Evaluation of a community dental service for homeless and 'hard to reach' people

Engagement and access to support for oral health, substance use, smoking and diet by people with severe and multiple disadvantage: A qualitative study

BACKGROUND

Severe and multiple disadvantage (SMD) is the combined effect of experiencing homelessness, substance use and repeat offending. People experiencing SMD have high burden of physical and mental health issues. Oral health is one of the most common health problems in people experiencing SMD which interacts with substance use, smoking, and unhealthy diet to create a cycle of harm and disadvantage. However, burden of these conditions is worsened by poor access to health services. This study aimed to identify pathways to improve engagement and access to health interventions, for oral health, substance and alcohol use, smoking and diet.

METHODS

Using a qualitative methodology, interviews/focus groups were conducted with: (a) people experiencing SMD in Newcastle Upon Tyne/Gateshead; and (b) frontline staff, volunteer workers, policy makers and commissioners from London, Plymouth and Newcastle Upon Tyne/Gateshead. Data was analysed iteratively using thematic analysis.

RESULTS

Twenty-eight people experiencing SMD (age range: 27-65 years; 21% females) and 78 service providers (age range: 28-72 years, 63% females) were interviewed or included in focus groups. Data were organized into two overarching factors: barriers to accessing health interventions and improving access to health interventions. Barriers included: wider disadvantages of people experiencing SMD leading to low priority for support for oral health and associated health behaviours, psychosocial factors, waiting period and physical space. Factors that improved access to interventions included: positive relationships between service provider and person experiencing SMD, including a support worker, location of services and outreach services.

CONCLUSIONS

The findings suggest the need for flexibility in offering services for oral health and related health behaviours for people experiencing SMD. Training health care providers and co-developing services with people with lived experience of SMD can help prevent (re)stigmatization. Systems-based approach to address factors on an environmental, organizational, inter-personal and individual level is needed. The results from this study could be extrapolated to other health intervention such as vaccinations and sexual and reproductive health.

A stakeholder co-design approach to designing a dental service for adults experiencing homelessness

Introduction

The homeless population faces a "cliff edge of inequality" when trying to access essential dental services. There are several additional barriers to accessing dental care in comparison to the general population and the heterogeneous nature of patients presents a significant challenge when designing dental services to meet their needs. Following the Smile4Life report in 2009, there is limited up-to-date and population-specific evidence available for the optimal model of service delivery.

Aim

This study aimed to co-design principles for a prospective dental service for adults experiencing homelessness.

Methods

A qualitative methodology was used to incorporate experts-by-experience into elements of co-designing a dental service for adults experiencing homelessness. The study combined elements of an experienced-based co-design framework for healthcare innovation with community-based participatory research. Focus groups with people experiencing homelessness and healthcare practitioners were conducted to identify principles for any prospective dental service, as well as several barriers and enablers to establishing a homeless dental service. The findings were transcribed and analysed using thematic analysis on Nvivo software.

Results

From the qualitative analysis five key themes emerged: (1) Impact and expectations of oral health while experiencing homelessness, (2) Barriers to accessing dental care; (3) Practitioner's views about homelessness and access to care; (4) Barriers to designing a homeless service and (5) Enablers for co-designing a new model of dental care delivery for the homeless population.Five key principles for a new model of homeless dental service were identified: (i) Services designed to address the needs of patients; (ii) Services delivered in a safe and welcoming environment (iii) Training and consistency of staff; (iv) Focus on dental education (v) Developing peer mentoring and peer support.

Conclusion

While the barriers to accessing dental care while homeless are well established and understood by healthcare practitioners, more work is required to gain consensus on the most effective way to deliver an innovative a sustainable dental service for patients experiencing homelessness. Previous negative experiences, lack of readily available information on services and barriers to access in the current system could be addressed by developing peer mentors within the homeless community, empowering individuals to share their knowledge and skills to support others in improving their oral health.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Models of dental care for people experiencing homelessness in the UK: a scoping review of the literature

Background People who experience homelessness have poor oral health and face barriers to accessing care. Recommendations have been outlined for health services to address their needs, termed 'inclusion health'. The Smile4Life report recommended three 'tiers' of dental service: emergency, ad hoc and routine care. Other medical services have developed into different models of care, for example mainstream practices with enhanced services for people who experience homelessness. There is little understanding of how inclusion health recommendations have been implemented across dental settings.Aims To describe and compare dental services that exist for people who experience homelessness in the UK.Methods Two Medline searches were performed in October 2020 to assess the models of dental care for people who experience homelessness in the UK.Results Nine dental services in the UK were identified who treated people who experience homelessness. Most did not explore definitions of homelessness. There were a mixture of models, including using blended approaches, such as different sites and appointment types, to flex to the needs of their population.Conclusion Many services that are dedicated to treat this population are based in the community dental services which allows for flexible models of care due to sporadic patient attendance, high treatment requirements and complex needs. More research is required to determine how other settings can accommodate these patients, as well as understanding how more rural populations access dental care.

