Adults with learning disabilities may be at higher risk of poor oral health. The community outreach programme attached to Plymouth University Peninsula Dental School used established links with local agencies for this group to try out an intervention using service users as dental ambassadors. A programme was developed to meet the needs of the group and training in oral health key messages was provided along with support in presentation skills. Early evaluation shows promise in terms of feasibility, interest and improved self-care. Public health competencies being illustrated: Strategic leadership, communication, teaching and training, and collaborative working for health and oral health improvement

Potterton, R

Smith, W

Witton, R

Plymouth Electronic Archive and Research Library

Community Dental Health (2017) 34, 77–79 © BASCD 2017Received 2 November 2015; Accepted 9 June 2016 doi:10.1922/CDH_3885Witton03Communities in action: developing a dental ambassador training programme for adults with learning disabilityR. Witton1, R. Potterton1 and W. Smith2 1Plymouth University Schools of Medicine and Dentistry, The John Bull Building, Plymouth Science Park, Plymouth, PL6 8BU, UK; 2Community Engagement Team. Peninsula Dental Social Enterprise CIC, New Cooperage Building, Royal William Yard, Plymouth, PL1 3RP, UKAbstract: Adults with learning disabilities may be at higher risk of poor oral health.  The community outreach programme attached to Plymouth University Peninsula Dental School used established links with local agencies for this group to try out an intervention using service users as dental ambassadors.  A programme was developed to meet the needs of the group and training in oral health key messages was provided along with support in presentation skills.  Early evaluation shows promise in terms of feasibility, interest and improved self-care. Public health competencies being illustrated: Strategic leadership, communication, teaching and training, and collaborative working for health and oral health improvementKey words: learning disability, oral health, dental health education, peer-led oral health promotion, community programme, Plymouth, EnglandBackgroundPlymouth University Peninsula Dental School operates a new, modern dental curriculum grounded in a socio-cultural approach to learning.  Community outreach placements for dental undergraduate students form a core element of the dental curriculum and students undertake projects with target groups in local communities. A key feature of the education programme is that when student-led projects finish the community groups or organisations are still supported by a dedicated community engagement team to ensure that projects are sustainable and the relationships are maintained and grown for the benefit of both parties.This report reflects on the experience to date of the team in delivering a peer-led dental ambassador training programme for adults with learning disability and the next steps for the project.  Initial impetus for actionThere are estimated to be one million adults registered with a disability in the UK. However, this may represent only a small proportion known to disability services (Owens et al., 2010). This figure is expected to rise, posing a challenge for policy makers and service providers in meeting future need. Adults with a learning disability have poorer oral health with fewer teeth, less restorative treatment (Faulks et al., 2012) and more gum disease compared to the gen-eral population (DoH, 2007). Together with evidence of significant unmet need and problems in accessing care, it is difficult to see how these oral health inequalities can be addressed in the future without a more upstream approach Correspondence to: R. Witton, Plymouth University Schools of Medicine and Dentistry, The John Bull Building, Plymouth Science Park, Plymouth, PL6 8BU, UK. Email: robert.witton@plymouth.ac.uk with emphasis directed at partnership working between all agencies supporting these specific groups, and more community focused prevention. Poor oral health in this group has important conse-quences for individuals’ quality of life, dignity, self-esteem and social integration (BSDH, 2012).  The effects of poor oral health are more profound in adults with disability than for non-disabled people and can impact on their education, employment and social opportunities. It also results in increased costs to the health system and the indirect costs to wider society through parents and carers’ time. While local treatment services are available for UK adults with disabilities, and UK health policy protects the rights of disabled people so they can access the same services, and expect the same level of care as everyone else, there is a lack of specific resource for community-based oral health improvement (BSDH, 2012). Most of the requirements for protecting the oral health of people with disabilities can be met in primary care by appropriately trained dental teams and through community action, but both require effective health and social care policy and supportive environments to ensure individual oral healthcare needs are met. Dental disease in this group, as in others, is, in theory, preventable if appropriate evidence-based self-care habits are adopted. In Plymouth local authority area there are approximately 1,546 adults registered with a learning disability with an estimated five times that number unknown to disability services. There are a number of community-based voluntary, charitable and third sector organisations providing adult dis-ability services. One of these is the Highbury Trust, (Plym-outh People First) a charity established in 1956 to support people with learning disabilities. Staff and volunteers work Dental Public Health inAction78towards building service users’ confidence, skill, self-esteem and independence and to promote and encourage inclusion in the local community. Support is provided for clients to access mainstream community-based activities and services with an emphasis on sport, social, health, leisure, education and work opportunities. An effective partnership had been created with