An Assessment of a Vocational Horticulture Training Program at a School for J...
Ibrahim Thesis
1. KNOWLEDGE SHARING IN
PROFESSIONAL COMMUNITIES OF
PRACTICE AND ITS ROLE IN TOBACCO
CESSATION IN NHS HOSPITAL BY
DENTIST:
A QUALITATIVE STUDY
A D I S S ERTA TI O N P RES E NTED TO TH E Q UEEN MA RY
UNI V ERS I TY O F L O ND O N I N P A RTI A L F UL F I L MEN T O F
TH E REQ UI REMENTS F O R TH E MA S TER O F S CI ENC E
D ENTA L P UBL I C H EA L TH
S UBMI TTED BY I BRA H I M BH A MJ I
8 A UG US T 2 0 1 6
I NS TI TUTE O F D ENTI S T RY
BA RTS A ND TH E L O ND O N S CH O O L O F MED I CI NE A ND
D ENTI S TRY
Q UEEN MA RY UNI V ERS I TY O F L O ND O N
2. A CK NO W L ED G EMENTS
First and foremost, I would like to express my gratitude to my supervisor Dr Dominic
Hurst for his valuable comments, feedback and engagement throughout this thesis
and consistently allowing this project to be my own work, yet guiding me in the right
direction whenever needed.
I would also like to thank the entire faculty members of Dental Public Health course,
whose teachings have inspired me to pursue Dental Public Health further.
Thank you to all the study participants who willingly gave up their time to be
interviewed and without their participation and input, this would not have been
accomplished.
Finally, I must express my profound gratitude to my wife, Sadiya, my parents and in-
laws for providing me with their unfailing support and continuous encouragement
throughout my year of study. This would not have been possible without them.
3. 3
Table of Contents
Tables and figures..........................................................................................................5
Abstract..........................................................................................................................6
Chapter 1 - Introduction................................................................................................8
Statement of problem....................................................................................................... 8
Research question.......................................................................................................... 10
Aims and objectives........................................................................................................ 10
Anticipated study contribution........................................................................................ 11
Definitions of key words and terms.................................................................................. 11
Terms of tobacco............................................................................................................ 11
Chapter 2 - Literature review......................................................................................12
Introduction................................................................................................................... 12
The prevalence of tobacco use........................................................................................ 12
Death from tobacco use.................................................................................................. 13
Impact of tobacco use..................................................................................................... 15
General health................................................................................................................ 15
Cardiovascular disease (CVD) .......................................................................................... 16
Oral health..................................................................................................................... 16
Oral cancer..................................................................................................................... 16
Periodontal diseases and tooth loss................................................................................. 17
Impact on the dental treatment ...................................................................................... 17
Economic impact............................................................................................................ 17
Interventions to reduce the use of tobacco use................................................................ 18
Unassisted attempt cessation.......................................................................................... 18
Non-clinical or population approach................................................................................ 19
Assisted attempt............................................................................................................ 20
Clinical approach............................................................................................................ 21
General Practice............................................................................................................. 21
Dental practice............................................................................................................... 22
Primary dental practice and tobacco use cessation........................................................... 23
Pharmacological intervention.......................................................................................... 24
Knowledge and attitude of oral health professional towards tobacco use cessation ........... 24
Patient knowledge and attitude towards tobacco use cessation intervention..................... 25
Barriers andfacilitators................................................................................................... 26
Communities of practice................................................................................................. 27
Knowledge seeking and sharing among COP..................................................................... 29
The use of Internetin community of practice................................................................... 31
Summary ....................................................................................................................... 32
5. 5
Tables and figures
Figure 1 - Major, minor and sub themes of knowledge sharing
Figure 2- Theme of perceived elements of effective smoking cessation intervention
Figure 3 - Dissemination of perceived elements
Table 1 - Demographic characteristics/background information of participants
6. 6
Abstract
Background
Tobacco continues to be the prominent preventable cause of death worldwide.
There is vital role to be played by health professionals in controlling tobacco use.
Dental health professionals have a prime responsibility in promoting tobacco free
lifestyles and culture. Yet, they feel unprepared to deliver such advice. Lack of time,
reimbursement, training, patient education materials and knowledge are major
restrictions in delivering successful tobacco cessation campaigns. Knowledge can be
increased through discussion and communities of practices aids to foster the
discussion. Communities of practice (COP) are possibly an eye-catching process for
public health practitioners to share knowledge and enhance evidence-informed
decision-making (EIDM).
Aims and Objectives
To explore how dentists, share knowledge with whom and why. To explore dentists’
views on the most effective way of delivering tobacco cessation practice. To
ascertain how dentists within their social networks or communities spread the
cessation intervention.
Methods
Qualitative research method was chosen and was conducted at Royal London Dental
Hospital. Dentist working in hospital were selected with non-probability purposive
sampling. Maximum variation sampling method was tried best to achieve as dentist
range from junior dentists to specialist and consultant level were selected. The
recruitment was done by my direct approach to individual dentists face-to-face in
their particular clinics, staff rooms and office. Data was gathered through the use of
semi-structured in depth interview methods along with topic guide. Data analysis
was done through thematic analysis.
7. 7
Result
Six interviews were conducted. The finding reveals three major themes, which were
further categorised in sub-themes. All of the dentist had experience of sharing
knowledge and had some influence for knowledge sharing (professional
responsibility and satisfaction, happiness and rewarding, judgemental perception)
with the foremost reason for improving and updating their knowledge. The key
finding was explicit knowledge, is inseparable from tacit knowledge, and how they
use tacit knowledge to interpret the explicit knowledge, specifically clinical
procedural. The knowledge acquisition-seeking behaviour was found such as through
peer discussion, case-based learning, and formal learning. Dentist perception for
effective smoking cessation intervention were disclose such as assessment of
willingness of patients, easy accessibility for patient and dentist for smoking
cessation intervention, communication barrier free between smoking cessation
service and dentist, development of training and teamwork within the dental team.
Dentist report to disseminate the perceived effective smoking cessation intervention
was through hospital meeting and sharing the stories of former smokers.
Conclusion
Knowledge sharing in professional community of practice appears as a promising
model for promoting effective smoking cessation intervention among hospital based
dentists. Future research should explore how community of practice will be
facilitated for knowledge sharing, specifically with dentists in hospitals and how they
will be constructed based on the findings.
8. 8
Chapter 1 - Introduction
This chapter covers the aims and objectives, statement of problem, research
questions and anticipated study contributions.
The consequences of tobacco use on ones general health, as well as oral health, in
smokers and non-smokers are recognised, yet despite this, tobacco continues to be
the primary preventable cause of death globally (World Health Organisation, 2013).
A vital role needs to be performed by health professionals in controlling tobacco use.
The World Health Organisation (WHO) in 2005 anticipated there were 1.3 billion
smokers in the world. They had also projected that if that consumption continues, by
the year 2020 the number of deaths will increase to 10 million, out of which 70% of
all deaths will be from developing countries (4.9 million a year in 2005) in contrast to
other countries (World Health Organisation, 2005).
An essential role needs to be played through government and legislation; yet, they
are not the only faction in society who needs to fundamentally participate. Within
these factions, health professional have an exclusive role to play because of their
professional duty to the health sector (World Health Organisation, 2005). Dental
health professionals have a prime responsibility in promoting tobacco free lifestyles
and culture.
Statement of problem
According to Health and Social Care Information Centre (Health and Social Care
Information Centre, 2015), amongst adults 35 years and over from England in 2013-
2014, there were over 1.6 million admissions in patients with a primary diagnosis of
a disease which could be caused by smoking. This amounts to roughly 4500 average
admissions in one day and on average, compares to 1.4 million of all admissions per
day. Out of this, the number of hospital admissions linked to smoking is 454,700. In
adults’ aged 35 and over it accounts for 4% of all hospital admission in contrast to
447,300 admissions in 2003-2004 (6% of all admission totals). The proportion of men
9. 9
admitted with relations to smoking as a percentage of all admission was larger than
women, and shown to be 6% and 3% respectively (Health and Social Care
Information Centre, 2015).
Increasingly, health professionals are encouraged to cultivate their practice
knowledge, and implement evidence based practice (EBP), including empirically
supported treatments, programs of prevention and assessment methods (Garland et
al., 2003). Evidence based practice denotes to the body of scientific knowledge
about service practice involving assessment, treatment, and referral (Sackett et al.,
1996).
The National Institute for Health and Clinical Excellence (NICE) guidelines, which
recommend dentists and other health professionals to implement smoking cessation
for patients in their practice(National Institute for Health and Care Excellence, 2006).
These guidelines can assist dental health professionals and their team in their
practice to assist in tobacco cessation.
These uptakes of tobacco cessation guidelines have shown a sign of improvement in
studies done in the UK by Johnson NW et al. However, the study reported that most
dentists perceive the promotion of tobacco cessation as a fundamental part of a
dentist’s duty; yet, they feel unprepared to deliver such advice. Lack of time,
reimbursement, training, patient education materials and knowledge are major
restrictions in delivering successful tobacco cessation campaigns (Johnson et al.,
2006).
Knowledge can be increased through discussion and communities of practices aids to
foster the discussion (Barwick et al., 2009). Communities of practice (COP) are
possibly an eye-catching process for public health practitioners to share knowledge
and enhance evidence-informed decision making (EIDM). This is because, in
additional to their external practice setting, public health practitioners value working
with peers and stakeholders. Through acting and interacting with each other, COP’s
are based on principles of social learning and not learnt in isolation. In the
healthcare sector, COP’s are promoted as a possibility of producing and sharing
10. 10
knowledge, as well as improving the organisations performance (Meagher-Stewart
et al., 2012).