Evaluation of Mobile and Community Dental Service Use among People Experiencing Homelessness

The aim of the study was to evaluate the patterns of mobile and community dental service use among people experiencing homelessness in Bratislava, Slovakia. Data from medical records of homeless people who visited the mobile and community dental clinic from November 2012 to July 2018 have been retrospectively reviewed. The experience of providing dental services has been reported from the perspective of the dental care provider. Descriptive statistics were used for data analysis. In total, 319 patients (75.5% men) attended the clinic. Extraction of a tooth was the main dental treatment indicated in more than 80% (n = 276) of patients. A total of 363 teeth were extracted with an average number of 1.6 extracted teeth per patient. The main indications for extraction were dental caries and its sequelae (83.7%) and periodontal disease (15.2%). The patients with the need for prosthetic and conservative treatment were referred to the clinics at University Hospital; however, only 19 patients received the treatment. The barriers to accessing dental care were cost, logistic problems and individual psychological factors. We found that people experiencing homelessness in Slovakia have high needs and demands of emergency dental care and many systemic and individual barriers prevent them from accessing care. Community-based dental services are important for improving access to dental care and reducing oral health inequities.

Community-centred oral healthcare for adults experiencing homelessness in Australia: Perceptions and experiences of key stakeholders

The objective of the study was to identify whether creating a responsive, respectful and trustworthy environment that provides free dental care for clients who are homeless using volunteer dental professionals was effective in meeting their oral health needs in Fremantle, Western Australia. Qualitative research conducted between October 2018 and August 2019 was guided by a social constructivist paradigm to gather and analyse data. Semi-structured interviews were conducted with adults experiencing homelessness accessing a community dental clinic and health providers and other stakeholders involved in its establishment, management and service delivery. An inductive approach to analysis was used to organise themes under the categories of 'establishing the oral health clinic' (OHC) and 'responses to the implementation of the clinic' Thirty-nine semi-structured interviews were conducted across eight participant groups: clients, executive management, the oral health clinical reference group, volunteer dentists, employed staff, nursing students, volunteer staff and other stakeholders. Key findings across all groups included positive responses to the establishment and implementation of the OHC, the quality of care and the safe and respectful environment in which services were delivered. Challenges related to sustainability include uncertainty around ongoing funding and recruitment of dental professionals. Whilst volunteer dental services fill a gap in meeting the complex needs of this population group, mainstream services must consider and address issues of equity in this context. Findings can be used to guide this process that includes creating environments of respect and trust where adults who are homeless or at risk of homelessness feel safe, welcomed and more likely to return to the service.

Access to healthcare for people experiencing homelessness in the UK and Ireland: a scoping review

BACKGROUND

People experiencing homelessness (PEH) have poorer physical and mental health than the general population. They are also more likely to have less access to healthcare. These processes of access can be better understood using Levesque's access framework which addresses both supply (service provision) and demand (user abilities).

METHODS

Following the Joanna Briggs Institute (JBI) guidelines, electronic peer-reviewed databases were searched in February 2022 for studies published since 2000 related to access to healthcare for PEH ages 16 and older in the United Kingdom (UK) and Ireland. Retrieved articles were screened and those eligible were selected for data extraction. Qualitative and quantitative studies were included.

RESULTS

Fifty-six papers out of 538 identified were selected and aliased. Six main themes were identified: staff education, flexibility of systems, service coordination, patient preparedness, complex health needs and holistic care. These relate to the Levesque access framework.

CONCLUSIONS

Improving access to healthcare for PEH requires changes to how services are provided and how service-user abilities are supported.