the Trust through successive student community projects, which have provided interventions to improve oral health awareness among the service users and staff. They also expose dental students to caring for people with learning disabilities, a group they are likely to encounter in practice, with the aim of promoting positive attitudes towards dis-ability and diversity early in their careers (Faulks et al., 2012). However, the time-limited nature of the student projects resulted in a desire by both parties to explore opportunities for more firmly embedding oral health improvement into the normal business of the Highbury Trust. It is well documented that many programmes fail due to lack of sustainability and the initial impact is lost when resources and/or funding are withdrawn. Creating something that could be community ‘owned’ and not rely in entirety on dental professionals for dissemination and delivery was vital.Solutions suggested In response a working group was established comprising staff from the Trust and the Dental School to see if inno-vative ways could be identified for creating a sustainable model for improving the oral health awareness and skills of service users. The idea of using peer-led education and training, a well-established practice in education and many fields, including healthcare, was considered by the group. Despite being an established model there is little information in the literature on its use in oral health with respect to learning disabilities, albeit there are studies to show adults with learning disability may be effective peer leaders (Bergstrom et al., 2013; Temple et al., 2011). The team therefore sought to develop a peer-led model among a select group of the adults with learning disability to see if it could be an effective option for delivering community-led prevention in this diverse population group.Actual outcomes to dateInitially six service users were trained over a six-week period to be ‘ambassadors’. The training package included key oral health messages along with other education and training to provide the participants with the skills and knowledge to be a dental ambassador for the organisa-tion, and to enable facilitated support for their peers using a cascade model (Table 1). This also included wider training in presenting skills, demonstration skills, working as a team and giving feedback. See Table 1 for the programme content. A key part of the package was a visit to a primary dental care clinic to ensure they were ‘expert’ by experience. All the training was delivered by the community engagement officer and a dental therapist with support from the Trust’s own staff. All oral health training was based on the evidence-based recommenda-tions contained in national guidance (PHE, 2014). During initial project planning the recruitment of ambas-sadors was considered to be a risk as it was not known if service users would be interested in such a responsi-bility. Volunteers were sought at a launch event, where dental school staff met with service users to promote and publicise the programme and to sign-up volunteers. Six potential ambassadors were enthusiastic to be involved. It is likely that ongoing engagement with dental students and the community engagement approach to partnership facilitated their motivation and interest. Minimal resources were required for the project. The Trust provided transport and staff to support the training programme. The Dental School provided the training, ongoing support and learning resources.   All six participants completed the training programme and have subsequently provided eight of their own train-ing sessions to peers. Five were internal and three to peers in external organisations. In total the ambassadors have trained 150 people in good oral health habits and signposting to dental services. A further outcome was the positive impact that par-ticipation had on each of the ambassador’s own self-care practices, confidence, self-esteem and own care needs, more independence and social inclusion. One ambassa-dor previously did not speak in public but now has the confidence to give presentations. Another, a 40-year-old, had not brushed his own teeth before relying on his parents but was now brushing independently and sharing his experiences with peers.  Increased knowledge and awareness of hidden sugars in food has resulted in one ambassador no longer consuming daily energy drinks, Week number and Activities1 Meeting everyone in the groupWhy you want to become a dental ambassadorUnderstanding some key oral health messages2 Teeth: what they look like and how they help us to eat foodToothbrushes: the best way to brush, when to change a toothbrushHow to care for people who do not have any teethHow a dental ambassador can support other people3 Visiting a dentist (visit to local clinic and familiarisation) Why people wear uniforms or protective clothingLooking at different items you will need when you become a dental ambassador; for example, tooth-brushes, toothpaste, brushing chart4 Working in groups to deliver a presentation to an invited audienceEach group focusing on a different aspect: brushing, toothpaste, diet, going to the dentistPracticing the presentationWorking as a team5 Delivering the presentation to an invited audienceBuilding skills and confidenceSupporting everyone in the teamListening to feedback6 Celebrating your successThinking back to the presentation; could it be improved?How you will use the training to help other peopleTable 1. Outline of the training programme79which in turn has improved his diabetes management. Throughout the training programme, staff had observed significant improvements in communication skills of the ambassadors and improved Makaton signing.  