Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions.

BACKGROUND: People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS: From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION: This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.

Factors influencing implementation and sustainability of interventions to improve oral health and related health behaviours in adults experiencing severe and multiple disadvantage: a mixed-methods systematic review.

OBJECTIVES: Among people experiencing severe and multiple disadvantage (SMD), poor oral health is common and linked to smoking, substance use and high sugar intake. Studies have explored interventions addressing oral health and related behaviours; however, factors related to the implementation of these interventions remain unclear. This mixed-methods systematic review aimed to synthesise evidence on the implementation and sustainability of interventions to improve oral health and related health behaviours among adults experiencing SMD. METHODS: Bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature were searched from inception to February 2023. Studies meeting the inclusion criteria were screened and extracted independently by two researchers. Quality appraisal was undertaken, and results were synthesised using narrative and thematic analyses. RESULTS: Seventeen papers were included (published between 1995 and 2022). Studies were mostly of moderate quality and included views from SMD groups and service providers. From the qualitative synthesis, most findings were related to aspects such as trust, resources and motivation levels of SMD groups and service providers. None of the studies reported on diet and none included repeated offending (one of the aspects of SMD). From the quantitative synthesis, no difference was observed in programme attendance between the interventions and usual care, although there was some indication of sustained improvements in participation in the intervention group. CONCLUSION: This review provides some evidence that trust, adequate resources and motivation levels are potentially important in implementing interventions to improve oral health and substance use among SMD groups. Further research is needed from high quality studies and focusing on diet in this population. PROSPERO REGISTRATION NUMBER: CRD42020202416.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness.

BACKGROUND: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD. METHODS: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416. FINDINGS: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions. INTERPRETATION: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes. FUNDING: National Institute for Health and Care Research (NIHR) Policy Research Programme.

"You Want Them Pretty, but Not Too Intelligent!": Everyday Talk and the Continuum of Men's Violence Against Women in Forensic Institutional Care.

The forensic setting houses persons with offence convictions who are also in receipt of ongoing mental healthcare-a criminal justice system and healthcare meeting-point. Extant literature highlights how this context is laden with interpersonal and institutional difficulties unique to a secure context that must provide care and custody concurrently. Our central argument is that the intertwining and interdependent cultural and custodial elements of forensic healthcare environments are integral and influential to care, culture, and conduct within such institutions-including concerning misogynistic everyday talk and the continuum of men's violence against women therein. We argue that the institution is a continuation of contemporary social issues experienced within community life (e.g., misogyny), as the boundaries of such institutions are porous-polis values traverse physical brickwork. This paper analyses ethnographic data from two male wards that are situated within a UK inpatient forensic mental health hospital. Ethnographic fieldwork occurred over 300 hours-overtly participating in, exploring, and recording the daily life of the community. Five excerpts of ethnographic data are presented, which evidence the gendered ward environment and highlight a series of encounters pertaining to problematic social life, which are the upholding of heteronormative gender roles, hegemonic masculinity, and misogyny. These views are problematised within the sexual offending rehabilitative context by considering the clinical risk associated. Further, we argue that to only focus on the end of the continuum often viewed as most serious (e.g., rape) ignores a pervasive cultural landscape of the polis in wider community, beyond the institution, that facilitates the more commonly experienced end of the continuum related to misogynistic values, encounters, and talk. We evidence how social norms and habitualised gendered actions permeate the institution, which bring into question the rehabilitative efficacy of the hospital. This paper embraces a feminist lens to explore everyday social interactions and the embodied experience of the female ethnographer within a male-dominated forensic setting. We contribute to the literature by newly theorising the influences of hierarchical heterosexual gender roles, violent language in forensic settings, and misogynistic attitudes and practice, on the care for, and rehabilitation of, patients.

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.

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.

Inpatient Institutional Care: The Forced Social Environment.

The landscape of mental health recovery is changing; there have been calls for a shift from the clinical expertise being the dominant voice within mental healthcare towards a more personalised and collaborative service that supports those in need of mental healthcare to define what recovery is for the individual. Within this new recovery movement, there has been a recognition of the importance of the social environment in which individuals are situated and the relationship of this to mental health and wellbeing. Included in this is the importance of an individual's role within society and the ways in which knowledge, such as experts by experience, can hold an important value. The argument then, is that social connectedness forms part of the recovery journey and that relationships can help us develop or re-connect with who we are in powerful ways. Such a view has only been strengthened by the recent and ongoing global COVID-19 pandemic. Within the UK, discussions of the importance of our wellbeing have become commonplace within the context of restricted social contact. With this heightened awareness of how the social contributes to wellbeing, it is important to consider the environments in which those in receipt of mental healthcare are situated. One of which is institutionalised care, where it is commonplace to restrict social contact. For example, by virtue of being within a locked environment, individuals' freedom of movement is often non-existent and thus contacts with those not residing or working within the institution is restricted. While such restrictions may be deemed necessary to protect the individual's mental health, such environments can be unintentionally toxic. Data are presented from an ethnography that was conducted within an inpatient forensic mental health hospital in the UK to highlight the problematic social environment which some individuals experience. Key interpersonal issues are presented, such as, trust, racism, the threat of physical violence and bullying that was experienced by staff and residents at the hospital. Consideration is given to the coping strategies enacted by residents and the pathologising of such behaviour. The consequences on interpersonal wellbeing are explored.