Unmet dental care needs of homeless adults in South Korea: Findings from a national survey

This study identifies the key factors underlying the unmet dental care needs of South Korean homeless adults that obstructed their dental service access. We analysed data from 551 Korea Homeless Survey respondents (17 years and older) who reported having an oral disease in the previous 12 months. We conducted multiple logistic regression analyses to examine the factors associated with homeless individuals' unmet dental care needs, using weights to make the data nationally representative. Approximately 43% of the homeless people reported having unmet dental care needs. Housing type (living in the street) was significantly associated with an increased odds ratio of unmet dental care needs. However, when social protection programs (housing benefits and Medical Aid [MA]) were included in the model, the statistical significance of the housing type disappeared. Homeless MA recipients were less likely to have unmet needs than those not covered by MA. On the other hand, homeless people who received housing benefits were more likely to receive dental care than people who do not receive these benefits. Consequently, policy makers should develop social protection programs influencing homeless individuals' access to dental care and ensure the sustainable implementation of integrated community-based dental services for homeless adults.

A survey of dental services in England providing targeted care for people experiencing social exclusion: mapping and dimensions of access

Introduction Poor oral health and barriers to accessing dental services are common among people experiencing social exclusion. This population experience a disproportionate and inequitable burden of oral disease. A small number of dental services have published models of care that target this population, but no national surveys have been conducted.Aims This study aims to identify what types of services are providing dental and oral healthcare for people experiencing social exclusion in England and the models of delivery adopted by these services.Methods A snowballing sampling strategy was used to identify services that provide targeted for adults experiencing social exclusion. The study used a survey to collect data about the location, service models and barriers and enablers of these services.Results In total, 74 responses from different services met the inclusion criteria for the study. Seventy one were included in the mapping exercise and 53 provided free-text comments that contributed to an understanding of barriers and enablers of services.Discussion Most services operated to meet the needs of the mainstream population and described inflexibilities in their service design models as barriers to providing care for socially excluded groups.Conclusion Limitations of current models of service delivery create frustrations for providers and people experiencing social exclusion. Creative commissioning and organisational flexibility are key to facilitating adaptable services.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an ‘evidence for practice’ briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

Dental Pain in Homeless Adults in Porto Alegre, Brazil

Objective

To evaluate the association of dental pain with time living on the street in a sample of homeless people in the city of Porto Alegre, Brazil.

Methods

A cross-sectional study was carried out with homeless people who accessed social services in 2017. A questionnaire was administered covering socioeconomic variables and including questions about general health, use of tobacco/alcohol/drugs, use of dental services and history of dental pain. The decayed, missing, and filled teeth (DMFT) index was calculated in an oral examination. The association between socioeconomic characteristics, health status, time of homelessness and dental pain was evaluated using chi-square, t-, and Mann-Whitney tests.

Results

A total sample of 214 homeless people was surveyed. Most were male (76.2%), had a low level of education (67.6%) and experienced many episodes of dental pain during life (91.0%). The last episode of pain was moderate or intense (79.7%) and do-it-yourself measures for pain relief were preferred (62.3%). Individuals who were homeless for longer than 1 year had more dental pain in the past (P < 0.001), more frequency of a recent episode of dental pain (P = 0.03), and sought a dentist or healthcare service to relieve pain less frequently (P = 0.03).

Conclusions

Dental pain is frequent in the context of homelessness and does not necessarily result in seeking dental services, even where there is universal oral health care.

Oral health perceptions and client satisfaction among homeless adults attending a community-centred dental clinic

BACKGROUND

The homeless face significant barriers accessing dental care. Community-centred dental clinics might provide more accessible care to this group. This descriptive epidemiological study aimed to measure oral health perceptions and client satisfaction among homeless and similarly disadvantaged adults receiving community-centred dental care.

METHODS

A sample of 79 clients attending St Patrick's Oral Health Clinic completed Locker's Global Oral Health Item, the Oral Health Impact Profile 14 and the Client Satisfaction Questionnaire 4.

RESULTS

High levels of satisfaction with St Patrick's Oral Health Clinic were based on positive staff attitudes, low cost, time effectiveness and staff sensitivity to anxiety. Ideas for improvement included shorter treatment waiting lists, offering additional treatment types and better communication and advertisement of the service. Compared to the general Australian population, participants reported a relatively poor self-perception of oral health and a high prevalence and severity of oral health impacts.

CONCLUSIONS

Participants experienced significant personal and social impacts due to their oral conditions. High levels of client satisfaction reflect the value of community-centred dental care for this group. An understanding of factors influencing satisfaction might be useful for similar services providing oral care to homeless and similarly disadvantaged groups.