Evidence was examined in a systematic review to assess if COP’s steered change in
the practice of healthcare. COP’s in the healthcare sectors vary in form and purpose.
Intervention has been found to be complex and multi-approached when researchers
assessed the effectiveness of COPs in healthcare, and therefore, making it difficult to
attribute the change of COPs (Ranmuthugala et al., 2011a). Thus, the purpose of this
study was to explore knowledge sharing in professional communities of practice and
its current and potential roles in tobacco use cessation in NHS hospitals by dentists.
Research question
How do dentists working in NHS hospital share knowledge in professional
community of practice and its role in promoting smoking cessation intervention?
This study’s aim is to seek answers to the following research questions about
knowledge sharing in professional communities of practice and its potential role in
tobacco cessation in hospital by dentists.
With whom, why and how do dentists share their knowledge in practice?
What do dentists perceive as an effective way to deliver tobacco cessation
practice?
How do dentists describe knowledge dissemination within their social
network and communities of practices?
Aims and objectives
To explore knowledge sharing of dentists with other colleagues and peers
within their communities of practice.
To get the opinion of a dentists’ views on the most effective way of delivering
tobacco cessation practice.
To know how dentists within their social networks or communities spread the
knowledge.
11. 11
Anticipated study contribution
This study may deliver an effective element for smoking cessation in hospitals, which
is perceived by dentists working in hospital to improve intervention for smoking
cessation. Finding how dentists share knowledge will also contribute towards
promoting COP in evidence-based information and decision-making in regards to
smoking cessation practice in hospitals. The study is also intended to improve future
research designs for tobacco cessation intervention.
Definitions of key words and terms
Knowledge sharing
“The exchange of ideas and experiences between two or more individuals”
(Knowledge Management, 2005).
Cessation
“Also called as quitting. The goal of treatment to help people achieve abstinence
from smoking or other tobacco use, also used to describe process of changing
behavior.” (Glossary, 2016)
Communities of practice
“Communities of practice are groups of people who share a concern or a passion for
something they do and learn how to do it better as they interact regularly.”
(Etienne and Beverly Wenger-Trainer, 2015)
“A group of professionals informally bound to one another through exposure to a
common class of problems, common pursuit of solutions, and thereby themselves
embodying a store of knowledge” (Alan Frost, 2010)
Terms of tobacco
The meanings of the terms in this study regarding tobacco can be found in “The
Glossary of the terms used in the Tobacco Atlas” which is referenced with link.
12. 12
Chapter 2 - Literature review
Introduction
The section will review past published research and evidence following firstly aspects
about prevalence of tobacco use, followed by the impact of tobacco use on health
i.e. both oral and general health and also giving some insight into the economic
impact of tobacco use. This section will also review intervention, which attempts to
tobacco use cessation, how effective this was, knowledge and attitudes of dentist
and patients in regards to tobacco use cessation following that will briefly review
knowledge sharing in the professional communities of practice.
The prevalence of tobacco use
Tobacco use amongst adults and adolescents:
In the past, tobacco use was a male phenomenon, however, in Sweden, United
Kingdom, Austria, Denmark, Ireland and Norway, the prevalence gap between male
and female adults is 5%. The report of global tobacco epidemic 2015 from WHO
shows that in 2013, 19% of women (aged 15 and above) in the European region
smoked tobacco and when comparing to women in African, Southeast Asia, Eastern
Mediterranean and Western pacific regions the prevalence is much less at 2-3%. The
prevalence level of tobacco in 2025 is forecasted in males to be 31% and females
16%. Tobacco use among teenagers is rising and in countries such as Latvia,
Lithuania and Czech Republic, tobacco use is similar to adults(WHO, 2015).
In 2013, approximately 1 in 5 adults in Great Britain, equivalent to 19%, aged 16 and
above were smokers and this rate had declined as, in 2003, just over 1 in 4 (26%)
were smokers. 22% of pupils ages 11 – 15 in England had tried smoking at least once
in 2013. Since 2003, this level continued to decline (42% op pupils tried smoking) and
since the data was first collected in 1982, 22% in 2013 was the lowest level
recorded(Health and Social Care Information Centre, 2015).
13. 13
Death from tobacco use
According to the WHO report the WHO European region, compared to the rest of
the world, had the greatest percentage of deaths related to tobacco use. The WHO
report had anticipated for adults aged 30 years or above in the region, tobacco use
would be responsible for 16% of all deaths. This is in contrast to African, Eastern
Mediterranean region and globally where tobacco related deaths are 3%, 7% and
12% respectively(WHO, 2015). The cohort study suggested that betel nut has a small
to moderate impact on mortality from oral cancer in this Bangladeshi population
(Wu et al., 2015).
The findings from England in 2013 reported that, compared to 19% in 2003, the
estimated cause of all deaths caused by smoking in adults aged 35 or over was 17%
(78,200)(Health and Social Care Information Centre, 2015).
These are the following products which were commonly used and recognised in the
2015 Euro barometer which assessed the attitude of European’s tobacco use:
Popular products mostly used in Europe:
86% boxed cigarettes
29% roll your own tobacco
2% cigarillos
1% pipes
Young people’s first product:
83% boxed cigarettes
6% roll your own tobacco
5% water pipes (shisha, hookah)
3% other products (European Commission, 2015)
14. 14
Nargis et al, 2015, studied the prevalence of use of tobacco between 2009 and 2012,
and bidi cigarette smoking in Bangladesh. Bidi’s are thin hand rolled cigarettes in
which the tendu leaf is rolled around tobacco and are made mostly in South Asian
countries. Generally, tobacco use shrunk from 42.2% to 36.3%. This reduction was
more pronounced with respect to smokeless tobacco than smoking. The prevalence
of smoking cigarettes exclusively had raised from 7.2% to 10.6%, bidi smoking
remained unchanged at approximately 2%, whereas smoking both cigarette and bidi
were at a downward trend with 4.6% to 1.8%, smokeless tobacco decreased 20.2%
to 16.9% and smoke and smokeless tobacco decreased from 8.4% to 5.1. The
prevalence of tobacco use was higher amongst males, increasing through age from
younger to older and was higher amongst the poor. Amongst disadvantaged people,
smoking prevalence was highest(Nargis et al., 2015).
Participants from South Asia were asked, in a health survey for England in 2004,
about their use of other tobacco products, including tobacco chewing. The
prevalence of chewing tobacco was low between 2% and 4% for men and 1% for
women among Indian and Pakistani groups. In Bangladeshi groups, the use of
tobacco chewing was more prevalent with 9% of men and 16% of women (centre.,
2006).
The study reports the prevalence of smokeless tobacco among adults in Bangladesh,
India and Nepal. Smokeless tobacco was noticed to be growing in Bangladesh (20.2%
to 23% men), and India (27.1% to 33.4% men and 10.1% to 15.7% women).
Respectively in Nepal, there was no difference among both male and female (39.1%
to 31.1% and 5.6% to 4.7% respectively) (Sinha et al., 2015).
The use of smokeless tobacco (ST) among professional baseball players was reported
in a survey between 1998 and 2003. Amongst baseball players, the use of ST tobacco
was much higher than young males in the general population. The survey also found
the use of ST was more prevalent amongst white non-Hispanic players. From 1998 to
2003, there was a decrease amongst minor league players. Through seven days of
self reporting, it was found the use of ST declined from 31.7% to 24.8% in 2003,
15. 15
however, among major league players no change was observed (Severson et al.,
2005).
Impact of tobacco use
Smoking affects a number of diseases including, lung cancer, oral cancer,
pneumonia, periodontitis, aortic aneurysm, acute myeloid leukaemia, cataract,
cervical cancer, kidney cancer and pancreatic cancer. In addition, the previously
known diseases, caused by smoking, include coronary heart disease, cardiovascular
disease together with the impact on the reproductive system which could lead to
sudden infant death syndrome.
General health
The evidence suggests that tobacco smoking has more prone risk towards the lung
cancer. A systematic review with meta-analysis was done with 13 specific sites of
cancer, which are at risk. The analysis was carried out in 216 studies. The results
seem to be prone more for lung cancer (RR=8.96; 95% CI: 6.73-12.11). The pooled
RRs for lung cancer were greater than the pooled estimate from other sites like
pharyngeal, laryngeal, upper digestive tract, and oral cavity(Gandini et al., 2015).
Similarly, one more evidence which was a (Lee et al., 2012)systematic review with
meta-analysis and stated that lung cancer was strongly associated with smoking. In
this systemic review, 287 studies were analysed, “the meta-analyses demonstrated a
relationship of smoking with lung cancer risk, clearly seen for ever smoking (random-
effects RR 5.50,95% CI 5.07-5.96) current smoking (RR 8.43,95% 7.63-9.31), ex
smoking (RR 4.30,95% CI 3.93-4.71) and pipe/cigar only smoking (RR 2.92,95% CI
2.38-3.57). It was stronger for squamous (current smoking RR 16.91,95%CI 13.14-
21.76) than adenocarcinoma (RR 4.21,95% CI 3.32-5.34), and evident in both sexes
(RRs somewhat higher in males), all continents (RRs highest for North America and
lowest for Asia, particularly China), and both study types (RRs higher for prospective
studies)”.
16. 16
Cardiovascular disease (CVD)
Smoking has a damaging effect on cardiovascular health and is the primary risk
element for causing peripheral vascular disease, coronary vascular disease, stroke
and aortic aneurysm. Essentially, it is important to recognise there is no risk-free
level of tobacco exposure at a minimum level and that all smokers are affected in
dosage dependent fashion(Mainali et al., 2015). Scientific evidence appears to be
approving cigarette smoking’s psychological, biological and genetic impact, which
seem to be more prominent in some population.
