A new primary dental care service compared with standard care for child and family to reduce the re-occurrence of childhood dental caries (Dental RECUR): study protocol for a randomised controlled trial

Background: In England and Scotland, dental extraction is the single highest cause of planned admission to the hospital for children under 11 years. Traditional dental services have had limited success in reducing this disease burden. Interventions based on motivational interviewing have been shown to impact positively dental health behaviours and could facilitate the prevention of re-occurrence of dental caries in this high-risk population. The objective of the study is to evaluate whether a new, dental nurse-led service, delivered using a brief negotiated interview based on motivational interviewing, is a more cost-effective service than treatment as usual, in reducing the re-occurrence of dental decay in young children with previous dental extractions. Methods/Design: This 2-year, two-arm, multicentre, randomised controlled trial will include 224 child participants, initially aged 5 to 7 years, who are scheduled to have one or more primary teeth extracted for dental caries under general anaesthesia (GA), relative analgesia (RA: inhalation sedation) or local anaesthesia (LA). The trial will be conducted in University Dental Hospitals, Secondary Care Centres or other providers of dental extraction services across the United Kingdom. The intervention will include a brief negotiated interview (based on the principles of motivational interviewing) delivered between enrolment and 6 weeks post-extraction, followed by directed prevention in primary dental care. Participants will be followed up for 2 years. The main outcome measure will be the dental caries experienced by 2 years post-enrolment at the level of dentine involvement on any tooth in either dentition, which had been caries-free at the baseline assessment. Discussion: The participants are a hard-to-reach group in which secondary prevention is a challenge. Lack of engagement with dental care makes the children and their families scheduled for extraction particularly difficult to recruit to an RCT. Variations in service delivery between sites have also added to the challenges in implementing the Dental RECUR protocol during the recruitment phase. Trial registration: ISRCTN24958829 (date of registration: 27 September 2013), Current protocol version: 5.0

