Inclusion Criteria
We will include all published journal articles in English-language on oral health promotion interventions for older people in RACF’s. Older people includes all older persons aged 65 years and above who are residing in RACF’s. Time restrictions will not be applied as we have a keen interest in understanding how behavior change interventions have evolved over time and also because of the limited number of articles that were obtained during preliminary database searches. The interventions targeting either or both older people residents and care staff in RACF’s will be included. All randomized controlled trials, quasi randomized trials and non-randomized before and after intervention comparison studies, intervention and control comparison studies will be included. Health promotion interventions may be any intervention that targets behaviour change such as; interventions administered by dentists or dental hygienists which may include one or more of the following, PowerPoint presentations on oral hygiene, good oral care and denture hygiene, demonstration of brushing or denture cleaning techniques, hands-on training in tooth brushing techniques, group discussions, distribution of booklets, practical advice, lectures, workshops, videos on oral health and hygiene. Studies reporting the outcome in terms of the primary outcome variable which is improvement in oral health status of older people will be included in the review. This could be indicators of oral hygiene namely plaque and gingivitis measured using standard indices such as the plaque index and gingival bleeding index and other indicators of oral health such as the presence or absence of denture stomatitis, angular cheilitis, mucositis, candidiasis, dry mouth and mucosal lesions. Our secondary outcomes include variables reporting on any other oral health related outcomes which maybe subjective or objective, clinical or non-clinical such as improvement in oral health knowledge, attitudes, beliefs and practices, self-rated oral health, oral health related quality of life (OHR-QoL), oral health literacy, oral hygiene behaviors, denture hygiene behaviors. Articles which report the outcomes in terms of our secondary outcome variables will also be included in the review.
Exclusion Criteria
All articles published in any language other than English will be excluded. Articles where the study population is below 65 years of age will be excluded. Editorials, letters to editor, opinion pieces, systematic reviews, narrative reviews, conference papers, conference reviews, books and book chapters will also be excluded. Articles related to oral health promotion interventions in community dwelling older people people will be excluded. Articles where the intervention solely focuses on effectiveness of oral care products or drugs in improvement of oral health in older people living in RACF’s will be excluded. Likewise, articles that solely focus on professional clinical oral care interventions in the improvement of oral health in older people will also be excluded. Articles where the outcomes reported are not oral health-related will be excluded.
SEARCH STRATEGY
Relevant articles for inclusion in the review will be identified by searching the following databases; Medical Literature Analysis and Retrieval System online (MEDLINE), Cochrane Central Register of controlled trials (CENTRAL), Cochrane Database for Systematic Reviews (CDSR), EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Web of Sciences and PsycInfo. In addition, the reference list of all studies included in the review will be hand-searched to identify additional studies. Likewise, the reference list of any systematic reviews on oral health promotion interventions for older persons living in RACF’s will also be screened for relevant articles. A detailed search strategy will be developed for each database, this will be based on search strategy developed for searching the MEDLINE database but will be revised for searching other databases with consideration to different Subject headings/ terms/ key words in different databases. The search strategy to be used in MEDLINE database is given in Table 1. These search terms will remain identical while searching all databases except for MeSH terms. All search terms under each concept will be combined using the OR operator, and all the search terms under the three concepts will be combined using the AND operator.