Similarly, (Vidyasagaran et al., 2016)systematic review with meta-analysis indicated a
strong association between smokeless tobacco and risk of cardiovascular diseases.
20 studies were involved in the meta-analyses.
A considerably increased risk of IHD deaths (1.15.95% CI: 1.01-1.30) and stroke
deaths (1.39, 95% CI: 1.29-1.49) were found in smokeless tobacco users.
Geographical variations were noted for IHD in Asian studies which signified
significant positive associations (1.40, 95% CI: 1.01-1.95), and in the Interheart study,
smokeless data was primarily reported from Asia (2.23,95% CI: 1.41-3.53).
Oral health
Oral health also had an impact from the use of tobacco. There were several studies
which were reviewed to understand its impact on oral health.
Oral cancer
Different forms of tobacco product varied on the impact of oral health. An increased
risk of oral cancer was discovered to be high in Asia, Europe and North America in 2
different systematic reviews, which were done with 3 different products. The first
(Lee and Hamling, 2009) systematic review compared the past products which were
used in North America to the new Scandinavian snuff, which stated that risk from
contemporary product (Scandinavian snuff) was much less than for smoking. The
(Khan et al., 2014)systematic review with meta-analysis in Asia had a different
finding than Europe which reported the combined odd radio (OR) for paan with
17. 17
tobacco and risk of oral cancer was 7.1 (4.5 – 11.1) and for chewing tobacco and risk
of oral cancer the risk was 4.7 (3.1 – 7.1). There was a strong association between
oral cancer and various forms of smokeless tobacco. It may be due to the possibility
of prevalence of paan chewing occurring more in South Asian regions. A study done
in Jakarta, which compared risk of oral cancer between smoking (kretek) and betel
nut chewing, found both products were positively associated in causing oral cancer
risk(Amtha et al., 2014).
Periodontal diseases and tooth loss
Two studies showed smoking had an effect on periodontal tissue, which resulted in
tooth loss. It also stated that this effect depended upon frequency of usage. On the
other hand, it also indicated that the effects would be reversed if there were a
smoking cessation (Ramón et al., 2015, Sherwin et al., 2013). Ramon et al case
control study found by logistics regression showed that smokers and former smoker
had 2.7 times and 2.3 times higher probabilities of having established periodontal
diseases than non-smokers.
Impact on the dental treatment
A (Chrcanovic et al., 2015) systematic review with meta-analysis was done to assess
the impact of smoking on treatment and showed that smoking was a factor that had
a potential to affect healing negatively and the implant treatment.
Economic impact
Parrot and Godfrey, 2004, found in their study that smoking cessation could be
beneficial to the health cost of the country. It showed data from USA, Australia,
Canada and UK. In respect to health resources, predictions had been made for the
economic cost of smoking. In the United States, they ranged from 0.6% to 0.85% of
GDP. For the treatment of smoking-related diseases, an estimated cost of $50 billion
a year was made by the US Public Health Department. This was in addition to an
annual $47 billion in earning and productivity. The predicted costs in Australia and
Canada, as a proportion of their GDP are 0.4% and 0.5%. The treatment of diseases
related to smoking had been estimated to cost the NHS £1.4 - £1.5 billion a year in
18. 18
the UK, which was about 0.16% of the GDP, including £127million for the treatment
of lung cancer alone. However, if there was a smoking cessation intervention it
could have saved up to 15% of the total health care cost along with increase in the
life expectancy(Parrott and Godfrey, 2004). Similarly, another study presented that
intervention which used the approach of raising the price of tobacco products
through taxation, generated substantial healthcare cost saving as well as providing
additional gains from enhanced productivity in work place(Contreary et al., 2015).
Interventions to reduce the use of tobacco use
Intervention means actions which are taken to improve. There were numerous
studies which indicated a lot of assisted and unassisted attempts which were made
to reduce the use of the tobacco. The purpose was to review the evidence to know
intervention was done to reduce the use of tobacco.
Unassisted attempt cessation
Andrea l Smith 2015 had conducted a systematic review to view the experience of
smokers who quit without any assistance. The aim was to review the qualitative
literature on the smoker’s opinions and experience and who gave up smoking
without any aid. The key themes related to unaided smoking cessation were based
on Thomas and Harden’s thematic synthesis methods which extracted key themes in
unassisted cessation and then further classified theminto relating themes.
Motivation, willpower and commitment were identified as three concepts vital to
giving up smoking without any assistance. It reported motivation was the one clear
reason for quitting. A technique such as willpower was proclaimed as a way to
overcome desires, cravings or personality traits to successfully quit smoking. Another
key aspect to successfully quit smoking was commitment, which was seen as being
serious and resolute to achieving their goal and was often used to distinguish earlier
failure attempts. It appeared that commitment could be provisional or small
duration, and also relaxing and could be built upon as the quit attempt
progressed(Smith et al., 2015a).
19. 19
Similarly, to know further about unassisted attempts, Smith Al conducted a
systematic review to know about the unassisted smoking cessation. They conducted
a literature search from four electronic databases from years 2005-2012 with
specifically searching for unassisted cessation. From these studies, data suggested
that 54% to 69% of ex-smokers had quit unassisted and of the current smokers, 41%
to 58% had attempted to give up without any aid. In Australia, the majority of
smokers had quit or attempted to quit, however, very less research had been
conducted to understand the process(Smith et al., 2015b).
Vangeli et al, 2011, conducted a systematic review to know further about the
predicator of smokers attempting to stop, as well as the quit success in the adult
general population. The finding was that out of 1654 articles, only 17 met the
inclusion criteria and out of these 17, 8 studies were referred. The prediction of quit
attempts was dominated by motivation factors, whereas cigarette dependence
always predicted achievement after an attempt had been made. Predictions of
success from social grades also emerged, but were only examined in two studies out
of eight. In contrast, the other socio-demographic factors did not predict making a
quit-attempt or success(Vangeliet al., 2011).
Non-clinical or population approach
The upstream action, which targeted the whole population with the creation of
policy, seemed to have made differences. There was evidence which suggested that
this upstream action had made an improvement.
Callinan et al, 2010, conducted a study, to assess the extent to which legislation-
based smoking ban or restrictions had reduced exposure on second hand smoking
(SHS) and assisted in reducing tobacco consumption. Imposing a legislative smoking
ban for the reduction of SHS exposure, smoking prevalence and tobacco
consumption was marked as a measure for reducing passive smoking exposure. A
greater fall was experienced in hospitality worker’s exposure to SHS after imposing a
ban when compared to overall population. There is a little evidence on the impact of
the ban on active smoking, despite this, the trend is declining and with the
improvement in health outcome there was evidence of an increase in support for a
20. 20
smoking ban(Callinan et al., 2010).
A study conducted to assess the impact on active smoking from public smoking ban
policy found the introduction of a smoking ban had a short-term effect. It identified
a significant difference in trends of smoking. Consumption across the survey period
by population subgroups found the evidence to be not sufficient enough to
summarise that these were affected by the introduction of the smoking ban(Jones et
al., 2015). Another study conducted to assess trend in smoking cessation by Scottish
smoke-free legislation found an increase in smoking cessation rates in first 3 months
of introduction. In the first year of legislation and the following year, overall quit
rates were consistent with increases in quit rates before the introduction of
legislation(Fowkes et al., 2008). Despite social economics not being linked to
smoking cessation, people from more affluent communities showed added positivity
towards the legislation. On the other hand, mass media seemed to have an effect on
smoking cessation. A study from Australia shows evidence that suggests
comprehensive tobacco control, including mass media campaigns, can be effective
smoking behaviour in adults(Bala et al., 2015).
Assisted attempt
A study found that smoking cessation with some assistance seemed to be effective.
Bauld L conducted a systematic review to assess the effectiveness of NHS smoking
cessation service. They measured the effectiveness through monitoring of carbon
monoxide, which confirmed quit rates of 53% falling to 15% in 1 year. They found to
help smokers quit smoking, therefore intensive NHS treatment smoking service had
seemed to be effective(Bauld et al., 2010).
Evidence suggested group treatments could be more effective than attempting alone
and the impact of “buddy support” varied, based on the type of treatment. Buddy
support meant where individual smokers teamed up to give each other support.
Smokers from a young age, females, pregnant smokers and more deprived smokers
quit smoking temporarily more than any other groups. Another study presented that
telephone counselling service has been effective in smoking cessation.
21. 21
Smokers who contacted helplines had higher quit rates to receive proactive
counselling service follow-up RR risk ratio 1.37 95%CI: 1.26 to 1.50. Quit line services
were effective and assisted the smokers with proactive tobacco counselling services
(Stead et al., 2015, Stead and Lancaster, 2015).
Clinical approach
The cessation service or advice, which could be provided in the health care setting
such as General Physician practices and dental practices, were effective in smoking
cessation services. There were several published studies which showed it is an
effective approach.
