How a dental anxiety service for torture, abuse and dental phobia patients works and why: A realist evaluation

Abstract

Background. Neglecting one’s oral health can negatively impact one’s general health, quality of life and well-being. Attending dental examinations is good step toward maintaining and attaining good oral health. However, people exposed to torture or abuse or affected by dental phobia tend to avoid dental examinations and care due to elevated anxiety or because the dental setting may trigger retraumatisation. The current literature suggests that cognitive behavioural therapy (CBT) administered by a dental practitioner can effectively alleviate dental anxiety. Nevertheless, research on how dental practitioners successfully deliver CBT or how service delivery incorporates this for heterogeneous patient groups remains scarce, leaving us with a knowledge gap. How are services incorporating CBT to cater to the different patient needs, and how are dental practitioners adopting CBT to alleviate dental anxiety in their service delivery? The TADA service. In 2010, the Norwegian government established the TADA (torture, abuse and dental anxiety) service, and as of 2018, 52 TADA teams existed across the country with the aim of alleviating dental anxiety for patients with a history of torture or abuse or who meet the diagnostic criteria of dental phobia. The TADA teams are interdisciplinary and include psychologists and dental practitioners. The psychologist oversees patient admission and trains dental practitioners, and dental practitioners deliver CBT. After dental anxiety is alleviated, patients are referred to a follow-up team that restores the patients’ oral health. Although the TADA service was rolled out as a national service more than 10 years ago, little research exists on the service itself or the patient group. Moreover, even though dental anxiety is an international challenge, the TADA service seems unique in its service delivery to its contextual patient group. A realist evaluation. A realist evaluation is a theory-driven approach that develops, tests and refines programme theories that articulate and explain what works within a programme, for whom, under what circumstances, how and why. A realist evaluation was thus chosen due to its ability to inform how, why and for whom the TADA service is working. Investigating the TADA service through a realist lens can inform us on the practice of CBT service delivery and the dental practitioner’s role. Evaluation question. The realist question of what works within TADA, for whom, under what circumstances, how and why was operationalised by answering the following three focused questions: 1. From a developer perspective, how is the service designed to achieve its outcomes of alleviating dental anxiety and restoring dentition for its users? 2. From a deliverer perspective, how and under what circumstances are TADA dental practitioners managing the role change of alleviating dental anxiety for TADA patients? 3. From a patient perspective, how is the TADA service alleviating patients’ dental anxiety? Data collection. To answer the focused questions, the study collected data in two phases. The first phase of the study used a sequential multimethod design and collected data from interviews with 12 service developers and 13 service documents. The second phase of data collection recruited 15 patients from one county in Norway and interviewed them after they had finished exposure treatment, an element of CBT, thus, the service assumed their anxiety was alleviated. Analyses methods. Data retrieved from the service developers in the first phase of collection were analysed through a direct approach of content analysis incorporating the heuristic logic formula: context + mechanism = outcome (CMO). The service developers were located across Norway and represented a national perspective of holding a dual role while acting as service deliverers. Thus, they informed theory development from both the developer and deliverer perspectives and answered focused questions one and two. Data retrieved from the individual patient interviews in the second phase were analysed through a template analysis that incorporated CMO heuristics. Individual patient interviews were used for the following phase to answer the last focused question. Key findings from investigating what works within TADA, for whom and under what circumstances through a realist lens led to 10 programme theories depicting structural and relational features. Four programme theories depict how, from a developer perspective, TADA’s structural features alleviate torture, abuse and dental phobia patients’ dental anxiety and restore their oral health. These programme theories conclude that the TADA service adopts a hybrid bottom-up/top-down service that allows teams to practice discretion and tailor their approach to meet individual needs. Moreover, the TADA service is free of charge for its patient group, which has improved service accessibility for patients otherwise found to avoid services. Nevertheless, the service still struggles to reach torture survivors (Paper 1, “Exploring the Contexts, Mechanisms and Outcomes of a Torture, Abuse and Dental Anxiety Service in Norway”). Three programme theories depict relational elements that, from a service deliverer’s perspective, impact how and under what circumstances the dental practitioners manage the role change in delivering the component of CBT, exposure therapy, to alleviate dental anxiety. These programme theories conclude that dental practitioners successfully alleviate patients’ dental anxiety by adopting roles that enable trust, a safe space and gradual desensitisation towards the patient’s fear triggers. For dental practitioners to adopt these roles, they need to be in a context that provides them with the resource of time and an institutional setting where they are in proximity to the psychologist and where an interrelationship between the psychologist and dental practitioner is fostered. This allows dental practitioners to build a skillset on how to effectively communicate and grade the therapy to individual anxiety levels (Paper 2, “More Than Just a Dental Practitioner”). The last three programme theories explain how patients address the relational service features leading to their alleviated dental anxiety. By building on the theory from phase one, patients explained that their dental anxiety was alleviated when dental practitioners provided them with a calm and holistic approach, positive judgement and predictability throughout the service pathway. This led patients to feel understood, cared for and in control, their shame to be reduced and their self-esteem to emerge. The patients insinuated that it was not the CBT intervention alone that alleviated their dental anxiety, but that it was affected by the approach taken by dental practitioners (Paper 3, “Seeing the Person Before the Teeth”). Conclusion. Dental anxiety and the effects it has on oral health and, in turn, the individual is well established in the literature. Nonetheless, a review of the literature shows that the TADA service’s approach to alleviating this specific type of patient’s dental anxiety and restoring their dentition seems unique to the Norwegian welfare state. Thus, the programme theories developed for the current study may be of interest to the international community looking at ways to tackle the challenge of dental anxiety for vulnerable patients. The specificity of the programme theories that this study has developed brings a certain transferability, in that the reader can assess if a similar programme can be implemented into their context. The findings of this study contribute to the knowledge gap on dental anxiety service delivery and how dental practitioners adopt therapeutic roles in anxiety treatment. The study findings imply that subsidising a dental anxiety service is essential for reaching a vulnerable patient population otherwise found to avoid general dental services. Moreover, the current structure is deemed valuable in that it permits the service to tailor itself according to patients’ individual needs. This means that the context must continue to permit professional discretion and not assume that “one size fits all”. The findings from the current study also indicate that the dental practitioner’s approach to a dental anxiety service plays a meaningful role in alleviating dental anxiety. For patients, they need to be met with an approach that reflects person-centred care. From a deliverer perspective, they need to be in an institutional setting that provides time as a resource and a context that allows them to learn from and lean on the psychologist.