Effectiveness of strategies to increase participation in school-based epidemiological surveys: a rapid review.

OBJECTIVE: Rapid review of the literature on strategies to increase participation rates in school-based epidemiological surveys. BASIC RESEARCH DESIGN: Rapid review. MEDLINE and Embase databases were searched for articles written in English from 2000 onwards. Synthesised evidence and primary research were included as data sources from peer reviewed journals and reports. INTERVENTIONS: Any strategy aiming to increase participation in school-based health surveys. The comparator was usual procedure or an alternative strategy to increase participation. MAIN OUTCOME MEASURES: Primary outcomes included participation and consent rates. Secondary outcomes were feasibility, acceptability and adverse effects. RESULTS: The search identified 591 unique records, of which 587 were excluded. Four studies were suitable for inclusion, including one systematic review, one randomised controlled trial, one cross-sectional study and one retrospective analysis. Based on very low certainty evidence, recommendations for maximising participation rates in one systematic review of US studies included: promoting the survey to school staff, parents and students; disseminating study information using direct rather than mediated methods; offering incentives to schools, staff and participants; following up non-responders; and employing a research team member to co-ordinate and monitor recruitment. However, UK studies found that different strategies did not increase participation more than that achieved by a standard approach (delivery of covering letter/consent forms via the child with no follow-up of non-responders). CONCLUSION: Given the lack of evidence of effectiveness of alternative strategies in the UK, additional measures beyond existing standard approaches for active consent cannot be recommended.

The acceptability of healthcare: from satisfaction to trust.

The assessment of healthcare quality increasingly emphasises lay acceptability, as evidenced by the emergence of patient satisfaction and patient-centred care in the literature and in policy. In this paper we aim to provide a conceptual overview of acceptability and propose ways to enhance its assessment. Firstly, we map how acceptability's importance in quality assessments has increased and how the term acceptability has been used as synonymous with patient satisfaction, despite it being a broader concept. We then critique the concept of patient satisfaction and its measurement and challenge its use as an indicator of acceptability and quality. By drawing on our research and those of others, the second half of the paper describes how trust in clinicians and health services has emerged as a related concept, including a theoretical discussion of trust in healthcare outlining how it can be built, undermined and abused. We propose trust as an alternative indicator of acceptability in healthcare quality and review its measurement. Finally, we consider how healthcare policy may impact on trust and make recommendations for future research.

What matters to patients when their care is delegated to dental therapists?

AIM: To explore the experiences of adult patients and parents of child patients when their oral healthcare is delegated to dental therapists. METHOD: Narrative study using semi-structured in-depth interviews of a purposive sample of patients (n = 15) and parents of child patients (n = 3) who have been treated by therapists. RESULTS: Overall, participants reported positive experiences of treatment provided by therapists. Two main themes emerged from the data. The first; perceptions of the nature of dental services appeared related to the second; trust and familiarity in the dental team. Perceptions of the nature of dental services ranged from viewing dentistry as a public service to that of a private service, consistent with a more consumerist stance. Within this theme, three dimensions were identified: rationale for skill-mix; team hierarchy and importance of choice and cost. Consumerist perspectives saw cost reduction, rather than increasing access, as the rationale for skill-mix. Such perspectives tended to focus on hierarchy and a rights-based approach, envisaging dentists as the head of the team and emphasising their right to choose a clinician. Trust in and familiarity with the dental team appeared critical for therapists to be acceptable. Two dimensions were important in developing trust: affective behaviour and communication and continuity of care. Two further dimensions were identified in this theme: experience over qualification and awareness of therapists. Where trust and familiarity existed, participants emphasised the importance of their experiences of care over the qualifications of the providing clinician. Equally, trust in the dentist delegating care appeared to reassure participants, despite awareness of the role of therapists and their training being universally low. CONCLUSION: Regardless of perspective, views and experiences of treatment provided by therapists were positive. However, trust in and familiarity with the dental team appeared critical. Trust was apparently founded on dental teams' affective behaviour, communication skills and continuity of care. There are implications for skill-mix where staff turnover is high, as this is likely to compromise familiarity, continuity of care and ultimately trust.