General Practice
One study presented the finding that little or plain advice from physicians had little
effect on smoking cessation but in contrast, brief cessation advice can achieve a
higher quitting rate(Stead et al., 2013). Another study with a new approach known
as ASK-ADVICE-CONNECT compared to the tradition 5 A’s approach (Ask, Advise,
Assess, Assist, Arrange) for smoking cessation treatment in health care setting,
showed the following findings; “in the AAC clinics, 7.8% of all identified smokers
involved in treatment vs. 0.6% in the AAR clinics (t4=9.19[p<. 001]; odds ratio, 11.60
[95% CI, 5.53-24.32], a 13-fold increase in the proportion of smokers who enrolled in
treatment. The system changes implemented in the AAC approach could be taken by
other health care systems and have tremendous potential to reduce tobacco related
mortality and morbidity” (Vidrine et al., 2013). One study from India on the
effectiveness of 5 A’s intervention to assess the agreement between patient and
physician was conducted. Agreement was measured by level of percentage (Low,
High, Medium) The results were that slight agreement was noticed between patient
and physician in regards to Ask and arrange component in contrast to Advise, Asses
and assist component, which low level agreement. Except advise, all other
components of 5A’s showed higher agreement for those who were made to quit
smoking (Panda et al., 2015).
22. 22
Dental practice
There were several studies which showed that tobacco cessation in dental practices
were effective. Dentists and their team played an essential delivering tobacco
cessation intervention.
To assess the effectiveness of tobacco cessation intervention delivered by
professionals working in oral health, Carr and Ebbert, 2012, conducted a systematic
review in a dental or community setting. They search the electronic database with
criteria of including RCT and psudo RCT that had assessed tobacco cessation
intervention in dental setting or community setting. 14 clinical trial met criteria,
Pooling fourteen studies recommended those intervention from oral health
professionals can raise tobacco abstinence rates (odds ratio (OR) 1.71, 95% CI 1.44 to
2.03) at 6 months or more, although there was evidence of heterogeneity (I2 = 61%).
Carr Ab reported that the evidence implied intervention behaviour for tobacco
cessation performed by professionals in oral health who were incorporating with an
oral examination component in dental offices or community centres, may rise
abstinence from tobacco rates between cigarette smoke and smokeless tobacco
users (Carr and Ebbert, 2012).
The tobacco cessation advice delivered via dental health care practitioners in
community health centres were effective (Gordon et al., 2010). RCT was to compare
the effectiveness of intervention (brief advice, and assistance, including nicotine
therapy) group with control group, which were usual care of patient in community
health centre dental clinics where diverse racial/ethnics groups in 3 states in USA.
The findings were that higher absences’ rate was reported in intervention groups at
7.5 month follow up compare to usual care groups for prolonged abstinence “(F
(1,12)=14.62:p<0.1)” and “point prevalence (F (1,12)=6.84:p<0.5)” The randomised
trial on low income smokers found it effective and viable. Similarly, other findings
from study in Finland and Sweden state that with smokeless tobacco users the very
brief and structured counselling in dentistry may achieve a positive behavioural
change amongst tobacco users, with the reduction of tobacco consumption
(Amemori et al., 2013, Virtanen et al., 2015).
23. 23
There was no clear evidence on whether a smoking cessation service was cost
effective or not in NHS dental practices. There was evidence that private practices in
UK provided more smoking cessation advice than their NHS counterpart, as well as
dental services indicating a higher number of verified quits than NHS stop smoking
service(Nasser, 2011).
Primary dental practice and tobaccouse cessation
“Public health England 2014. Smoke and free smiling”
This document provides updated guidance for dental teams, commissioner and
educators on how contributions can be made to reducing rates of tobacco use, as
well as emphasising available resources for support(Public Health England, 2014).
Guidance for dental teams (2015)
The NICE has provided guideline to be followed by dental teams and other health
care professional(NICE, 2015).
“List of quality statements:
- Statement 1. People are asked if they smoke by their healthcare
practitioner, and those who smoke are offered advice on how to stop.
- Statement 2. People who smoke are offered a referral to an evidence-
based smoking cessation service.
- Statement 3. People who smoke are offered behavioural support with
pharmacotherapy by an evidence-based smoking cessation service.
- Statement 4. People who seek support to stop smoking and who agree to
take pharmacotherapy are offered a full course.
- Statement 5. People who smoke and who have set a quit date with
evidence-based smoking cessation are assessed for carbon monoxide
levels 4 weeks after quit date.”
A several study which review on the uptakes of guidelines and guidance.
The one study from Finland conducted to assess the tobacco use counselling
guideline and factors related with counselling behaviour. The study found that there
24. 24
was a chance for improvement for tobacco use cessation guidelines. The recognised
Theory Domain Framework (TDF) was linked to tobacco use counselling behaviours
which give an avenue for targeted intervention to enhances the guidelines (Amemori
et al., 2015).
A survey was conducted for oral health practitioners and their smoking cessation
practices in Australia. It found that 90.01% of practitioners frequently screened for
smoking behaviour, 51.1% has assisted patients to quit smoking. 45.7% of referrals
were made to the Quit Line and 44.4% were made to a general medicine
practitioner. 93% of professionals believed it is the role of professionals to advice,
however, 21% did not (Ford et al., 2015).
Pharmacological intervention
There were various pharmacological substitutes available, which appeared to be
effective in reducing tobacco use and replaced it with pharmacological products.
There were several studies which showed evidence that all market products for NRT
(nicotine gum, transdermal patch, the nicotine spray, nicotine inhalers and
sublingual tablets/lozenges) was beneficial in smoking cessation. Bupropion may be
more effective and promising compared to all other products (Silagy et al., 2000,
Schnoll et al., 2015, Wang et al., 2008).
Knowledge and attitude of oral health professional towards tobaccouse cessation
There were many studies conducted to assess the knowledge and attitude of dental
professionals towards tobacco use cessation.
In the UK North Deanery, a question-based survey was conducted to understand the
attitudes and activities of professionals working in primary care, explicitly regarding
the delivery of smoking cessation. It found that dentists and their teams needed
further training and appropriate remuneration to assist their patients to quit
successfully, likewise, revealing that dental teams in primary care were aware of the
importance of offering advice on smoking cessation (Stacey et al., 2006). Similarly,
one study with oral surgeons reported most were engaged about the smoking habits
of their patients. On the other hand, it was essential for dentists to receive specific
25. 25
training by providing treatment programs as part of their professional responsibility.
Oral surgeons recognised direct association between smoking habits and oral cancer
as well as the significant role of dentists in the prevention of this disease (Gonzalez-
Martinez et al., 2012). Likewise, a study conducted with dentists from the Oxford
region reported that a high response rate (78%; 674/869) was obtained. Most of the
respondents asserted that dentists should encourage their patients to stop smoking,
however, few were active in this area (John et al., 1997).
A study from Florida found that dentists tend to spend less time in smoking
cessation service and also many dentists were ready to receive specific training,
which would have assisted them in tobacco use cessation (Succar et al., 2011).
The national survey for Irish student hygienists, dentists, dental nurses and newly
qualified dentists had shown a positive attitude towards tobacco use cessation in
their practices. There other findings revealed that dentists were not incorporating
smoking cessation into their practice (McCartan et al., 2008).
Another finding presented smoking cessation activity, as part of oral health
promotion between private and NHS dentists, was not similar. The NHS dentists
were reluctant due to lack of time, no incentive and lack of training in comparison to
private dental practices. With this result, it suggested that NHS dentists had tended
to raised inequalities (Csikar et al., 2009).
Patient knowledge and attitude towards tobaccouse cessation intervention
In contrary to dentists and health professionals, it was reasonable to review the
patient’s side even. There were several studies, which reported patient’s attitudes
and perception towards tobacco use cessation.
A cross sectional study was conducted to examine the health knowledge and their
intention towards quitting smokeless tobacco chewing (STC). It revealed women’s
knowledge of the adverse effects of STC showed a vast gap in rural Bangladesh.
(Hossain et al., 2015).
Four main motives for water pipe usage were revealed to be socialising, relaxation,
26. 26
pleasure and entertainment from a systematic review conducted by Akl et al. Water
pipe smokers perceived, in contract to cigarettes, water pipe smoking was less
harmful, less addictive and more socially acceptable. Likewise, they were confident
in their ability to quit this (Akl et al., 2013).
Ahmady et al conducted the randomised controlled trial to know the attitudes of
patient towards dentists 5A’ approach between intervention group receiving chair
side counselling and control group receiving no intervention showed significantly
positive attitudes towards the dentists roles in advising smoking cessation compared
with control groups. 88.9% who were planning to quit smoking, 72.27% had agreed
that they discussed the ill effects of tobacco, 82% said dentists should offer
assistance and services aiding them to quit tobacco. The majority of the patients
were not aware of the resources available to them to aid them to quit. Dentists are
at the forefront to providing information to patients who need help in quitting the
use of tobacco (Ahmady et al., 2014). Interventions groups were given tobacco
counselling and control groups were given no counselling, and were compared it pre
and post test with and without intervention. The mean attitudes scored of
counselling groups, which were intervention compared to control groups
significantly higher post tobacco counselling [68.09(SD 13.5) VS 77.4(SD 15.4)]
(p=0.009).(Ahmady et al., 2014)
The findings from an Australian study revealed that most of the patients wanted
their dentists to be keen about their smoking status and discuss smoking with them
(Rikard-Bell et al., 2003).
Barriers and facilitators
Several studies were reviewed to know the barriers and facilitators for delivering
smoking cessation. The most common barrier in providing smoking cessation
intervention, reported in few of these studies, was lack of time. A study conducted
by Dalia et al to assess the management of patients who are smokers through post
questioners with specialist periodontics and dental hygienist. The findings presented
were barriers such as lack of time and poor response from patient which may inhibit
them to deliver smoking cessation advice (Dalia et al., 2007). A question-based
27. 27
survey with dentists, dental hygienists and dental nurses was established to
determine the attitudes and activities of dental professionals in primary care in
Northern Deanery of UK. The survey found that potential barriers which dental
professionals had towards delivering smoking cessation were lack of training, lack of
time and lack of remuneration (Stacey et al., 2006). Alongside this some additional
studies reported some were lacking training/expertise knowledge, lack of patient
interest, concern about remuneration, lack of confidence in delivering cessation
service and supervising staff were not to supportive and damage to the practitioner–
patient relationship, lack of patient education material, smoking cessation not
thought to be relevant concern about the effectiveness lack of staff (Watt et al.,
2004, Edwards et al., 2006, Rosseel et al., 2011).
