AN overview of oral health needs assessments - to support NICE public health guidance, "Oral health : local authority strategies to improve oral health, particularly among vulnerable groups"

Abstract

Executive Summary
• This report, produced by the Dental Public Health Unit Cardiff University, describes work commissioned by NICE to determine what methods and sources of information would help local authorities identify the oral health needs in their local community, to inform the development of guidance for Local Authorities on strategies to improve the oral health of vulnerable groups.
• In order to do this, three pieces of work were undertaken:
o identification and analysis of OHNAs produced by Consultants in Dental Public Heath (CDPHs) across the United Kingdom
o a primary qualitative research study involving a series of semi-structured interviews with CDPHs to seek their views on the OHNA process
o two structured reviews of the literature:
 one examining the evidence base on oral health needs assessment and vulnerable groups
 the other a review of the literature around methods used to produce general health needs assessments.

• From these three components, a set of general principles and good practice points were identified and were used to devise a template for a model oral health needs assessment.

• Key findings from the work are highlighted in text boxes throughout the report and a number of important issues for further consideration are described.

• In total, 72% of CDPHs in the UK responded to the request for examples of OHNAs which they and their employing organisations had produced that were of relevance to assessing oral health needs of vulnerable groups. In combination with an Internet search we identified 105 unique OHNAs. These were subjected to analysis and a 59 item framework was used to conduct a framework analysis of the OHNAs.

• From this activity, it became clear that a wide variety of approaches were taken to OHNAs. Indeed what the submitting CDPHs considered to be OHNAs differed greatly. Virtually no two documents were the same, either in content or format. This made gathering robust evidence from these data sources problematic. A diverse range of topics were covered ranging from overarching oral health needs for a defined geography to assessments focussing on specific groups or services. A good number of OHNAs did make reference to vulnerable groups. However, the aims of the OHNAs were not always made explicit nor indeed how the OHNA linked to the sponsoring organisations priority setting or commissioning plans. The degree of patient and public involvement was variable and in many cases corporate partners or health alliances were not mentioned. Finally, from the OHNAs submitted by the CDPHs for analysis, it often wasn’t clear how these fitted into an on-going overview or monitoring of need. Two sample OHNAs are provided as an Annex to this report to demonstrate the type of documentation currently being produced.

• In parallel with the OHNA analysis, qualitative work comprising five in-depth semi-structured interviews were undertaken with senior and experienced CDPHs. Those interviewed were purposively selected on the basis of their past involvement with the OHNA process, such as authors of previous guidance on OHNAs and those who had held senior posts in Dental Public Health. A range of geographic bases were also represented by the interviewees. The intention of this element of the work was to seek individual opinions from experts rather than come to a nationally representative or consensus view.

• The points made by the CDPHs interviewed did however contain many points in common. All viewed OHNA as a key element of the oral and dental health service commissioning process. The view was expressed that OHNA should be on-going process, rather than a one off and OHNA could take a variety of formats dependant on local circumstances. The CDPHs concurred that when it comes to assessing the need of vulnerable groups, lack of robust epidemiological data was often an issue – and indeed while the national surveys gave a good overall picture of oral health, it would be necessary to explore the needs of vulnerable groups separately. The use of proxy measures of need was not ruled-out. Patient and public involvement was identified as an area that had posed difficulties for some in conducting OHNAs in the past, though this is recognised as good practice.

• Having oral health identified as a priority by Local Authorities was seen as an issue and the importance of achieving this objective from the outset and in linking with the Strategic Joint Needs Assessment process in Local Authorities was crucial post April 2013. The consultants were of the view that on occasion it was helpful to have the outcomes in mind when embarking on an OHNA. They also said that it was important to involve the key decision makers in the OHNA process from the outset. Finally, the close relationship between oral health improvement and dental service commissioning was thought important and difficult to separate in conducting an OHNA.

• Two distinct literature reviews were conducted, examining OHNAs and vulnerable groups and separately on the methodology of health needs assessment in the general health literature. In the first search of 1426 articles identified, 59 were selected as relevant to the question asked while in relation to health needs assessments in general, 90 of 1014 articles were relevant.

• In neither search were we able to find any publications which as a single piece of research, described an OHNA that had been taken forward as a strategy, been implemented and then evaluated in terms of clinical and cost-effectiveness. We regard this as a key finding from the literature review. Although we did not conduct a formal systematic review, we are of the view that our search strategy was sufficiently rigorous to conclude that we are unlikely to have missed such research, should it exist.

• There were however, many studies which described parts of what should be incorporated into an OHNA. It is likely that incorporating some or all of these characteristics would result in an OHNA of reasonable quality and comprehensiveness The literature on:

o patient and public involvement
o socio-dental indicators
o data collection
o the merits of more detailed measures of health inequalities
o geographic mapping as they relate to OHNA
are described.

• From the wider literature we identified documents that define approaches to the conduct of HNAs – but much of this is in the form of policy documents and the approaches have not been formally tested in before/after or intervention studies.

• From all of the forgoing evidence – we have suggested principles and practice for the conduct of oral health needs assessments. Conducting OHNAs is a circular process, with optional elements for a slimmed down approach to OHNAs and which we envisage could link to the Joint Strategic Needs Assessment Process in Local Authorities.

• In light of the limited evidence available, we propose a 10-step approach to the conduct of OHNAs and a template document for reporting OHNAs is provided.

• Finally we have highlighted a number of issues for consideration.