Strategies to improve oral health behaviours and dental access for people experiencing homelessness: a qualitative study

Objectives The present study aimed to identify strategies to improve oral health behaviours as well as access to and provision of dental care for people experiencing homelessness.Method We conducted focus groups with people living in a residential homeless centre and semi-structured interviews with other stakeholders working with or supporting people experiencing homelessness. Following an inductive approach, thematic analysis was used to synthesise the findings on NVivo software.Results Participants included 11 British males experiencing homelessness and 12 other stakeholders from various professional backgrounds. Themes identified included: awareness and empowerment; supportive environment and dental health system; flexible and holistic care; outreach and community engagement; collaboration with other health and social services; and effective communication.Conclusions Efforts to improve oral health among people experiencing homelessness via improved oral health habits and engagement with services need to be directed at both the recipients of care and the healthcare teams. Well-powered empirical studies are needed to evaluate whether the strategies identified can improve engagement and care provision for this population.

Evaluation of a community dental clinic providing care to people experiencing homelessness: A mixed methods approach

Background

People who experience homelessness have higher dental treatment needs compared to the general population. However, their utilization of dental services and levels of treatment completion are low. Peninsula Dental Social Enterprise, a not‐for‐profit organization in the United Kingdom, established a community dental clinic to improve access to dental care for this population.

Objectives

To evaluate the impact and acceptability of the community dental service for patients and examine the barriers and enablers to using and providing the service.

Methods

The evaluation included a retrospective assessment of anonymous patient data and thematic analysis of semi‐structured interviews with patients, support staff and service providers. The interviews were thematically analysed. A cost analysis of the dental service was also conducted.

Results

By 18 February 2020, 89 patients had attended the clinic. These included 62 males (70%) and 27 females (30%), aged 38.43 years on average (SD ± 11.07). Of these, 42 (47%) patients have completed their treatment, 23 (26%) are in active treatment and 24 (27%) left treatment. In total, 684 appointments (541.5 hours clinical time) were given. Of these, 82% (562) of appointments were attended (452.5 hours clinical time). The 22 interviews that were conducted identified flexibility, close collaboration with support services and health‐care team attitudes as key factors influencing service utilization and continuity of care.

Conclusions

This study provides details of a highly acceptable and accessible dental care model for people experiencing homelessness, with recommendations at research, practice and commissioning levels.

Differences in Utilization of Medical and Dental Services among Homeless People in South Korea

(1) Background: Homelessness contributes to both needs for care and barriers to access. This study aimed to explore the utilization of medical or dental services using Andersen's model for a vulnerable population of homeless in South Korea. (2) Methods: The data were applied from the first national survey for homeless people in South Korea, 2016. Totally 2032 persons participated in the interview survey. This study team requested the raw data through the public portal and analyzed them. (3) Results: The participants who were homeless for more than ten years, staying in small rooming house or shelter, non-employed, earning less than 500,000 won per month, and having a medical condition showed a significantly higher chance of using Medicaid. The use of outreach programs had a significant relationship with gender, duration of homelessness, and monthly income. Among dental patients, the homeless who did not consume alcohol, stayed in a shelter, and were employed had higher chances of using dental service. (4) Conclusions: Medicaid service was strongly related to enabling factors but outreach programs with predisposing factors. Dental service showed strong relationships with the enabling domain, but the pattern was opposite: the jobless had less chance to avail it. The policymakers need to consider these domains of service utilization to provide equitable access to healthcare services.

Inclusion oral health: Advancing a theoretical framework for policy, research and practice

In response to headlines about the oral health of persons experiencing social exclusion resonating in high-income countries, and research demonstrating the need for urgent action, a symposium entitled 'International Perspectives on Socially Inclusive Dentistry: A Call to Action' was organized for the IADR International Meeting of 2018. The aim of the symposium was to initiate an international dialogue on barriers to care, multidisciplinary action and examples of best practice for service delivery for people experiencing social exclusion; in other words, to develop the idea of inclusion oral health. Through our international exchange, what emerged was an awareness of a lack of professional consensus: What exactly is inclusion oral health? A theoretical framework to push forward the policy, research and practice agenda was clearly needed. This paper advances such a framework. Over the decades, dentistry has forged an approach to service delivery mainly through a business, demand-led model. While oral health continues to improve globally, an important consequence of this approach is that it compounds the social exclusion that many people are already experiencing because of a constellation of economic, political, cultural and individual factors. Thus, many people are simply not getting the dental care they need. In contrast, drawing on the theoretical literature on social exclusion, intersectionality and othering, we suggest that dentistry could act as an agent for social inclusion as a more responsive, all-encompassing form of oral health care and delivery. This paper advances a theoretical framework for inclusion oral health, and an action plan to show how inclusion oral health may become one solution in an armamentarium to tackle the global phenomena of oral health inequities.