On the other hand, there were factors, which acted as facilitators in delivering
smoking cessation. There were studies, which found the facilitating factors and
showed the following (John et al., 2003, Johnson et al., 2006, Watt et al., 2004):
Patient with oral health problem are motivated than other patients.
Reimbursement of smoking cessation services, advice or nicotine
replacement therapy prescribed can increase interest of the dentists in
delivering smoking cessation activities.
Roseel JP et al stated social support was an essential facilitator to encourage more
smoking cessation advice and counselling. Implementation strategies for the support
of smoking cessation in dental care should be focused on creating a positive advice
culture amongst colleagues (Rosseel et al., 2009).
Communities of practice
Wenger (Lave and Wenger, 1990) is the person who first noted and observed
communities of practice in education and also in business later by Brown and Duguid
(Brown and Duguid, 1991). COP was expressed as “groups of people who share a
concern or a passion for something they do and learn how to do it better as they
interact regularly” (Wenger et al., 2002). The notion of COP had put the theory that
structure around social learning systems and theory that learning was derivative or
28. 28
involved in social world (Wenger, 1998). Three elements of COP, vital to the domain,
community and the practice were (Wenger et al., 2002):
The domain, commitment and sense of identity was implied by membership,
value of collective competence and within their general area of interest
learning was done from each other.
The community, the social fabric for learning environment was created by
member involvement in discussion, joint activities and built relationship.
The practice, members who are practitioners had produced a shared
gathering of resources such as stories, experiences, tool and problems
around the interests of practice.
Generally, the notion of the COP is the sharing of knowledge with the whole
community of the knowledge becoming superior to single participant’s knowledge.
Wenger explained practice by interrelating three facets; mutual engagement, joint
enterprise and shared repertoire. The communications between individuals leading
to share meaning in regards to issue or problems represented mutual engagement.
The processes of involvement of members working together is joint enterprise, with
the resources used between the members’ leads to groups shared repertoire. The
process of individual communication is with COP is supported by this three facets.
The fourteen indicators which is also proposed by Wenger were used to detect
community within the COP(Wenger, 1998).
In the contemporary world, organisation and professional associations were using
COP to promote professional development, help members to engage in learning and
sharing knowledge. Numerous studies had insight that communities of practice used
one method to foster knowledge sharing and provided practitioners valuable
opportunities to form networks. In the healthcare sector for seeking and sharing
knowledge, COP was recognised one of the useful methods.
(Li et al., 2009) conducted a systematic review from Wenger and colleagues’ concept
of COP that gave insight into the practice of COP in business and the health sector
between 1991 and 2005. 1421 articles were assessed out of which 13 primary
studies of health care sectors and 18 from businesses met the Wenger’s concept of
29. 29
criteria of domain, community and practice. The Wenger’s notion of COP as social
learning revealed multidisciplinary use in organisation and health care setting was
supported by the review.
Ranmuthugala 2011, to understand the concept of COP more in detail, did the
systematic review from 6605 electronic healthcare databases. It discovered that
from 33 (n=31) and two systematic reviews from 1990 and 2009, 19 out of 33 papers
were published after 2007 and most of them were from Australia UK, Canada, US.
The objective of the review was to gain understanding how COP functions in
healthcare. Face to face, email or web-based system discussions were found
(Ranmuthugala et al., 2011a). Ranmuthugala described trends where COP was used
as evidence based practice and clinical practice enhancement. The extensive
systematic review concluded that COP could be beneficial to a healthcare
organisation (Ranmuthugala et al., 2011b).
Knowledge seeking and sharing among COP
Modern learning theory supported the learning setting with values of
communities(Wenger et al., 2002). Wenger has stated knowledge as both explicit
and tacit.
Explicit knowledge was expressed in numbers and words in shared data, whereas
tacit knowledge is more difficult to communicate due to knowledge not being
transferred verbally it can only be conveyed via training or personal
experiences(Rodríguez et al., 2004). An endeavour, which aimed to disseminate
individual knowledge to other part of organisation, was known as knowledge
sharing. The course of disseminating tacit and explicit knowledge was denoted as a
knowledge creation(Jackson, 2006). There were several studies, which interrelate
explicit and tacit knowledge.
Fugill M in his study of tacit knowledge in clinical teaching dentistry reported that
the procedural knowledge, which is explicit form, has dependence on tacit
knowledge. But he also reported that dependence creates communication barriers
between clinical teachers and students(Fugill, 2012).
30. 30
Kothari et al reported in a qualitative study of use of tacit and explicit knowledge in
public health in Ontario Canada that tacit knowledge along with explicit knowledge
should be applicable in public healthcare planning programme(Kothari et al., 2012).
A study by J.Gabbay explored in depth on how primary care clinicians make their
individual and health care decisions by using ethnographic standard methods (non-
participant observation, semi structure interview). The study found that clinicians
very rarely used access to explicit information directly, however dependence upon
“Mindlines”, in which they collectively fortified internalised tacit guidelines, by their
brief reading or primarily by their own experiences or colleague’s experiences,
conversation with each other’s and with opinion leaders, patient and pharmaceutical
representatives and with other sources of tacit knowledge. These findings recognise
the potential advantage of exploiting informal and formal interacting for evidence
based decision making to clinician(Gabbay and May, 2004).
Senge et al 1990 cited in Barwick MA et al 2009 that knowledge acquisition inside
the environment of practice interaction assisted to promote continuous learning and
structure learning organisation that would be more willingly adapted to innovative
practices and approaches as they emerged from discovery research(Barwick et al.,
2009).
The significance of knowledge sharing and learning had made the health sector to
focus on COP as equipment to enhance practice and patient care by enabling
knowledge sharing among providers .Due to the feeling of shared sense of
ownership, knowledge sharing seems to be easier in COP(Curran et al., 2009,
Ranmuthugala et al., 2011b).
Dawes and Sampson’s 2003 conducted a systematic review on clinical practicing
physicians to know their behaviour of seeking the information. Dawes and Sampson
extract the paper from electronic database from 1966 to 2001. They selected 19
trials to review. The methods of collection of information were questioners (n=9
47%), interviews (n=8 42%) or some combination and records review and
observations.
31. 31
The systematic review discovered that physicians used a range of key sources to
obtain information. Most frequently used was text source (n=13), and books (n=7),
followed by papers (n=2) and desk references (n=4) and colleagues (n=7). It also
found that healthcare professionals in group practice used professional colleagues
more compared to those in individual practices, along with that, health care
professional in urban counties utilized more than in rural counties. Furthermore, a
list of convenience of access, habit, reliability, quick use and applicability as factors
were stated and these aid in successful information seeking by physicians. Barriers
were stated such as lack of time to access materials, information, amount of
materials and vagueness(Dawes and Sampson, 2003).
The use of Internet in community of practice
The widespread use of Internet, along with the combination of COP, had resulted in
virtual communities of practice (VCOp). The following social networking tools
provided opportunities for exchanging knowledge amongst practitioners regardless
of their locality; Facebook, Twitter, Pinterest, LinkedIn, Yahoo, Google Plus(Hanson
smith, 2013).
(Cheston et al., 2013) conducted a systematic review upon social media use in
medical study. The purpose was to find out how intervention, using social media
tools, affected outcomes of satisfaction, knowledge, attitude and skills for physician
and physicians-in-training and also to find out about difficulties and opportunities
specific to social media came across on educators. They searched electronic
databases from September 2011 using the keywords “social media” and “medical
education” and in 14 studies met their criteria. Reported social media was linked to
enhanced knowledge (e.g. exam scores), attitudes (e.g. empathy), and skills (e.g.
reflective learning). Opportunities that were reported were promoting learners’
engagements (71%), feed back (57%) and alliance and professional development
(36%). Challenges were reported such as technique problems (43%), variable learner
participant (43%) and privacy/security concern (29%).
32. 32
Summary
Taking all things into consideration, tobacco use is still prevalent and also tobacco
has a very big impact on human health as well as economy, however, oral health
professionals can assist on individual and population levels, to reduce tobacco uses.
Plenty of guidance is available to get dentists and other healthcare workers to be
active in promoting tobacco use cessations, however, few seem to do so and the
community of practice seems to be an effective method in other healthcare and
business sectors. In making an evidence based decision and sharing evidence based
information within the professional communities, there is a lack of evidence and
literature in community of practice models in dentistry.
Based on the community of practice model, which is successful in other health and
business sectors, this research aims to explore knowledge sharing among dentists
working in an NHS hospital and how it can facilitate in promoting effective smoking
cessation intervention.
33. 33
Chapter 3 - Methodology Section
Introduction
The methodology and study designs used are outlined in this particular chapter. This
chapter will cover and explain research paradigms, study designs, research site,
sampling method and data- collecting process and also key concepts of ethics,
trustworthiness, followed by data analysis methods used.
The goal of qualitative methodology is to interpret, explore, or acquire an in-depth
understanding of social phenomena (Bower et al., 2007).
Research question requires exploration therefore qualitative approach is used
(Stewart et al., 2008). Asking ‘How or What’ is usually how qualitative research starts
so the researcher can understand in depth of what is happening with regards to the
topic (Agee, 2009).
