lack of knowledge on the importance of oral health and the need to introduce a poster educational intervention to address the same, the first step will be to identify the challenges that may interfere with the delivery of the education intervention. Tague (2005) argues that there is a need for change agents to give a clear justification of the proposed change so that the target population and other stakeholders in the change management process do not perceive the process as being manipulative. Hence, the hospital management, staff, and other workers within the mental healthcare setting will be involved in the decision-making process right from the beginning of the project. According to Reiss (2012), this will serve in empowering them and making them feel more valued so as to motivate them towards embracing the proposed change.

Having said so, it is expected that some resistance will be encountered while implementing the poster intervention in mentally challenged patient wards. To address such resistance, the lead implementing health practitioner will apply various leadership skills and qualities to address such resistance, particularly highlighting the various challenges that led to the development of the poster intervention. This will not only create common ground among the staff to embrace the intervention but also create a sense of urgency for the project (Finch, 2011).

As part of the planning process, there will be a series of meeting throughout the entire project timeline so as to keep the staff with adequate information on the project aims and objectives and to provide a platform for evaluating the project, receiving feedback and providing answers to any questions raised by the staff about the project. Hiatt & Creasey (2003) argues that regular meetings provide a platform for the staff to brainstorm and make suggestions about the project that could have not been made without having opportunities to meet. In fact, meetings will go a long way in embracing the “no decision about me without me” policy as espoused by the government white paper on healthcare (DoH, 2010).

The planning process will also entail communication as an important aspect of the change management process. According to Sharma (2007), any change implementer must keep an on-going communication with all the stakeholders; and therefore there will be constant communication with the hospital staff during the entire process of implementing the poster intervention. Ideally, the communication will be maintained both face-to-face and through electronic conduits such as phone and email. This constant communication will create an opportunity for a continuous conversation about the project; receiving suggestions and opinions necessary for managing the project to success (Moen et al, 2009).

Last but not least, the planning stage will be concerned with the project evaluation so as to identify how effective the project was in bringing the expected change. As part of the project, a post-intervention questionnaire will be introduced to identify the success of the project. The questionnaire will aim at identifying whether the project achieved all its objectives, and the questions will be aligned to the objectives to see whether:

• The oral hygiene message was effectively passed across to people with learning disabilities

• The message about oral hygiene has effectively been communicated

• The project has helped maintain good and basic oral hygiene

• The project has provided guidance and encouragement on regular tooth brushing

However, generally, the key aspect of the evaluation will be to identify whether

There will be a change of behavior characterized by more regular visits to the dentists as the intervention is meant to improve the target audience’s attitude towards oral health.

Do

After the planning stage, the next step will be the Do. Firstly, this step will begin with training nurses within the mental health department on how to deliver the posters while interacting with each patient. Dubberly (2008) says that there are many ways of passing communication skills to other people, some of them being delivery by an experienced facilitator, or by simply observing an experienced peer.

While there are several ways of organizing staff training (Pless et al, 2007), the current study will adopt a simple model of ‘learning by observation’, where the rest of the staff will observe the lead change agent while delivering the poster to the first few patients (i.e. on-site training). This will not only provide the staff with new skills but also signpost to them the communication skills they need to improve on as the project continues to roll on (Moen et al, 2009).

Study

This will be the third sage and will involve a constant collaboration between the staff and the change agent to get feedback and reflect on the implementation process of the poster intervention. Ideally, according to Hiatt & Creasey (2003), this will help in identifying what went wrong or what went right during the poster delivery process especially in the earlier stages of the project when change can be made for the better.

This stage will also entail turning to the patients to gain their perspective on the project and how it was implemented. As recommended by Dubberly (2008), the change agent will be expected to encourage both the staff and the service users to open up and share their thoughts on the entire project process because such an open and honest sharing of opinions will help in the effective analysis of the project. Meanwhile, the project will closely be monitored as it progresses, so as to enable the initiation of any necessary changes that would help produce better outcomes.

Act

Known as the last step of the process, the Act step entails measuring the change that has been affected by the intervention and recognizing such change (Hiatt & Creasey, 2003). In the proposed project, the lead change agent together with the staff will publish the project outcome because it might be useful information for any other change agent who would like to implement the same project. According to Pless et al (2007), allowing other practitioners or the public know about the project will go a long way in improving practice. Hence, the project will be published in newspapers, broadcasted in conferences and other communal organizations.

SWOT analysis for the project

In conclusion, we have explored a ton of literature on poster intervention and its effectiveness in delivering health education to target audiences. Our literature review reveals that while there are several previous studies that have confirmed the effectiveness of poster interventions, other propose that poster intervention should be implemented alongside oral discussions with the target audience to enhance the target audience’s understanding of the health message. Ultimately, the project has settled on a combination poster and oral discussion as the method of delivering the intervention. So, the intervention will be quite simple: The lead change agent, together with the nursing staff at the mentally ill ward will deliver posters to the patients as they interact with them orally to enhance their understanding of the message. We have also explored and adopted the PDSA change management tool – due to its potentiality to enable an effective change i.e. more knowledge and practice of effective oral health hygiene among the mentally challenged. Within the PDSA, an important element that is up for consideration during the project implementation is constant communication with all the project stakeholders. It is our expectation that the PDSA will be an effective tool for the implementation of the proposed project.

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