#Teeth&Tweets: the reach and reaction of an online social media oral health promotion campaign

Aim The aim of the study was to investigate: i) the geographical reach and reaction of the online participants engaging in an oral health campaign 'National Smile Month' UK 2016 (NSM); and ii) whether dental practices during NSM were using Twitter to help address regional oral health inequalities.Methods Twitter posts, that is 'tweets', were collected using the application programming interface (API) software Mozdeh, for one month. Tweets were classified into high, medium or low engagement. Participants' postcode data of the organisation/practice were obtained via an internet search using Google. The geolocation of tweets was then linked by organisations' postcode to the 2015 Index of Multiple Deprivation and the oral health survey of five-year-olds 2014/15, and subsequently mapped using Google Fusion Tables.Results A total of 23,100 tweets were captured with a final total of 2,968 usable tweets from 763 separate accounts. Two hundred and twelve tweets were from dental practices, with 107 classified as low engagement, 99 medium, and 45 high engagement (39 of those tweets were from organisations allied to oral health). Interactive maps were created to give a visual representation of the relationship between those participants producing 'high' impact tweets and the level of dental decay in five-year-olds and deprivation levels.Conclusion The majority of tweets did not promote any specific preventative behaviour. Dental practices in England were not contributing to National Smile Month via Twitter in a way that would improve regional oral health inequalities. In areas of high-need there is evidence of proactive engagement with NSM via Twitter by local authorities and their healthcare partners.

Strategies to improve access to and uptake of dental care by people experiencing homelessness in Australia: a grey literature review

Objectives The poor oral health of Australians experiencing homelessness negatively affects their quality of life. Better oral health is associated with having annual dental check-ups. Because there is limited peer-reviewed literature describing strategies that improve access to and uptake of dental care by homeless people, in this study we searched the grey literature to discover what strategies are used. Methods The Informit database and Google and Bing search engines were searched using the keywords 'homeless and oral and dental services'. Bing and Google were searched unrestricted by site and Google was searched for sites ending in 'org.au'. Searches were restricted to Australia from June 2008 to June 2018. The first 300 websites were read, and those describing or linking to pages describing a strategy that improved access to or uptake of dental care were included in the study. The content of the webpages was evaluated and summarised, with common strategies reported as a narrative description. Results Nineteen programs were described. Common strategies were providing free care, in-reach care, outreach care and the need to work closely with support organisations. Conclusions To improve access to and uptake of dental care by people experiencing homelessness, dental services need to be free and organised in collaboration with support organisations. What is known about the topic? The peer-reviewed literature describing strategies used to improve access to and uptake of dental care by people experiencing homelessness in Australia is limited. The authors could only locate two such studies, one based in Melbourne and one in Brisbane. Both programs had a similar aim, but used different strategies to achieve it, suggesting a lack of consensus about the best way to encourage dental visiting by people experiencing homelessness. What does this paper add? This paper used the grey literature to describe common strategies used in Australia to improve access to and uptake of dental care by people experiencing homelessness. What are the implications for practitioners? Dental service providers aiming to increase access to and uptake of dental care by people experiencing homelessness need to work collaboratively with support organisations and provide care free of charge.

Management of plaque in people experiencing homelessness using 'peer education': a pilot study

Introduction People who experience homelessness have poor oral health and limited access to dental services.Aim To examine whether 'peer education' could yield improved plaque management among people experiencing homelessness.Methods A quasi-experimental, one-group pre-test-post-test study was conducted, with follow-up at one and two months. Participants were living in temporary accommodation in Plymouth, UK. Plaque levels were assessed using the simplified oral hygiene index. A questionnaire and the oral health impact profile (OHIP-14) were administered. Patient satisfaction and barriers to dental care were explored by interviews.Results The baseline sample included 24 people with a mean age of 36.88 ± 10.26 years. The mean OHIP-14 score was 25.08 ± 19.56; finding it uncomfortable to eat and being embarrassed attracted the highest values (2.46 ± 1.53 and 2.33 ± 1.63, respectively). Plaque levels decreased by month one and month two, though the changes were not statistically significant. Positive changes in confidence in toothbrushing at month two were identified (p = 0.01).Conclusion Experiencing pain and the opportunity to access treatment were key drivers of study participation. The study indicated that it is feasible to conduct oral health promotion projects for people in temporary accommodation. Adequately powered studies examining the impact of peer education on improving homeless people's oral health are warranted.