Qualitative research was an appropriate method to research the aims and objectives
and to address the research problem.
This study explored who Dentists shared their knowledge with by using the
Vignettes technique, which would provide some examples of the scenarios of
knowledge sharing and asked them if they had similar experiences such as these.
Secondly, qualitative research permits the Researcher to explore feelings or thought
processes, as collecting and learning this would be difficult through conventional
research methods (Strauss and Corbin, 1998). The study explored the dentist’s
perceptions and experiences of effective smoking cessation and referral service for
this on-going study. Thirdly, the qualitative research method is best in a natural
setting and to understand the social process in the environment they work in (Al-
Busaidi, 2008). The on-going study was based on the dentist’s experiences of
knowledge-sharing in communities in their professional practice and sharing the
effective smoking cessation with other colleagues, as dentists are hold oral health
34. 34
professional positions in the NHS hospital. Lastly, the fourth reason is that the
Researcher is seen as the research instrument as the Researcher is proactive in their
role (Sofia Fink, 2000, Denzin and Lincoln, 2003). For this on-going study the
Researcher was the key instrument in data collection and interpreting the findings.
Research paradigm
Qualitative, quantitative and mixed methods are the three main designs which are
frequently used to perform research, as these designs have different theoretical
beliefs with regards to what forms knowledge and how it develops (Creswell, 2009).
The Researcher, who is a positivist, adopts the quantitative research approach. A
positive minded researcher supports the application of the method of natural
science as indeed science is the reliable source of knowledge that is varied on the
basis of observation and experiment, the consequence being the research can be
conducted objectively and impartially that is “value free” (Dash, 2005, Bryman,
2016).
In contrast, for interpretivist researchers, knowledge is acquired from inner
understanding through their deliberation of personal experiences. A person makes
sense of these experiences based upon memories and expectation and that meaning
is developed and revised over time by creating multiple interpretations based on
dynamics and subjectivity (Bryman, 2016, Dash, 2005). Therefore, they adopt the
qualitative approach.
Qualitative research is not a single-handed process, it is interrelated with three
activities; Ontology, Epistemology and Methodology in which it is assessed (Denzin
and Lincoln, 2003).
Epistomology is the relationship between the researcher and the research. As it
acknowledges the human situation through meanings, intentions, actions and
experience, this current research study was based on the interpretive epistemology
(Richie and Lewis, 2003). It also required having closeness between the Researcher
and participants. In this study, researcher worked closely with dentists who worked
in an NHS hospital.
35. 35
Ontology is known as the view of the nature of reality. Qualitative methods are with
subject methodology based on multiple realities and it depends upon the social
actors to complete this role. This research dissertation was based on this
constructivism (Richie and Lewis, 2003).
The research paradigm for this dissertation was constructivism and interpretivism as
ontology and epistomology are interrelated to each other (Gialdino., 2009). The
epistemological and ontological framework of qualitative research manifest that
knowledge is self experience rather than received exterior source, which is based on
multiple realities. Therefore explicit use of qualitative research methods is to
discover the meaning that people has given to event they experiences (Gialdino.,
2009, Bryman, 2016).
Research design
For this research a descriptive qualitative research design was applied and an
examination was done by semi-structured in depth interviews. “The in depth
interviews are personal, intimate encounters using open, direct and verbal questions
to elicit details, narratives and stories” (DiCicco‐Bloom et al., 2006). The reason for
conducting an in depth one-to-one interview was to gain detailed, in depth
individual understanding for this study (Legard et al.). It was better to do one-to-
one’s rather than focus groups for the following reasons; it explores very sensitive,
embarrassing, controversial or personal topics (Gill et al., 2008). It also avoids
interpersonal conflicts which would have had a maximum chance if the focus group
interview was done for the dentists, rather than doing one-to-one (Hughes and
DuMont). Doing focus groups for the Dentists was not possible because of the lack of
time and also difficult to get all the Dentists together in one room.
Research sites
The research was conducted in the Royal London Dental Hospital, which is part of St
Bartholomew’s Healthcare NHS trust. They are a leading specialist in dental and oral
health care and by serving a population of 2.5 million in East London and beyond; it
is the biggest NHS trust in the UK. It is also one of Europe’s major and strongest
36. 36
academic health science partnerships that is known as the UCL partnership. The
objective of the UCL partnership if to convert advance research and innovations into
quantifiable health improvement for patients and populations through collaboration
with other sectors, as well as excellence in education(trust, 2016).
Participants
The research participants were all Dentists working in the NHS Royal London Dental
Hospital. Ideally, the qualitative research method used is non-probability purposive
sampling. It is a non-probability and non-randomised form of sampling. The goal of
purposive sampling is to sample the participants in a tactical way so those samples
are appropriate to the research questions being displayed. The maximum variation
method sampling was tried best to be achieved as it selects a wide range of
participants (Bryman, 2016). For instance, in this study a range from junior dentists
to specialist and consultant level dentists were selected. Alternatively, it can also be
assumed that it is a convenience sampling, as a convenience sampling is for those
who meet the entry criteria and are easily accessible to the Researcher (Hulley,
2001, Bryman, 2016).
The inclusion criteria were Dentists working in a hospital with no gender preference
and could range from junior dentists to specialist consultants. There is no certain
number of the sample size as it relies upon the concept of data saturation. This
means we will continue to interview until we reach a saturation level and no new
surprising information will emerge (Sandelowski et al., 2007, Patel, 2015). However,
due to the time limit, it may not be possible to reach saturation. Thus, it was
expected that thematic analysis might be 10 or fewer dentists.
The recruitment was done by direct approach to individual Dentists face-to-face in
their particular clinics; staff rooms and office, with a prepared speech with can be
seen in Appendix 8. At the time of the approach, Researcher provided the copy of
the Information Sheet (Appendix 4), which gave the relevant information of the
study. The other alternative method was via email invitations.
37. 37
Ethical consideration
Universities and professional associations have a code of ethics and research review
board with the purpose to protect human subjects from unnecessary harms
(Marshall and Bossman, 2006). A research proposal was submitted to the Research
Supervisor. The supervisor, before the start of the project, obtained ethical approval.
In conducting any type of research the research must bear in mind about the impact,
which their research will have on participants and on society. There was no harm to
any one for that ethics was approved.
Queen Mary Research and Ethics Committee provided the ethical approval for this
study (Ref: QMREC1458) and can be seen in Appendix 3. The only two issues were
confidentiality and consent in regard to ethics. The participant was given written and
verbal information about which can be seen in Appendix 4 about the purpose of the
study and any query was clarify before written consent was taken. Participants were
also assured about the confidentiality of data collected, which would be maintained
throughout.
Data collection
Data was collected through the use of semi-structured in depth interview methods
along with topic guide (Appendix 6) and a uniform set of open-ended questions to
gain:
1. To gain the information about Dentist’s demographics.
2. To check the dentist’s understanding and concept of knowledge for this
interview.
3. To explore whom dentists share their knowledge with in the hospital.
4. To explore the perception of dentist’s effective smoking cessations and
referrals
5. To ascertain how dentists would share effective tobacco use cessation
approach with other colleagues.
The topic guide navigated to keep the interview as exclusive to the topic as possible
open-ended questions were particularly useful when it is significant to list what the
38. 38
respondent had to say in their own words (Bryman, 2016). This also encouraged
participants to respond freely and openly. Probing and followed questions were also
used to encourage participants to explain a response (Denzin and Lincoln, 2003).
Before the study started, the topic guide was tested through a small pilot exercise,
which was organised by one of the tutors as part of practical learning. The purpose
of piloting is to recognise the issues that the participants might have in
understanding or interpreting questions(Kumar, 2014).
Interviews
The interviews were done at the Royal London Dental Hospital with the prepared
topic guide. After providing the Information sheet and answering any queries, the
participants were asked to sign a written consent form. At the start of the interview,
the purpose of the study was reiterated again and reassurance of confidentiality was
conveyed. Moreover, researcher also used the technique of the Vignettes in the
qualitative interview (Bryman, 2016). Mason 2002 (Bryman, 2016) p.476 has stated
that the use of general questions sometimes makes the interviewees usually ask to
clarify what they mean by the question therefore alternatively vignette may be used
as one way of asking specific questions. The Vignette technique usually presents the
interviewee with one or more scenarios which prompt them answering how they
would respond when confronted with that scenario (Bryman, 2016). For this study
vignette were used for understanding the knowledge-sharing experiences of
dentists. The vignettes were recorded from real life experience of dentists which was
edited slightly, for example:
“A colleague is doing Masters in Restorative and Aesthetic dentistry, and he is doing
a complex case submission in which the patient has severe wear of the teeth due to
Para functional habit, wear of the anterior and endodontic treatment for anterior
teeth and darkening of anterior tooth, secondary decays in some of the filled teeth in
which is doing occlusion rehabilitation. He happens to be in a situation where there is
a molar tooth root canal treated and heavily restored with amalgam and the patient
doesn’t want the tooth to be touched as it was done 10 years ago and its not giving
any problem to patient. Patient feels it is not necessary to disturb that tooth if it is
39. 39
not giving any trouble. His examination and x-ray states that at some point in the
future, the patient will need a crown. However, your dentist colleagues had to go
through all the evidence of literature supporting either to crown or not and he had
found a lot of debates and controversy either to crown or not and he is in very
conflicting situation. He therefore asks your opinion about what will be best to do?”
This scenario was from experience which Researcher noted.