Co-creating strategies and actions to tackle oral health-related stigma

Stigma is the greatest barrier faced by people experiencing social exclusion when accessing healthcare. Recent WHO framework for meaningful engagement of people living with noncommunicable diseases [1] builds on different types of evidence to acknowledge and empower people through participation in related health processes that address the systemic inequalities and inequities experienced around the globe. This framework sets up principles, enablers, and actions for the equitable inclusion of individuals in co-creating healthcare services and policy. Eliminating stigma is one of the core enablers for operationalizing this framework with one of the actions focused on reviewing and monitoring engagement work to prevent stigmatization and discrimination.Oral health-related stigma has been identified and defined as a unique health stigma that harms people and groups with oral health that differs from the prevailing cultural norms [2, 3, 4]. Health-related stigmas affect individuals by discouraging access to services, impairing adherence to treatment, diminishing mental health and social resources, and impacting quality of life. Social signalling through the media, social networks, advertising, and other sources gives rise to Western cultural ideals of straight white teeth as synonymous with health, wealth and social status (5). Even minor irregularities such as mild spacing or normal racial pigmentation were cause for concern in the PPI group who have shared their insights on this topic. However, despite the ubiquity of oral health-related stigma in society, there is a paucity of research in the dental literature that explores the concept of oral health stigma and no published literature that explores attempts to destigmatise differences in oral health [2].An increasing concern is stigma consciously and unconsciously perpetrated by dental health professionals and/or oral health researchers towards patients also highlighted in the paper by Doughty et al [2] and others [5]. This hands-on workshop will further expand on the ideas put forwards in this paper in an opening interactive segment that will use visual images to stimulate discussion and unpack clinicians’ and oral health researchers’ perspectives of oral health-related stigma. It will then use snapshot presentations by expert speakers to share patients’ perceptions of oral health related stigma. This will showcase research that has prioritised listening and learning from patients and people with lived experience of social exclusion across the globe. The group will then work together in the final segment of the session to identify and co-create strategies and actions to reduce professional and oral health perpetuated oral-health stigma. 3. Sponsorship : proposal submitted to Global Oral Health Inequalities Research Network (GOHIRN) and Behavioural, Epidemiologic and Health Services Research Group (BEHSR) 4.Learning Objectives4.1.Increase knowledge on oral health-related stigma. 4.2.Critical understand of the effects and experiences of oral health-related stigma of vulnerable groups.4.3.Critical reflect on strategies to tackle stigma in dental health services that prioritise involvement of patients and people with lived experience.5.ParticipantsCorresponding organizer: Andrea Rodriguez Organisers: Andrea Rodriguez (University of Dundee, UK); Janine Yazdi-Doughty (University of Liverpool, UK); Barry Gibson (University of Sheffield, UK); Vanessa Muirhead (Queen Mary University of London, UK)Chair Moderator : Vanessa Muirhead (VM)6.Speakers: Janine Yazdi-Doughty (JD); Barry Gibson (BG); Andrea Rodriguez (AR)Speaker’s titles for short presentations:-‘Conceptualizing Oral Health-related Stigma’ (JD)-‘Life after tooth loss: efforts to preserve a sense of self’ (BG)-‘Perspectives of vulnerable groups in Scotland and Brazil on the consequences of stigma’ (AR) The Hands on Workshop will involve four moments:Section ComponentsTiming Chair/speaker initialsWelcoming participantsIntroduction/background4 minutesVMBreakout workshop 1Group discussion: Practitioners’ understanding of oral health-related stigma 15 - 20 minutesWhole group Presenting consequences of stigma from the patient’s perspective (PPI members)5 minutesJDWhole group feedback 10 minutesVMPresentations Conceptualizing Oral Health-related Stigma7 minutesJDLife after tooth loss: efforts to preserve a sense of self7 minutesBGPerspectives of vulnerable groups in Scotland and Brazil on the consequences of stigma’7 minutes ARBreakout workshop 2Strategies/actions for engagement work to tackle stigma15 minutes Whole group Feedback from participants 10 minutesVM Opportunity for questions 5 minutesVM, AR, JDi.Welcoming participants (VM)ii.20 min breakout workshop group discussion comprised as follows:o1. ‘Practitioners’ understanding of oral health-related stigma’ and group discussion o2. Presenting the Consequences of stigma from the patient’s perspective followed by group feedback. iii.Speakers’ short presentations + Q&amp;A with participants (JD, BG, and AR)oConceptualizing Oral Health-related Stigma (JD)oLife after tooth loss: efforts to preserve a sense of self (BG)oPerspectives of vulnerable groups in Scotland and Brazil on the consequences of stigma’ (AR)iv.30 min breakout workshop group discussion 3. o20 mins discussion ‘Strategies/actions for engagement work to tackle stigma’ o10 min group feedback. TOTAL Time: 90 minutesKey words : Stigma, Inclusion Oral Health, Empowerment, Patient Engagement. References1.World Health Organization (2023). WHO framework for meaningful engagement of people living with noncommunicable diseases, and mental health and neurological conditions. Global Coordination Mechanism Secretariat for NCDs, 10 May 2023, 73p. https://www.who.int/publications/i/item/9789240073074 2.Doughty, J., M. E. Macdonald, V. Muirhead and R. Freeman (2023). "Oral health-related stigma: Describing and defining a ubiquitous phenomenon." Community Dentistry and Oral Epidemiology n/a(n/a).3.Moore D, Keat R. Does dental appearance impact on employability in adults? A scoping review of quantitative and qualitative evi-dence. Br Dent J. 2020.4.Seehra J, Newton JT, DiBiase AT. Bullying in schoolchildren – its relationship to dental appearance and psychosocial implications: an update for GDPs. Br Dent J. 2011;210:411- 4155.Yuvaraj, A., V. S. Mahendra, V. Chakrapani, E. Yunihastuti, A. J. Santella, A. Ranauta and J. Doughty (2020). "HIV and stigma in the healthcare setting." Oral Diseases 26: 103-111.<br/

