Intelligent policy making? Key actors' perspectives on the development and implementation of a national early years' initiative

Increased political enthusiasm for evidence-based policy and action has re-ignited interest in the use of evidence within political and practitioner networks. Theories of evidence-based policy making and practice are being re-considered in an attempt to better understand the processes through which knowledge translation occurs. Understanding how policy develops, and practice results, has the potential to facilitate effective evidence use. Further knowledge of the factors which shape healthcare delivery and their influence in different contexts is needed.<p></p> This paper explores the processes involved in the development of a complex intervention in Scotland's National Health Service (NHS). It uses a national oral health programme for children (Childsmile) as a case study, drawing upon key actors' perceptions of the influence of different drivers (research evidence, practitioner knowledge and values, policy, and political and local context) to programme development. Framework analysis is used to analyse stakeholder accounts from in-depth interviews. Documentary review is also undertaken.<p></p> Findings suggest that Childsmile can be described as an ‘evidence-informed’ intervention, blending available research evidence with knowledge from practitioner experience and continual learning through evaluation, to plan delivery. The importance of context was underscored, in terms of the need to align with prevailing political ideology and in the facilitative strength of networks within the relatively small public health community in Scotland. Respondents' perceptions support several existing theoretical models of translation, however no single theory offered a comprehensive framework covering all aspects of the complex processes reported. Childsmile's use of best available evidence and on-going contribution to knowledge suggest that the programme is an example of intelligent policy making with international relevance.<p></p&gt

Using a realist approach to evaluate smoking cessation interventions targeting pregnant women and young people

Background This paper describes a study protocol designed to evaluate a programme of smoking cessation interventions targeting pregnant women and young people living in urban and rural locations in Northeast Scotland. The study design was developed on so-called 'realist' evaluation principles, which are concerned with the implementation of interventions as well as their outcomes. Methods/design A two-phased study was designed based on the Theory of Change (TOC) using mixed methods to assess both process and outcome factors. The study was designed with input from the relevant stakeholders. The mixed-methods approach consists of semi-structured interviews with planners, service providers, service users and non-users. These qualitative interviews will be analysed using a thematic framework approach. The quantitative element of the study will include the analysis of routinely collected data and specific project monitoring data, such as data on service engagement, service use, quit rates and changes in smoking status. Discussion The process of involving key stakeholders was conducted using logic modelling and TOC tools. Engaging stakeholders, including those responsible for funding, developing and delivering, and those intended to benefit from interventions aimed at them, in their evaluation design, are considered by many to increase the validity and rigour of the subsequent evidence generated. This study is intended to determine not only the components and processes, but also the possible effectiveness of this set of health interventions, and contribute to the evidence base about smoking cessation interventions aimed at priority groups in Scotland. It is also anticipated that this study will contribute to the ongoing debate about the role and challenges of 'realist' evaluation approaches in general, and the utility of logic modelling and TOC approaches in particular, for evaluation of complex health interventions

Patient-, organization-, and system-level barriers and facilitators to preventive oral health care:A convergent mixed-methods study in primary dental care

Background: Dental caries is the most common chronic disease of adult and childhood, a largely preventable yet widespread, costly public health problem. This study identified patient-, organization-, and system-level factors influencing routine delivery of recommended care for prevention and management of caries in primary dental care. Methods: A convergent mixed-methods design assessed six guidance-recommended behaviours to prevent and manage caries (recording risk, risk-based recall intervals, applying fluoride varnish, placing preventive fissure sealants, demonstrating oral health maintenance, taking dental x-rays). A diagnostic questionnaire assessing current practice, beliefs, and practice characteristics was sent to a random sample of 651 dentists in National Health Service (NHS) Scotland. Eight in-depth case studies comprising observation of routine dental visits and dental team member interviews were conducted. Patient feedback was collected from adult patients with recent checkups at case study practices. Key informant interviews were conducted with decision makers in policy, funding, education, and regulation. The Theoretical Domains Framework within the Behaviour Change Wheel was used to identify and describe patient-, organization-, and system-level barriers and facilitators to care. Findings were merged into a matrix describing theoretical domains salient to each behaviour. The matrix and Behaviour Change Wheel were used to prioritize behaviours for change and plan relevant intervention strategies. Results: Theoretical domains associated with best practice were identified from the questionnaire (N-196), case studies (N = 8 practices, 29 interviews), and patient feedback (N = 19). Using the study matrix, key stakeholders identified priority behaviours (use of preventive fissure sealants among 6–12-year-olds) and strategies (audit and feedback, patient informational campaign) to improve guidance implementation. Proposed strategies were assessed as appropriate for immediate implementation and suitable for development with remaining behaviours. Conclusions: Specific, theoretically based, testable interventions to improve caries prevention and management were coproduced by patient-, practice-, and policy-level stakeholders. Findings emphasize duality of behavioural determinants as barriers and facilitators, patient influence on preventive care delivery, and benefits of integrating multi-level interests when planning interventions in a dynamic, resource-constrained environment. Interventions identified in this study are actively being used to support ongoing implementation initiatives including guidance, professional development, and oral health promotion

CATCH: development of a home-based midwifery intervention to support young pregnant smokers to quit