Like the above scenario, the Vignettes were shown to the dentists during the
interview which help us to reveal the kind of knowledge of knowledge-sharing
experience they felt and how they felt about the hypothetical knowledge-sharing
experience would be (Bryman, 2016) which are in Appendix 7, the
vignettes(unpublished) were collected by supervisor on interview with dentists . The
interview lasted approximately 35-45 minutes duration in a silent room. The
interviews were conducted between 1st May and 30th May 2016. They were audio
recorded and transcribed verbatim was done by an outside agency who are outside
the research team. Audio recording prevents against bias and also provides the
record of the discussion (Gill et al., 2008, Hayes et al., 2016). Poland expresses
verbatim transcription as the word for replica of vocal data, where the written word
are a correct replication of the audio recorded words (Poland, 1995). Correct
transcription with verbatim was a vital stage in qualitative data analysis (Halcomb
and Davidson, 2006, Pope et al., 2000).
Data analysis
To accomplish qualitative research, there is no one official way, as data analysis is
the process of making sense (Bradley et al., 2007). It is a creative process, which
usually follows an inductive theory approach(Burnard et al., 2008). Qualitative data
happens in dissimilar patterns and therefore should be analysed according to
multiple analysis structures, which includes thematic analysis and framework
analysis (Thorne, 2000). The data analysis process should follow three things which
are describing, classifying and connecting which is based on content analysis (Hsieh,
2006, Coffey and Atkinson, 1996). Analysis should describe the meaning, process and
40. 40
context of the social actions. Before patterns emerge and final analysis, data must be
accurately categorised into codes.
In this research study, the data analysis was done by thematic analysis, in which, the
data identifies and describes implicit and explicit ideas (Guest et al., 2012). Thematic
analysis focused on coding which is typically inductive or bottom up theory for the
qualitative data (Fugard and Potts, 2015). It gathers text with similar meaning and it
also, such as the concept, captures the phenomenon of interest. For this dissertation
data analysis followed the thematic analysis’ 6 steps given by Braun and Clarke 2006.
These are as follows (Braun and Clarke, 2006):
1. Familiarisation (getting intimate with your data).
2. Begin the detail analysis of coding process.
3. Searching for themes by putting the codes into themes.
4. Reviewing the themes.
5. Defining and naming themes.
6. Producing a final report on the identified themes (Braun and Clarke, 2006).
In coding the transcript and verifying the new themes two researcher were involved.
Two of them discussed with each other what they found in each transcript. I.b
researcher determined the final themes and review with supervisor.
Trustworthiness and rigour
The qualitative research method demands the Researcher to take an active role in
the collection and interpretation of data. So it should be valid and reliable like
quantitative methods. In the qualitative research it assess the validity and reliability
by following the criteria purposed by renowned qualitative researcher (Lincoln and
Guba 1985) which is termed as ‘trustworthiness and rigour’ which are further classify
as credibility, transferability, dependability, conformability (Bryman, 2016,
Golafshani, 2003).
Credibility: It means that how consistent are the findings? It parallels internal
validity. For achieving credibility respondent validation was used, in which sending
41. 41
the copy of transcription to the participant to confirm the accuracy, and also
requested peer reviews.
Transferability: It means can the finding can be applied to another study ‘parallels
external validity’. It was achieved by providing the thick description of data collecting
method in detail and also a rich description of the location and characteristics of the
participants involve in study.
Dependability: It means that if work is repeated again in the same context using
same approach and participants would it be the same result ‘Parallel reliability’. It
was achieved by the rich description of detailed data gathering process.
Conformability: The study finding should be confirmed with the concurrent data.
‘Parallel objectivity’.
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Chapter 4 - Results
Introduction
This chapter will present the findings. The purpose of this study was to know with
whom, why and how dentists share knowledge in a professional community of
practice and also to get the dentist’s point of view for best effective intervention to
deliver tobacco cessation and to know how dentists, with their social network or
professional communities of practice, will disseminate this effective intervention and
make it work. 15 participants were approached and out of 15, 13 were approached
directly and 2 were via email. Out of those who were approached directly, 6 became
participants of the study.
During the interview participants describe their approach of knowledge sharing
within communities of practice or hospital. They also gave their perception of
effective intervention of tobacco cessation in hospital by dentists and also how they
will disseminate this effective intervention in social network and community of
practice in hospital.
The findings, which are in the chapter, are based on the data analysis of the semi-
structured interview with participants.
Study findings
The first section finds the demographic and back ground information about dentists
working in hospital followed by that the second section emerging themes between
two different ways of knowledge sharing and seeking, which appear to show both
similarity and little difference in knowledge providing and seeking followed by that is
the third section perceived element of effective intervention for smoking cessation
in hospital by dentists and lastly, some common themes about how dentists will
disseminate that effective approach within their professional communities of
practice in hospital.
43. 43
Themes
The emerging themes are three major themes, which are further subdivided into
minor themes:
FI GURE 1 - MAJOR, MINOR AND SUB THEMES OF KNOWLEDGE SHARING
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FI GURE 2- THEME OF PERCEIVED ELEMENTS OF EFFECTIVE SMOKING CESSATION INTERVENTION
FI GURE 3 - DISSEMINATION OF PERCEIVED ELEMENTS
45. 45
Section 1 - Background information
The participants of the study were comprised of 6 dentists working in a university
teaching hospital in London, the Royal London Hospital. The age range was from 27-
55 years. All the six participants had an experience of working in hospital. Out of six
dentists, four were female and two were male dentists. Out of six, one was a
Consultant, four of them were Specialists and one was in a Junior Dentist position
and was studying part time for MSc Restorative and Aesthetic Dentistry. The six
dentists had experience of working in a team with different consultants and different
specialities. Four dentists reported of working in restorative speciality closely and
sharing a common interest and knowledge together. They all had a wide range of
working experiences in hospital and even in practice in private and NHS practices.
Most of the participant’s journey of their remuneration was through NHS and only
two of them said they were remunerated through private. They all are members or
belong to particular dental professional groups, of which they mentioned were Royal
College Society, British Dental Association and also some online communities.
Most of them agreed and understood the concept of knowledge, except two who
thought that social knowledge was different from the scientific knowledge term.
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TABLE 1 - DEMOGRAPHIC CHARACTERISTICS/BACKGROUND INFORMATION OF PARTICIPANTS
CHARACTERISTICS Sample (n)
Gender
Female 4
Male 2
Age
25 - 35 3
35 - 45 2
45- 55 1
Level of experience
Less than 5 years 1
More than 5 years 5
Remuneration
NHS -
Private 2
Mixed 4
Working with other teams
Yes 6
No -
Professional membership
British Dental Association
47. 47
Section 2 - Knowledge sharing
Most of the interviewees had their experience of sharing their knowledge with their
peers, students, juniors and seniors as the interview questions were based
hypothetically by showing them some vignettes of some real life experiences of
dentists, which they encountered. Most of them had similar situations and
experience, as the scenarios in the vignettes, within their communities of practice.
“Okay yes I have had things like that. People coming to ask for advice
[Interviewee 3]
“Okay, So I see these groups of patients a lot through being a special care dentist”
[Interviewee 4]
“Ok. I’ve come across a not too dissimilar case to the number five that you’ve asked
me to read and that was similarly a colleague who had….”
[Interviewee 5]
“Ok, yeah I’ve come across situations like this before”
[Interviewee 6]
As you can see, most of the participants responded to having a past experience of
knowledge sharing. It seems to appear they mostly agree with the scenarios
presented and through this they have reported knowledge sharing experiences in
the past within the professional community of their practice within the hospital
setting.
Tacit and explicit knowledge interdepended
The participants, who are clinical academics, mostly shared their knowledge with
students, patients, peers, juniors, and seniors. The participating dentists asserted
that some knowledge couldn’t easily be learnt or adapted from a textbook, which
48. 48
could be termed as explicit knowledge and only learnt through practical
demonstrations.
Dentists felt even though they share explicit knowledge, which is written and verbal,
but they share with demonstration, and practically which is a tacit knowledge form.
Therefore with dentistry being involved in mostly practical work, the interviewees
through demonstrations and ‘tell-show-do’ methodology more often shared the
knowledge sharing use of tacit knowledge and explicit knowledge.
The interviewees mostly shared their knowledge with students, colleagues and
patients, as the participants were from the Royal London Hospital, which is a
university teaching hospital.
Interviewee 1 compares how effective tacit knowledge is compared to explicit
knowledge when referring to a skilled speciality. He uses the example below to
assert his belief that practical skills knowledge which can be shared or learned
effectively through demonstration.
“Yeah. We have ideas and techniques that we share. For example, in Endo because
you need to be very skilled at removing broken instruments so showing somebody
how to do this is part of the sharing of knowledge. Yeah, practical skills must be
shared in that way, you cannot easily learn it from a textbook.”
[Interviewee 1]
A similar finding was found from Interviewee 5, as below. The knowledge sharing
was of both explicit and tacit knowledge to, despite this, there was more emphasis
on tacit knowledge, which is practical sharing of knowledge through the tell-show-do
method.
49. 49
“It’s sort of show, tell, do so we discuss the principals behind we choose certain
stitches for the skin and certain stitches for inside the mouth and then we would do it
for them while they watch closely or perhaps we would do the first half and then they
would do the second half so it’s very hands on.”
[Interviewee 5]
Interviewee 3, in their capacity as a clinical lecturer, relies on tacit knowledge as this
can only be shared through a demonstration on the patient itself.
“Yeah actually. It is part of my role as a clinical lecturer. I do many demonstrations.
In the clinic when I supervise the students I may have to see their patients, explain in
the patients mouth itself to the student what, really in the diagnosis part.”
