Health policy analysis on barriers and facilitators for better oral health in German care homes: a qualitative study

Abstract

Objectives: To assess possible health policy interventions derived from the theoretical domains framework (TDF) by studying barriers and facilitators on the delivery of oral healthcare and oral hygiene in German care homes using a behavioural change framework.

Design: Qualitative correlational study to evaluate a national intervention programme.

Setting: Primary healthcare in two care homes in rural Germany.

Participants: Eleven stakeholders participating in the delivery of oral healthcare (hygiene, treatment) to older people, including two care home managers, four section managers, two nurses/carers and three dentists.

Interventions: Semistructured interviews conducted in person in the care homes or by phone. A questionnaire developed along the domains of the TDF and the Capabilities, Opportunities and Motivations influencing Behaviours model was used to guide the interviews. Interviews were transcribed and systematised using Mayring's content analysis along the TDF.

Results: 860 statements were collected. We identified 19 barriers, facilitators and conflicting themes related to capabilities, 34 to opportunities and 24 to motivation. The lack of access to professional dental care was confirmed by all stakeholders as a major limitation hampering better oral health.

Primary outcome: A range of interventions can be discussed with the methodology we utilised. In our interviews, lack of dentists willing to treat patients at these facilities was the most discussed barrier for improving oral health of nursing home residents.

Secondary outcomes: Dentists highlighted the need for better incentives and facilities to deliver oral healthcare in these institutions. Differences with urban settings regarding access to healthcare were frequently discussed by our study participants.

Conclusions: Within our sample, greater capacitation of care home staff, better financial incentives for dentists and increased cooperation between the two stakeholders should be considered when designing interventions to tackle oral health of care home residents in Germany.

Keywords: GERIATRIC MEDICINE; HEALTH ECONOMICS; Health policy; ORAL MEDICINE.

Figure 1

Overview of the analytical process and data flow, and display of identified key themes of barriers, enablers and possible associated intervention types. The figure displays how the domains of the COM-B model interlink with those of the TDF (theoretical domains framework) and the behaviour change wheel (BCW). The COM-B includes possible sources of behaviour that are susceptible to responding to interventions. The TDF helps to make explicit potential areas of intervention which then are reflected in the BCW. The BCW then allows to convert them to a subset of policy categories for developing interventions. In BOLD, the domains are shown (and examples given) that were discussed in our interviews when assessing how to increase the provision of and access to professional dental healthcare of care home residents. In italic, the domains that were discussed in our interviews when assessing how to improve oral hygiene in care homes are indicated. The flow of identified themes for a possible intervention development is shown at the bottom. For example, for the provision of and access to dental healthcare, a lack of dentists attending the care home was identified as the main barrier, while for improving oral hygiene, improved cooperation between carers and patients is necessary. From the flow of themes, possible interventions emerged. COM-B, Capabilities, Opportunities and Motivations influencing Behaviours.