Objective to develop, implement and evaluate a supportive midwifery intervention, Community Action on Tobacco for Children's Health (CATCH), to help young pregnant smokers to quit. Design action research project funded from April 2002 to June 2005. Setting and participants CATCH was based in a single hospital maternity unit in the West of Scotland and targeted a deprived population of pregnant smokers aged 25 years and under. Outreach work was undertaken in the local community and cessation support was provided in women's own homes. Intervention CATCH aimed to meet the particular needs of young pregnant women through a tailored, non-judgmental approach. The service was distinctive as it employed a holistic approach to smoking cessation which focused not only on individual choices and motivations, but on the wider life circumstances that may preclude behaviour change. Measures internal and external teams collaborated to ensure a comprehensive evaluation, gathering of both process and outcome data. Outcomes (including self-reported and carbon monoxide validated quit status) were assessed by quantitative surveys undertaken at enrolment to the service and at 3- and 12-month follow-up. All those lost to follow-up were assumed to still be smoking. Participants’ views of the service were gathered independently by an external evaluation team, and a detailed qualitative case study, capturing ongoing learning, was undertaken. Data were collected from participants who joined the project over a 16-month period (November 2002–February 2004). Findings the study demonstrated a feasible approach to engaging young pregnant smokers to help them quit. Obstetricians and midwives were willing to refer to a service based in their maternity unit run by a specially trained midwife, and users reported a positive experience of the service. Of 152 eligible clients referred within the 16-month period, 79 (52%) joined CATCH. Of those who joined, 18 (22.8%) were self-reported non-smokers at 3 months, of whom 16 (20.3%) were validated as non-smokers using carbon monoxide monitoring. Thirteen (16.5%) clients reported being smoke free at 12 months, of whom 10 (12.7%) were validated as non-smokers at 12 months. Implications for practice CATCH suggests that close partnership with the multi-disciplinary maternity team and integration into the maternity system is invaluable for smoking cessation services targeting pregnant women. It points to the benefits of the service being delivered by a trained midwife in clients’ own homes. Flexibility and a non-judgmental approach are essential to engagement. Attention to the context and wider circumstances of clients’ lives and involving friends and family enables clients to focus on their own smoking

Fissure seal or fluoride varnish?

Data sources: Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, the US National Institutes of Health Trials Register and the World Health Organization (WHO) Clinical Trials Registry Platform Study selection: Randomised controlled trials (RCTs) with at least 12 months follow-up, in which fissure sealants, or fissure sealants together with fluoride varnishes, were compared with fluoride varnishes alone for preventing caries in occlusal surfaces of permanent teeth of children and adolescents. Data extraction and synthesis: Two reviewers independently screened search results, extracted data and assessed risk of bias of included studies. Studies were grouped and analysed on the basis of sealant material type (resin-based sealant and glass ionomer-based sealant, glass ionomer and resin-modified glass ionomer) and different follow-up periods. Odds ratio were calculated for caries or no caries on occlusal surfaces of permanent molar teeth. Mean differences were calculated for continuous outcomes and data. Evidence quality was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. Results: Eight RCTs involving a total of 1747 children aged five to ten years of age were included. Three trials compared resin-based fissure sealant versus fluoride varnish. Results from two studies (358 children) after two years were combined. Sealants prevented more caries, pooled odds ratio (OR) = 0.69 (95%CI; 0.50 to 0.94). One trial with follow-up at four and nine years found that the caries-preventive benefit for sealants was maintained, with 26% of sealed teeth and 55.8% of varnished teeth having developed caries at nine years. Evidence for glass-ionomer sealants was of low quality. One split-mouth trial analysing 92 children at two-year follow-up found a significant difference in favour of resin-based fissure sealant together with fluoride varnish compared with fluoride varnish only (OR 0.30, 95% CI 0.17 to 0.55). The evidence was assessed as low quality. Three studies assessed but did not report any adverse effects. Conclusions: Currently, scarce and clinically diverse data are available on the comparison of sealants and fluoride varnish applications; therefore it is not possible to draw clear conclusions about possible differences in effectiveness for preventing or controlling dental caries on occlusal surfaces of permanent molars. The conclusions of this updated review remain the same as those of the last update (in 2010). We found some low quality evidence suggesting the superiority of resin-based fissure sealants over fluoride varnish applications for preventing occlusal caries in permanent molars, and other low-quality evidence for benefits of resin-based sealant and fluoride varnish over fluoride varnish alone. Regarding glass ionomer sealant versus fluoride varnish comparisons, we assessed the quality of the evidence as very low and could draw no conclusions

Childsmile:the national child oral health improvement programme in Scotland. Part 2: monitoring and delivery

This paper, the second of two reviewing the Childsmile programme, describes monitoring arrangements and summarises monitoring data covering the period 2006-2009. By mid-2009, around 28,000 infants in deprived areas of the West of Scotland had been given caries risk assessments by Health Visitors; 14,000 were enrolled with 142 Childsmile practices or clinics; and over 10,000 had begun making practice visits. The Childsmile Nursery and School programmes had provided 28,000 fluoride varnish treatments to nursery and primary school children. Daily supervised toothbrushing and distribution of oral health packs covered almost 100% of nursery schools and P1 and P2 classes in primary schools in the most deprived areas of Scotland. Feedback of monitoring information to programme managers is used to identify any variation or shortfall in programme coverage and delivery