What do we really know about UK paediatric dental general anaesthesia services?

Dental general anaesthesia (DGA) is only permitted within a hospital setting where critical care facilities are available. Recently, concern has been expressed about the number of hospital admissions for the dental care of children following the publication of a high profile paper which highlighted an apparent increase in children being admitted for extractions due to caries under DGA. Coincidentally new best practice standards for paediatric DGA services have been published. An evaluation of DGA services in Yorkshire and the Humber suggested that existing monitoring was inadequate and is unlikely to represent true levels of activity and that any apparent increase may reflect the method of remuneration for services. In fact, recent changes in service structure and changes to improve quality have reduced DGA activity in some areas. In addition, the evaluation revealed that many services were not meeting standards of best practice.

An evaluation of paediatric dental general anaesthesia in Yorkshire and the Humber.

BACKGROUND: Following major change in UK policy regarding dental general anaesthesia (DGA) in 2001, there appears to be little information available about paediatric DGA services, their organisation, availability and utilisation. AIMS: To establish the location, organisation and monitoring systems of paediatric DGA services in Yorkshire and the Humber Strategic Health Authority and to audit these services against existing standards of best practice. DESIGN: A postal survey of all potential paediatric DGA providers in Yorkshire and the Humber. RESULTS: Thirty-one possible DGA service providers were identified, 24 of which provided paediatric DGAs. Of 84 DGA lists identified, 75 regularly treated children, and nine were run on an ad hoc basis. The lists were held in 20 centres. The number of patients treated per list varied depending on treatment provided, ranging from 3.9 to 7.5 patients per list. Maximum waiting times varied from three to 84 weeks. Outcome data recording methods varied. Just over half of respondents used the Hospital Episode Statistics system; the remainder used other systems, or none. CONCLUSIONS: There was much variation in how DGA lists were organised. Most lists met some of the accepted standards, but very few met all. Waiting times were largely in accordance with national targets.

The oral health of adults in Yorkshire and Humber 2008.

BACKGROUND AND AIM: Although national surveys are conducted of the oral health of adults in the UK, few data are available at regional and primary care trust levels to inform local commissioning. A postal survey was conducted to investigate the oral health and use of dental services by adults in the Yorkshire and Humber region. METHOD: A questionnaire was developed and piloted, then sent to a random sample of 25,200 adults. Data were analysed by sex, gender, age and deprivation. RESULTS: 10,864 (43.0%) questionnaires were returned completed. Nearly three-quarters (71.6%) of respondents had 20 or more teeth and approximately one quarter (25.3%) rated their oral health as fair, poor or very poor. The percentage reporting painful aching, discomfort when eating and being self-conscious about their mouths (occasionally or more often in the last 12 months) were 28.8%, 32.8% and 29.1% respectively. Overall, 80.3% reported attending a dentist in the last two years, although nearly a quarter (22.6%) of respondents reported difficulties accessing routine care. However, there were marked inequalities between those living in the most and least deprived neighbourhoods. CONCLUSION: This survey was the first to investigate the oral health and service use of adults in the Yorkshire and Humber region. The findings have implications for the local commissioning of dental services.

A health equity methodology for auditing oral health and NHS General Dental Services in Sheffield, England.

OBJECTIVES: To describe a method used in a health equity audit (HEA) of oral health and National Health Service (NHS) General Dental Services. METHODS: Need, demand and provision of NHS General Dental Services were estimated by electoral ward using readily available data. Need was estimated using five-year-old dmft data. Scheduled and unscheduled demand were differentiated; scheduled demand was estimated using NHS dental registration data and unscheduled demand using emergency clinic and NHS Direct call activity data. Provision was estimated using self-declared dentist NHS hours and NHS Units of Dental Activity practice allocations. All variables were correlated with socioeconomic deprivation in each electoral ward, estimated by rates of receipt of Income Support. SETTING: Sheffield, England. RESULTS: Estimated need in electoral wards varied and correlated positively with increasing socio-economic deprivation. Scheduled demand tended to be lower and unscheduled demand higher in more deprived wards. Estimates of NHS General Dental Service provision indicated marginally higher provision in more deprived wards, though the correlation was weak. A synthesis of the findings estimated where need was least well met by provision. CONCLUSION: A HEA of oral health and NHS General Dental Services can be undertaken using readily available data. However, data used to estimate need, demand or provision may have to change for future audits as the data routinely collected changes.