The second cohort of six ambassadors at the Trust are now being trained and a cascade model of delivery is being implemented, owned and led by the community. The next phase of the project will work with organisations that provide residential care to this population group.Challenges addressedIt was critical to design a programme that was realistic to the abilities and skills of the participants, accounting for their diverse needs. In addition to its educational value it was also important to design training that was interactive, activity based and fun to participate in. Careful planning was undertaken in collaboration with the Trust to ensure the content for ambassadors to use was suitable for their intended audiences. The Self Advocacy Project Officer from Highbury Trust advised on suitable session lengths to obtain maximum focus and concentration and the most suitable font and text size for learning resources. To optimise comfort and provide a safe learning environment it was agreed training would be undertaken in a teaching room at the Trust that was familiar to all participants. The evaluation was designed in conjunction with the staff at the Trust and made allowance for the participants’ abilities. A simple framework was developed to evaluate the different aspects of project delivery with an emphasis on the ambassadors’ opinions and experiences. A simple feedback tool evaluated the value and ‘pitch’ of the training programme and the method for gathering data was identical for each of the training sessions. A display board presented the question “Your thoughts…” with the response options: enjoyed it?; was ok?; was confused?  Participants were required to stick a picture of a toothbrush onto a board under the response of their choice. To reduce bias, Trust care staff not involved in the programme were there to support the ambassadors. All ratings were ‘enjoyable’ except two ‘OK’s in the first two weeks and one in the third. Overall the ambassadors found the programme was enjoyable and within their competencies. Focus groups and interviews were arranged with care staff for qualitative feedback. The feedback was extremely positive and revealed wider benefits beyond the objective of training ambassadors. For example:“a fantastic project I have learnt a lot myself”“this project has had far reaching impacts, the ambas-sadors have improved their confidence and skills far more than we could ever have imagined.” This included a greater understanding of participants’ abilities, more focus on promoting independence and self-care among service users, better information sharing within the organisation and with partner agencies, and more awareness among care staff, families and friends regarding the importance of oral health and regular dental visits.  An increase in dental knowledge and retention from baseline to week six was demonstrated using a nine ques-tion multiple choice quiz covering the learning topic areas of tooth brushing, use of toothpaste, dietary advice and how to access dental services. To celebrate their success a graduation event was arranged to an invited audience of external com-munity public and healthcare organisations.  This gave the ambassadors an opportunity to present what they had learnt and how they intended to share this information with their peers. They each received a certificate of course attendance. To capture qualitative feedback from the ambassadors more comprehensively a film was produced by the dental undergraduates capturing their experiences and reflections (Peninsula Dental, 2015).  Future implicationsNational bodies supporting adults with learning disability are interested in the model for integrating oral health into the support packages for adults with learning disability and discussions are taking place as to whether it can be stand-ardised and rolled out more widely. This would complement other health ambassador initiatives. Learning points• This model of peer-led education and training in oral health can be delivered by adults with learning disabil-ity. This is the first peer-led dental ambassador training programme we are aware of.• High levels of engagement and enjoyment from the ser-vice users and good acquisition of skills and knowledge were identified. Partnership working and a collaborative approach to working with communities were vital in creating a supportive environment, healthy public policies and a sustainable programme utilising this community asset approach.• Dental professionals have an important oral health ad-vocacy role in communities.References Bergstrom, H., Hagstromer, M., Hagberg, J. and Elinder, L.S. (2013): A multi-component universal intervention to improve diet and physical activity among adults with intellectual disabilities in community residences: a cluster randomised trial. Research in Developmental Disabilities 34, 3847-3857British Society for Disability and Oral Health (2012): Clinical guidelines and integrated care pathways for the oral health care of people with learning disabilities. London: Faculty of Dental Surgery, The Royal College of Surgeons of England.Department of Health (2007): Valuing people’s oral health. A good practice guide for improving the oral health of disabled children and adults. London: Department of HealthFaulks, D., Freedman, L., Thompson, S., Sagheri, D. and Dougall, A. (2012): The value of education in special care dentistry as a means of reducing inequalities in oral health. European Journal of Dental Education 16, 195-201.Owens, J., Dyer, T.A. and Mistry, K. (2010): People with learning disabilities and specialist services. British Dental Journal 208, 203-205.Peninsula Dental (2015): Flying the Flag for Dental Ambassador Training. Plymouth: Peninsula Dental Social Enterprise. http://www.peninsuladental.org.uk/in-the-community/flying-the-flag-for-dental-ambassador-training Public Health England (2014): Delivering better oral health: an evidence based toolkit for prevention. London: Public Health England.Temple, V.A. and Stanish, H.I. (2011): The feasibility of using a peer-guided model to enhance participation in community-based physical activity for youth with intellectual disability. Journal of Intellectual Disabilities 15, 209-217.

Communities in action: developing a dental ambassador training programme for adults with learning disability.

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Communities in action: developing a dental ambassador training programme for adults with learning disability.

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