Co-creating strategies and actions to tackle oral health-related stigma

Stigma is the greatest barrier faced by people experiencing social exclusion when accessing healthcare. Recent WHO framework for meaningful engagement of people living with noncommunicable diseases [1] builds on different types of evidence to acknowledge and empower people through participation in related health processes that address the systemic inequalities and inequities experienced around the globe. This framework sets up principles, enablers, and actions for the equitable inclusion of individuals in co-creating healthcare services and policy. Eliminating stigma is one of the core enablers for operationalizing this framework with one of the actions focused on reviewing and monitoring engagement work to prevent stigmatization and discrimination.Oral health-related stigma has been identified and defined as a unique health stigma that harms people and groups with oral health that differs from the prevailing cultural norms [2, 3, 4]. Health-related stigmas affect individuals by discouraging access to services, impairing adherence to treatment, diminishing mental health and social resources, and impacting quality of life. Social signalling through the media, social networks, advertising, and other sources gives rise to Western cultural ideals of straight white teeth as synonymous with health, wealth and social status (5). Even minor irregularities such as mild spacing or normal racial pigmentation were cause for concern in the PPI group who have shared their insights on this topic. However, despite the ubiquity of oral health-related stigma in society, there is a paucity of research in the dental literature that explores the concept of oral health stigma and no published literature that explores attempts to destigmatise differences in oral health [2].An increasing concern is stigma consciously and unconsciously perpetrated by dental health professionals and/or oral health researchers towards patients also highlighted in the paper by Doughty et al [2] and others [5]. This hands-on workshop will further expand on the ideas put forwards in this paper in an opening interactive segment that will use visual images to stimulate discussion and unpack clinicians’ and oral health researchers’ perspectives of oral health-related stigma. It will then use snapshot presentations by expert speakers to share patients’ perceptions of oral health related stigma. This will showcase research that has prioritised listening and learning from patients and people with lived experience of social exclusion across the globe. The group will then work together in the final segment of the session to identify and co-create strategies and actions to reduce professional and oral health perpetuated oral-health stigma. 3. Sponsorship : proposal submitted to Global Oral Health Inequalities Research Network (GOHIRN) and Behavioural, Epidemiologic and Health Services Research Group (BEHSR) 4.Learning Objectives4.1.Increase knowledge on oral health-related stigma. 4.2.Critical understand of the effects and experiences of oral health-related stigma of vulnerable groups.4.3.Critical reflect on strategies to tackle stigma in dental health services that prioritise involvement of patients and people with lived experience.5.ParticipantsCorresponding organizer: Andrea Rodriguez Organisers: Andrea Rodriguez (University of Dundee, UK); Janine Yazdi-Doughty (University of Liverpool, UK); Barry Gibson (University of Sheffield, UK); Vanessa Muirhead (Queen Mary University of London, UK)Chair Moderator : Vanessa Muirhead (VM)6.Speakers: Janine Yazdi-Doughty (JD); Barry Gibson (BG); Andrea Rodriguez (AR)Speaker’s titles for short presentations:-‘Conceptualizing Oral Health-related Stigma’ (JD)-‘Life after tooth loss: efforts to preserve a sense of self’ (BG)-‘Perspectives of vulnerable groups in Scotland and Brazil on the consequences of stigma’ (AR) The Hands on Workshop will involve four moments:Section ComponentsTiming Chair/speaker initialsWelcoming participantsIntroduction/background4 minutesVMBreakout workshop 1Group discussion: Practitioners’ understanding of oral health-related stigma 15 - 20 minutesWhole group Presenting consequences of stigma from the patient’s perspective (PPI members)5 minutesJDWhole group feedback 10 minutesVMPresentations Conceptualizing Oral Health-related Stigma7 minutesJDLife after tooth loss: efforts to preserve a sense of self7 minutesBGPerspectives of vulnerable groups in Scotland and Brazil on the consequences of stigma’7 minutes ARBreakout workshop 2Strategies/actions for engagement work to tackle stigma15 minutes Whole group Feedback from participants 10 minutesVM Opportunity for questions 5 minutesVM, AR, JDi.Welcoming participants (VM)ii.20 min breakout workshop group discussion comprised as follows:o1. ‘Practitioners’ understanding of oral health-related stigma’ and group discussion o2. Presenting the Consequences of stigma from the patient’s perspective followed by group feedback. iii.Speakers’ short presentations + Q&amp;A with participants (JD, BG, and AR)oConceptualizing Oral Health-related Stigma (JD)oLife after tooth loss: efforts to preserve a sense of self (BG)oPerspectives of vulnerable groups in Scotland and Brazil on the consequences of stigma’ (AR)iv.30 min breakout workshop group discussion 3. o20 mins discussion ‘Strategies/actions for engagement work to tackle stigma’ o10 min group feedback. TOTAL Time: 90 minutesKey words : Stigma, Inclusion Oral Health, Empowerment, Patient Engagement. References1.World Health Organization (2023). WHO framework for meaningful engagement of people living with noncommunicable diseases, and mental health and neurological conditions. Global Coordination Mechanism Secretariat for NCDs, 10 May 2023, 73p. https://www.who.int/publications/i/item/9789240073074 2.Doughty, J., M. E. Macdonald, V. Muirhead and R. Freeman (2023). "Oral health-related stigma: Describing and defining a ubiquitous phenomenon." Community Dentistry and Oral Epidemiology n/a(n/a).3.Moore D, Keat R. Does dental appearance impact on employability in adults? A scoping review of quantitative and qualitative evi-dence. Br Dent J. 2020.4.Seehra J, Newton JT, DiBiase AT. Bullying in schoolchildren – its relationship to dental appearance and psychosocial implications: an update for GDPs. Br Dent J. 2011;210:411- 4155.Yuvaraj, A., V. S. Mahendra, V. Chakrapani, E. Yunihastuti, A. J. Santella, A. Ranauta and J. Doughty (2020). "HIV and stigma in the healthcare setting." Oral Diseases 26: 103-111.<br/

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research