People with learning disabilities and specialist services.

Valuing people and Valuing people's oral health both advocate choice and inclusion for people with learning disabilities. Research suggests that services and policy and guidance, while prescriptive and available, have not been effective in reducing oral health inequalities for people with learning disabilities. There is a risk that specialist services led by newly created consultants in special care dentistry may have the unintended effect of reducing choice if general dental practitioners are encouraged to refer all those with learning disabilities. A modified model of access is proposed that primary care organisations could use as a commissioning tool for dental contracts to facilitate choice and maximise involvement in oral health care for those with learning disabilities.

Public awareness and social acceptability of dental therapists.

OBJECTIVES: To investigate public awareness and the social acceptability of dental treatment provided by dental therapists in the UK. METHOD: A telephone survey of a representative quota sample of 1,000 UK adults. RESULTS: 10.4% of participants were aware of dental therapists as a professional group, of whom none correctly identified their permitted duties. 61.3% were willing to receive simple restorative treatment from a therapist, with acceptability predicted by being male [OR 1.44 (95% CI 1.09-1.90)], being younger [OR 1.024 (1.016-1.032)] and having a perceived need for treatment [OR 1.49 (1.09-2.5)]. Fewer were willing to allow a therapist to restore a child's tooth (54.7%, p <0.001, McNemar's test) with acceptability predicted by being younger [OR 1.026 (1.018-1.034)]. Those receiving some private treatment were less likely to report acceptability of simple restorative treatment for themselves [OR 0.61 (0.46-0.81)] or for children [OR 0.54 (0.41-0.72)]. 48.2% of participants expected to pay less for treatment provided by therapists, with acceptability of equal costs predicted by the participant being male [OR 1.81 (1.50-2.40)]. CONCLUSION: These findings identify a need for education and reassurance of the public on the training and permitted duties of dental therapists and the rationale for skill-mix in dentistry.

Evaluation of an NHS practice-based minor oral surgery service.

OBJECTIVES: To evaluate a pilot specialist practice-based minor oral surgery service. METHODS: Service monitoring data were analysed to evaluate activity, waiting times and outcomes. Patient satisfaction was assessed by a modified version of the Dental Visit Satisfaction Scale. RESULTS: Of 705 treatment appointments, 12.7% were not attended and treatment was not provided in another 11.6%. Mean waiting time from referral receipt to treatment was 6.8 weeks. Treatment provided included surgical removal of third molars, surgical removal of non-third molars and surgical endodontics (26.7%, 60.4% and 4.9% of cases, respectively). Antibiotics were prescribed in 15.0% of treatment cases and 2.3% of treatment cases required appointments for postoperative complications. The response rate for the satisfaction survey was 81%. All participants reported overall satisfaction and strongly agreed/agreed with positive attitudinal statements about the oral surgeon's communication/information giving, technical competence and understanding/acceptance. 77.8% were seen on time and 22.2% within 15 minutes of their appointment. Overall 74.1% felt the standard of service was better than they would expect from a hospital and none felt it was worse. CONCLUSION: The findings of the evaluation suggest that specialist minor oral surgery can be successfully provided in dental practice and is acceptable to patients.

Public awareness and social acceptability of dental therapists.

OBJECTIVES: To investigate public awareness and the social acceptability of the use of dental therapists in dental care. METHOD: A telephone survey of a representative quota sample of 500 adults (>18 years of age) in South Yorkshire, England. RESULTS: Fifteen per cent of participants were aware of dental therapists as a professional group, of whom only three people correctly identified their 'permitted duties'. Those without problems of access to care were more likely to report awareness (P < 0.05). Fifty-seven per cent were willing to receive simple restorative treatment from a therapist, with acceptability predicted by being younger [OR 1.016 (95% CI: 1.015-1.017)] and having a perceived need for treatment [OR 1.301 (1.053-1.607)]. Fewer were willing to allow a therapist to restore a child's tooth (47%, P < 0.001, test for paired proportions) with acceptability predicted by being younger [OR 1.016 (1.015-1.017)] and being an irregular attender at the dentist [OR 1.309 (1.138-1.697)]. Forty per cent of participants expected to pay less for treatment provided by therapists with the acceptability of equal costs predicted by having access to care [OR 1.346 (1.017-1.781)]. CONCLUSION: These findings have implications for the use of dental therapists. They question patients' and the public's ability to provide informed consent for the treatment provided by them and identify a need for education of the public on the training and competence of therapists and the rationale for employing skill-mix in dentistry.