[Interviewee 3]
On the other hand, Interviewee 6 given as example of explicit knowledge which is
shared by giving them the provision of information which is written and
recommended.
“I think yes, not so much they’ve asked me whether they are taking the medicine
correctly. It’s normally the case that I ask them and they volunteer the information
how they’ve been taking the medication and they would normally tell me whether
they are talking it correctly or not and I would tell them if they had been doing it
correctly or not.”
[Interviewee 6]
50. 50
Sources of knowledge sharing
There are common findings to the sources of sharing knowledge which includes:
Emails
“I don’t know, following their emails, sometimes they ask for surveys or information
so I would try to participate in those.” [Interviewee 3]
Facebook
The source of knowledge is through Facebook social media, which is an online
community for knowledge sharing with specific dental networks.
“Yeah, so there is a Facebook forum that I regularly contribute to”. [Interviewee 1]
“Sharing their Facebook, well not their Facebook, their programs, they have Smile
Programs or things like that. I share them on Facebook so I think I do my job. But
that’s all.” [Interviewee 3]
Expert opinions
There is always an expert in one’s own field. There were findings, which showed that
dentists shares knowledge with expertise. It may be possibly that knowledge from
experts is more reasonable and trustworthy.
“From there I discussed with one of the consultants I was working for, if he was to
receive a referral, how he would like the case managed.” [Interviewee 5]
"You have the clinical expertise, I'll just go by what you say" [interviewee 4]
“If I’m not sure about something there are a lot of colleagues at the same level of
seniority and maybe higher level of expertise in the specific field that I can directly
approach them.” [Interviewee 2]
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Knowledge seeking-acquisition
The other commonality in the study was knowledge acquisition seeking, where
dentists revealed they acquired or sought knowledge through peer discussion, case-
based learning and formal learning. Most of the dentists felt that acquiring
knowledge from their peers had a great impact on themselves. Whereas, case-based
learning seems to be very useful for them to seek/acquire knowledge as case-based
learning is where a dentist learns a general principle and applies this to a particular
case. Cases are like stories, which use metaphors to help convey tacit
understanding/knowledge with artefacts, which is similar to the above section of
tacit ‘know how’. The other behaviour of dentists for knowledge seeking-acquisition
was through formal learning. A dentist working in a hospital and seeking-acquiring
knowledge regularly reads journals, participates in conferences and watches
presentations.
Peer discussion
“Yeah, I've learnt a lot off her. She helped with my training, so she's someone that I
really respect. [Interviewee 4]
“But not that I have got this information from a colleague and then I have to call
another one to get information on behalf of the first colleague. ”[Interviewee 2]
Case based learning
“They don’t provide notes they just give you a description of what the case is with the
photographs. They’re always consented. People then comment or criticise or
appraise, or be supportive of the results.” [Interviewee 1]
“And just out of interest, looking at the other people’s cases. And of course, to see
how I can improve.”[Intervewee1]
“I quite like it. I mean I believe dentistry as a profession is very open to discussing
cases.” [Interviewee 5]
52. 52
Formal learning
Knowledge seeking-acquiring by reading, learning, speaking and listening as well as
participation in conferences. Dentists seek and acquire knowledge by regularly
reading dental journals, which is not only specific to one area but cover, all areas of
the dentistry. It means dentists are more keen to see the interesting information.
“So Dental Update is a journal that covers all areas of dentistry not particularly
targeted at one area of dentistry and that’s why I find it interesting because it’s not
just one thing. It’s very broad. It’s very easy to read so it’s quite clearly written so …
and it keeps the interest there so you don’t get bored whilst reading it.”
[Interviewee 6]
“Well the societies that I’m members of, they release journals regularly, every…
depending on the association… every month, every quarter I’ll get a journal through
the post and I read that. So that’s probably the biggest input because it comes
through my letterbox and I read that every month.” [Interviewee 5]
“Yeah. Listening and watching presentations. Reading what’s on the presentations.”
[Interviewee 6]
“I only go to the SAAD conference once a year. And the Dental Sedation Teachers'
group conference once a year.” [Interviewee 4]
“However, I also go to the conferences, especially if I’m part of the local meetings,
then they’re much easier to get to, so I can go on my way home from work and quite
often they have from six to nine o’clock they’ll do a lecture on a particular topic or
they’ll do an update on where the NHS is going and the future for the contracts and
things like that.” [Interviewee 5]
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Reason for knowledge seeking-acquisition
Dentists felt that they seek-acquire knowledge so that they can be updated with
latest information and knowledge’s what they are lacking. It also reflects that
dentists are keen and enthusiastic to learn and develop their skills.
Keep updated with knowledge and improve your knowledge
“New knowledge, new research, new developments. Just to be updated on what’s
happening.” [Interviewee 3]
“It’s just to (a) give advice, (b) to get more information, (c) to see what’s out there at
the moment to keep myself updated, am I falling behind? And just out of interest,
looking at the other people’s cases. And of course, to see how I can improve.”
[Interviewee 1]
“Well, I guess it makes me think about different techniques I can use, or gives me a
broader knowledge of the medical aspects of patient care.” [interviewee 4]
Influences on knowledge sharing
The third minor theme was influences of knowledge sharing. Dentists felt positive
that most of the dentists working in the hospital believe that it is a professional
responsibility, as well as satisfaction, for sharing knowledge. Dentists also reported
that they share knowledge as it gives them confidence as well as feeling appreciative
and rewarding. On the other hand some dentists had a judgemental perception
about sharing knowledge where dentists would assess the level of understanding
and decide to share knowledge after assessing who is asking. Similarly, dentists also
felt that they wouldn’t share knowledge if they were uncertain about something.
They will only share which is definite and evidence based. Dentists also perceived a
influence of political barrier would resist them to share knowledge, as they believe
their opinion will not be given importance and only people with high power are
given consideration
The finding in regards to influences on dentist for knowledge sharing includes:
54. 54
Professional satisfaction and responsibility
The participants who are working in a university teaching hospital feel it is their
responsibility to share their knowledge with patients, colleagues and students.
“I’m a Clinical Academic in a way, I’m a teacher, so it’s a part of my job. It’s one of
the reasons why I’m doing this job, so obviously it’s part of my professional
satisfaction.” [Interviewee 2]
“It’s my job actually. It’s what I have to do.” [Interviewee 3]
Perceived happiness and rewarding
“I find it interesting, I find it rewarding, you know helping people to learn, I do find it
quite rewarding.” [Interviewee 6]
“ I feel quite confident because I have the knowledge.” [Interviewee 4]
“No, I'm quite happy to share my knowledge with anyone.” [Interviewee 3]
Judgemental perception
“you’ve got to look at who’s asking and then decide whether it’s gonna be
appropriate to, what sort of level of information they need to know to manage the
case” [Interviewee 1]
“I think I would not share knowledge if I wasn’t a hundred percent sure on the thing
that I was trying to share. So I would make sure I’d check first before sharing such
knowledge.” [Interviewee 6]
Similarly dentist perceived sometimes it is necessary to gain understanding and
rationale of being asked, even though the information is easily available and they
have not tried to look it up themselves or followed simple instruction. This will lead
them to be reluctant to share knowledge.
55. 55
“Of course the other reason is sometimes what is the rationale for someone asking
for this information? To give an example sometimes people just want to scratch the
surface instead of following an organised educational pathway. For example, they
will ask you how to do this instead of trying to find out whyit should be done. In
some cases, some people want to be spoon-fed with an easy question to them, so
probably some maybe a little bit reluctant to share information.” [Interviewee 2]
Perceived political barriers:
“So when these politics and these guiding forces sometimes fail to maintain an
equilibrium and to be presented as fair and only specific people there are preferred to
do presentations, or specific scientific dogmas if you prefer. Then I may have a
problem….” [Interviewee 2]
Section 3 - Perceived elements of effective intervention smoking cessation
The third section was to know their opinion on effective and efficient smoking
cessation advice. These are the following elements, which dentists perceived would
be ideal to make smoking cessation effective in hospital practice:
Assessment of willingness will incline them to give effective smoking cessation
advice
Dentists’ felt to assess the willingness of patients to quit tobacco is important and
will incline them to provide them with smoking cessation service and advice.
Dentists also believe that if patients are willing to quit then this shows a sign of
motivation. Similarly, dentists also feel that patients initially show a willingness to
quit smoking but later they become unsure to quit or are not so certain.
56. 56
“And we would ask the question about quitting, if they have tried quitting or if they
are interested in quitting and based on that we might give the number or otherwise
we will just say whenever you are ready there is the number or we will be able to
point you in the right direction.” [Interviewee 3]
“If we see that the patient really would like to stop smoking and there are signs of
motivation but finds it very difficult for biological reasons to stop smoking, then
through the patient’s….” [Interviewee 2]
“Whether they have any interest in smoking cessation because a lot of people will say
I thought about quitting but I’ve just not got around to it.” [Interviewee 5]
Easy accessibility:
The research found most of the dentists believe there is no easy accessibility for
patients and even for dentists themselves. There should be joint clinics set up
together with the dentists in the hospital clinics so it is made easily accessible for
dentists, as well as well patients, to get smoking cessation advice there and then. It is
perceived that providing quick help there and then will be beneficial for saving time
and future visits for dentists, as well as patients, and believed this would lead to
more chances of accepting the cessation advice in the future. It will be more
effective if accessibility is taken into consideration and given more importance.
Dentists also perceived, from a language point of view, there should be easy access
both for patients and dentists to make an effective intervention. Dentists specified
language is a barrier for them to give effective assistance. The hospital is located
where there is a diverse community population of people, and where the population
speak different languages, this can be an occasional problem.
