The document evaluates the Dental Health Support Worker (DHSW) role in Scotland's Childsmile program using realist case studies. Interviews and observations were conducted with DHSWs and stakeholders in three health boards. The findings were analyzed using a realist approach to understand how context influences outcomes. Three key themes or "demi-regularities" emerged from the analysis.

1. University of Glasgow, charity number SC004401
Evaluating Childsmile’s Dental
Health Support Worker role
using Realist case studies
M.Young¹, A.Sherriff ¹, A. Ross¹, L.M.D.Macpherson¹, W.Gnich¹
¹Dental School, College of Medical, Veterinary and Life Sciences, University of Glasgow, Scotland.
Demi-regularity 3: The wider context
Mid-range Theory: Health-damaging environments reduce parents’
locus of control to engage with positive oral health behaviours.
Context: In geographically large rural localities, supermarkets are often
situated out of town. Public transport is unreliable and many families do
not have access to a car. Families rely on small community shops for food.
Healthy, low-sugar/sugar-free options are not widely available in small
local shops. Mechanism: Parent’s locus of control to engage with oral
health parenting behaviours are reduced. Outcome 1: Parents have
difficulty engaging in oral health parenting behaviours. Outcome 2: Oral
health messages are not supported by the environment.
Background
Childsmile, the national oral health improvement programme for children in
Scotland, aims to reduce oral health inequalities and improve access to dental
services.
Childsmile is delivered, in part, by a new category of lay/community-based worker
known as the Dental Health Support Worker (DHSW). DHSWs support families to
improve oral health behaviours and attend the dental practice.
Aim
The aim of this study was to compare the delivery of the DHSW role between NHS
boards in Scotland to gain an in-depth understanding of which variants impact on
effectiveness of the role; and establish what works, for whom, and under what
circumstances.
Findings will be fed back to the Childsmile programme to facilitate optimisation of
the DHSW role.
Multiple case studies were designed using findings from a previous scoping exercise
which identified programme theory for the DHSW role and variation in delivery across
NHS boards in Scotland.
Case studies comprised 1 DHSW and key stakeholders involved in delivery of the role,
from three NHS boards. Participants (Fig. 1) were selected using theoretical sampling
based on characteristics which were known to influence delivery of the role.
26 interviews and 10 observations, involving 16 stakeholders and families in receipt of
support, were conducted. The study was granted NHS ethical approval.
Analytic Approach
Data were analysed using ‘Realist-inspired’ analysis derived from Pawson et al (2004):
a theory-based approach to synthesising data, best suited for complex health
interventions.
Programme theory (known as Mid-range Theory) was the unit of analysis. The aim was
to test and refine Mid-range Theories by investigating the causal relationships
embedded within the DHSW role using CMO configuring.
CMO configuring involved identifying the chain of causation between the Context (C),
Mechanism (M) and Outcome (O) of the DHSW role (Fig. 2) across NHS boards.
Mid-range Theories and CMOs were grouped into Demi-regularities (semi-predictable
themes). Three key Demi-regularities are selected for this presentation.
Methods
Demi-regularity 1: The Peerness of the DHSW role
Mid-range Theory: The right person for the DHSW role is someone
who has shared experience with parents in receipt of support.
Context: The DHSW has 5 daughters. She uses her experiences of being a
mother, and refers to these experiences, when supporting families.
Mechanism 1: The DHSW identifies with parents. Mechanism 2: Parents
perceive the DHSW to be knowledgeable about oral health parenting
behaviours. Outcome 1: DHSW delivers practical and person-centred
support. Outcome 2: Parents engage with the DHSW.
“I don’t go in and try to be authoritative. I go in and try to identify
with the parent as a parent as well as doing the job.”
(Case Study 1. DHSW)
Findings
Conclusions
Demi-regularity 2: Supporting parents to engage with positive oral
health parenting behaviours
Mid-range Theory: Complex oral health information is easier for
parents to digest when it is presented visually.
Context: DHSWs use visual aids to communicate oral health messages to
parents. For example, ‘Sugar Bags’ (Fig. 3) demonstrate the sugar content
within drinks and snacks typically consumed by children. Mechanism 1:
Complex information is easier to digest. Mechanism 2: Products are
recognisable. Outcome 1: Grab parents’ attention. Outcome 2: Retention
and recall of information is improved.
Peerness presents DHSWs as an equal and an authority on oral health
parenting behaviours. Visual aids enable DHSWs to deliver complicated oral
heath advice in a natural, conversational manner. These factors positively
influence parental engagement with Childsmile.
Health damaging environments reduce parents’ perceived ability to engage
with positive oral health parenting behaviours.
A one-size fits all model is not suitable for the DHSW role and adaptation of
programme theory for the role is necessary at a local level.
Figure. 3. ‘Sugar Bags’ to demonstrate the sugar content of drinks and snacks
Figure. 2. Context, Mechanism and Outcome (CMO) Configuration
Figure. 1. Participants included within the case studies
Pawson, R., Greenhalgh, T., Harvey, G. & Walshe, K. (2004). Realist Synthesis: An Introduction
Poster No. 3325