School-based epidemiological surveys and the impact of positive consent requirements.

A requirement to obtain positive consent for participants in school-based dental epidemiological surveys was introduced in 2006. Concern has been expressed about the impact of the changes on the validity of results as the need to obtain positive consent is likely to reduce the numbers participating. An additional concern is that the new requirement may also lead to samples that are biased, resulting in them being unrepresentative of the population from which they are drawn. This paper aims to discuss the implications of the changes on the quality of future school-based dental epidemiological surveys, and whether they threaten the validity of survey findings at a time when such information is critical in informing the local commissioning of dental services.

General health promotion in general dental practice--the involvement of the dental team Part 2: A qualitative and quantitative investigation of the views of practice principals in South Yorkshire.

AIM: To investigate the factors that might influence the provision of general health promotion through seven different health interventions by dental teams in general dental practice. METHOD: A mixed-method was used comprising cross-sectional qualitative research using semi-structured interviews of a purposive sample of 10 practice principals, and a cross sectional survey of a practice principal from every dental practice in South Yorkshire, using a self-complete questionnaire. RESULTS: Two core categories emerged from the qualitative data: seeing health or disease and practitioners' views of the structure of dental practice. The former refers to the participants' general outlook and cut across many dimensions constituting the structure of dental practice. Health-orientated dentists were more likely to be involved in prevention and were more open-minded to expanding the dental team's role into general health promotion. However participants perceived that barriers existed to involvement such as time and financial factors, current workload and lack of personal skills. The response rate of useable questionnaires in the cross sectional survey was 84%. Reported levels of involvement in general health promotion were low. Most frequently reported barriers were 'insufficient funding' and 'poor use of time'. 'Poor use of time' and 'lack of training/knowledge' were reported less frequently for professionals complementary to dentistry (PCDs) than dentists (p<0.05). Most dentists agreed that PCDs could be trained to deliver health interventions and would be happy for PCDs to do so in their practice if reported barriers were removed. CONCLUSIONS: Although dental teams' involvement in general health promotion is low, there is willingness to increase involvement, particularly among health-orientated dentists. Some reported barriers to involvement might be removed by impending changes to the GDS in England. Other important factors include a lack of education and workforce shortages of dentists and PCDs. Respondents indicated a high regard for PCDs and there was broad agreement that they were suitable to be involved in this work.

General health promotion in general dental practice--the involvement of the dental team. Part 1: a review of the evidence of effectiveness of brief public health interventions.

OBJECTIVES: To review the evidence of the effectiveness of dentists, dental teams and other healthcare workers in seven different brief public health interventions that might contribute to Government targets in cancer and circulatory disease. The interventions were: smoking prevention, smoking cessation, advice on alcohol consumption, diet counselling, advice on physical exercise, advice on skin cancer prevention and blood pressure monitoring. METHOD: A series of literature reviews, using a generic systematic approach, were undertaken to investigate the effectiveness of dentists, dental teams and other healthcare workers in each intervention. RESULTS: Apart from smoking cessation and dietary advice, no studies were identified on the effectiveness of dentists or dental teams in the interventions investigated. There is some evidence that dentists and dental teams can be effective in smoking cessation. There is minimal evidence for effectiveness in dietary counselling, and that which exists shows only a transient effect. There is evidence that other healthcare workers can have some effect in all interventions, though the effect in preventing skin cancer is questionable. CONCLUSIONS: Due to the paucity of studies undertaken, there is minimal evidence of effectiveness of dentists and dental teams in any of the seven interventions. However other healthcare workers are effective in most of them. Dentists and dental teams' involvement in such brief general health promotion interventions might contribute to Government targets on cancer and circulatory disease.