Barriers and enablers to accessing dental services for people experiencing homelessness: A systematic review

OBJECTIVES

The aim of this systematic review was to identify and conceptualize the barriers and enablers to accessing dental services for people experiencing homelessness in the United Kingdom.

METHODS

A literature search for studies relevant to homelessness and dental care was conducted. The PRISMA and ENTREQ guidelines were followed. Electronic databases (EMBASE, MEDLINE, DOSS, CINAHL, SOCINDEX and PsycINFO) and grey literature sources (Electronic Theses Online Service - EThOS, Kings Fund, NICE Evidence, Open Grey, Google and the Health Foundation) were searched up to 28 August 2018. The critical appraisal was conducted using CASP and an adjusted version of a JBI Critical Appraisal tool. Thematic analysis was used to develop the themes and domains.

RESULTS

Twenty-eight papers were included. Barriers to homeless people accessing dental care stemmed both from the lived experience of homelessness and the healthcare system. Within homelessness, the themes identified included complexity, emotions and knowledge. Regarding the healthcare system, identified themes included staff encounter, accessibility and organization issues.

CONCLUSION

Homelessness can actively contribute to both an increased need for dental care and barriers to accessing that care. The arrangement of dental healthcare services can also act as barriers to care. This is the first systematic review to conceptualize the factors associated with access to dental care for people who are homeless. It provides a set of recommendations for overcoming the main barriers for homeless people to accessing dental care. It also offers directions for future research, policy and commissioning.

Homeless adults' access to dental services and strategies to improve their oral health: a systematic literature review

Homeless people have poor oral health and high treatment needs, yet tend to make problem-based dental visits. This review aimed to determine how and where homeless adults receive oral health care, the barriers that prevent homeless adults accessing dental care and find strategies to promote oral health to homeless adults. The databases MEDLINE via OvidSP, PubMed, CINAHL and Scopus were searched using the keywords: homeless, roofless, houseless, rough sleeper, couch surfer, shelter, hostel, dental and oral health. The inclusion criteria were: participants over the age of 17 years, studies written in English, based in developed countries and published after 2003. Selected articles were assessed using the Mixed Methods Appraisal Tool and data extracted were thematically analysed. Twenty-two studies met the inclusion criteria. Five main themes were found: how homeless people accessed dental care; factors affecting the uptake of care; strategies used to improve access to care; the effect of non-dental staff on dental care; and challenges with providing care to homeless people. Dental care for homeless adults was affected by numerous factors. Improving their access to dental services requires collaboration between support service providers, dental care to be near homeless populations and flexibility by dental services.

Anxiety and anger of homeless people coping with dental care

OBJECTIVES

To reveal and describe from open-ended interviews how homeless people in Vancouver interpret, appraise and cope with dental care.

METHODS

Audio-recorded interviews with 25 homeless people (18 men and 7 women; age range: 25-64 years), purposefully selected for a range of experiences, were transcribed and analysed inductively. The process of interpretive description drawing from the Behavioral Model for Vulnerable Populations and Lazarus's Theory of Emotions identified how participants appraised and coped with dental care.

RESULTS

Four dominant themes emerged: barriers to care; service use; opinions on dental health; and improving dental services. Participants were anxious about the cost of dentistry and fearful of dentists. They got emergency dental care with difficulty, usually in hospital emergency departments although mostly they preferred self-treatment. They acknowledged the importance of dental health but felt stigmatized by their homelessness and visibly unhealthy mouths. They wanted accessible dental services with financial assistance from government, more widespread information about community dental clinics, and, notably among the Indigenous participants, less humiliating discrimination from dentists.

CONCLUSIONS

Homeless people have difficulty coping with dental care. They believe that dentistry is frightening, humiliating and expensive, and governments are neither sympathetic to their disability nor willing to provide helpful information about community dental clinics or sufficient dental benefits for their needs.