Purification of active chloroplast sedoheptulose-1,7-bisphosphatase expressed in Escherichia coli.

Sedoheptulose-1,7-bisphosphatase (SBPase) is an enzyme unique to photosynthetic organisms and has a key role in regulating the photosynthetic Calvin cycle through which nearly all carbon enters the biosphere. This makes SBPase an appropriate target for intensive study. We have expressed wheat SBPase in Escherichia coli either with or without an N-terminal polyhistidine tag. The identity of the recombinant SBPases was confirmed by SDS-PAGE analysis and immunological detection with a specific antibody. Recombinant SBPase with a polyhistidine tag (His-SBPase) was obtained in soluble, active form and purified by one-step metal-chelate chromatography. Like the native enzyme, recombinant His-SBPase was specific for the substrate sedoheptulose-1,7-bisphosphate and required the presence of a reducing agent for activity. Polyclonal antibodies were raised against recombinant SBPase and were then used to determine relative levels of the enzyme in plant extracts. The availability of large amounts of active recombinant SBPase will also allow detailed structural studies by site-directed mutagenesis and X-ray crystallography.

Differential gene expression of chloroplast and cytosolic phosphoglycerate kinase in tobacco.

Northern blot analysis of RNA extracted from leaves of increasing age and different organs, indicates that genes encoding both isoenzymes of tobacco phosphoglycerate kinase (PGK, EC 2.7.2.3) are differentially expressed in a developmental and tissue-specific manner. The genes for both chloroplast PGK (chl-PGK) and cytosolic PGK (cyt-PGK) also show light-modulated gene expression in vivo. In dark-grown developing cotyledonary leaves of tobacco both PGK mRNAs are present, but only the concentration of the chl-PGK mRNA increased on illumination. In contrast, on transfer to darkness, the concentration of both mRNAs decreased in light-grown seedlings and then increased again on resumption of illumination.

Developmental, circadian and light regulation of wheat ferredoxin gene expression.

A genomic clone encoding the precursor of wheat leaf ferredoxin has been isolated and characterised. The uninterrupted PetF gene encodes a polypeptide of 143 amino acid residues, consisting of an N-terminal presequence of 46 amino acid residues and a mature polypeptide of 97 amino acid residues. Southern blot analysis suggests that six copies of the PetF gene are present in the wheat haploid genome. Northern blot analysis has shown that the genes are both developmentally and light regulated in wheat seedlings and provides evidence that a circadian rhythm regulates the steady-state levels of ferredoxin transcripts. The intact wheat gene and several chimeric constructs, containing portions of the 5'-upstream region fused to the beta-glucuronidase reporter gene, have been introduced into tobacco plants, but levels of beta-glucuronidase activity above background were not detected, suggesting that the 5'-upstream region is unable to function as a promoter in tobacco plants.

cDNA and gene sequences of wheat chloroplast sedoheptulose-1,7-bisphosphatase reveal homology with fructose-1,6-bisphosphatases.

The nucleotide sequence encoding the chloroplast enzyme, sedoheptulose-1,7-bisphosphatase [Sed(1,7)P2ase], was obtained from wheat cDNA and genomic clones. The transcribed region of the Sed(1,7)P2ase gene has eight exons (72-507 bp) and seven introns (85-626 bp) and encodes a precursor polypeptide of 393 amino acids. Comparison of the deduced amino acid sequence of Sed(1,7)P2ase with those of fructose-1,6-bisphosphatase [Fru(1,6)P2ase] enzymes from a variety of sources reveals 19% identity, rising to 42% if conservative changes are considered. Most importantly, the amino acid residues which form the active site of Fru(1,6)P2ase are highly conserved in the Sed(1,7)P2ase molecule, indicating a common catalytic mechanism. Interestingly, although the activities of both Sed(1,7)P2ase and chloroplast Fru(1,6)P2ase are modulated by light via the thioredoxin system, the amino acid sequence motif identified as having a role in this regulation in chloroplast Fru(1,6)P2ase is not found in the Sed(1,7)P2ase enzyme.