Table 1
Search terms for screening articles in MEDLINE database
Concept 1 (Population of interest) | Concept 2 (Intervention) | Concept 3 (Outcome) |
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“Older persons in residential aged care” OR “nursing home” OR “nursing homes” OR “residential aged care facility” OR “residential aged care facilities” OR “older people” OR “aged care” OR “older persons” OR “older people residents” OR “older people in long-term care facilities” OR “older people in long term care” OR “older people in long term care facility” OR “homes for the aged” OR “old age home” OR “old age homes” OR “aged” | “Health education” OR “behavior change” OR “behavior modification” OR “behaviour change” OR “behaviour modification” OR “health promotion” OR “health program” OR “health programs” OR “behavior change technique” OR “behaviour change technique” OR “conditioning therapy” OR “behavior therapy” OR “behaviour therapy” OR “behavior therapies” OR “behaviour therapies” OR “modelling” OR “self-efficacy” OR “motivational interviewing” OR “conditioning therapies” OR “facilitation of behavior” OR “facilitation of behaviour” OR “action control” OR “maintenance” OR “relapse prevention” OR “practice” OR “guided practice” OR “health related behavior” OR “health related behaviours” OR “health behavior” OR “health behaviour” OR “health behaviors” OR “health behaviours” OR “behavior change techniques” OR “behaviour change techniques” OR “locus of control” OR “sense of control” OR “internal external control” | “Oral health” OR “dental health” OR “dentistry” OR “dentist” OR “dental hygiene” OR “oral health related quality of life” OR “dentists” OR “oral hygiene” OR “oral health therapist” OR “dental caries” OR “gingivitis” OR “dental hygienists” OR “dental care” |
DATA COLLECTION AND ANALYSIS
The articles retrieved by the searches will be imported to EndNote 20 (Thomson Reuters, Philadelphia, PA, USA) reference management software and duplicates will be removed. Two independent reviewers (NA and SR) will evaluate the titles and abstracts articles returned by the searches against the inclusion and exclusion criteria for the review. Articles that do not meet the eligibility criteria will be removed. The full-text of all the remaining articles will be retrieved for further assessment. Based on the information given in the full-text of the articles, two reviewers (NA and SR) will decide which articles to include in the review, any discrepancies between the two reviewers will be resolved by discussion with a third reviewer (SKT). Records will be kept of all articles excluded at this stage and the reasons for exclusion.
DATA EXTRACTION AND MANAGEMENT
Two review authors (NA and SR) will independently retrieve extract data from the articles included in the review using a customized data extraction form piloted prior to use. The data extraction form will be used to extract relevant data on the study design, study setting, study duration; population demographics, baseline characteristics; details of interventions including the type of intervention, number of participants and intervention provider; control conditions or comparisons; methodological issues, follow-up, outcome measures, results; recruitment, study completion rates and information needed for assessment of risk of bias.
Where there is missing data in any study, the original authors will be contacted to obtain data where possible. In case of multiple publications of the same study, we will try to extract and combine all data where possible. Where this is not possible, the original publication will be given priority over others.
COVIDENCE systematic review tool will be used for data extraction and quality assessment by both review authors NA and SR.25 As COVIDENCE provides options to choose templates for risk of bias assessment we will use custom templates for risk of bias assessment based on whether we are assessing an RCT or observational studies.
BCT CODING
The health promotion intervention content will be coded according to the behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques.23 Two qualified coders (NA and SR) will independently code behaviour change techniques, Kappa statistics and percentage disagreement will be calculated for the same. The two reviewers will resolve any discrepancies through discussion with third reviewer involvement to resolve differences if necessary. The intervention content will be coded for the presence (+) or absence (-) of behaviour change techniques (BCTs). To evaluate the use of BCTs in interventions, the percentage of individual BCTs across interventions and total number of BCTs per intervention will be calculated. The BCTs which have the most effect on our primary and secondary outcomes will be identified and tabulated.
RISK OF BIAS ASSESSMENT
As the review will include both randomized controlled trials and non-randomized studies, risk of bias assessment tools appropriate for the study design will be used. Two independent review authors will independently assess the risk of bias in each study included in the review. For randomized controlled trials (RCT) the risk of bias 2 tool (RoB2) following guidance from the Cochrane Handbook for Systematic Reviews of Interventions will be used.26 All the five domains of the RoB2 tool will be considered while assessing risk of bias namely evidence of bias arising from randomization process, deviation from intended intervention, missing outcome data, measurement of outcome and selective reporting of results. This tool will be used to report whether a RCT is at high risk, some concerns or low risk of bias.
For non-randomized studies, the risk of bias in non-randomized studies of interventions (ROBINS-I) tool will be used.27 Seven domains of the ROBINS-I tool will be considered, bias arising due to confounding, selection of participants in the study, classification of interventions, deviation from intended interventions, missing data, measurement of outcomes and selective reporting of results will be assessed. The ROBINS-I tool will be used to decide whether a non-randomized intervention study is at low risk of bias, moderate risk, serious risk, critical risk or has no information on which to base a judgment of risk of bias.
A summary of the risk of bias assessment and quality of the studies included in will be provided in the review and a narrative account of any serious flaws encountered in the studies will also be provided.
DATA SYNTHESIS
A narrative synthesis of the findings from the included studies will be provided focused around the type of interventions, target population characteristics, intervention content and robustness of evidence. Summaries of intervention effects in each study will be provided with calculation of risk ratio for dichotomous outcomes or standardized mean difference for continuous outcomes.
Careful consideration will be given to the appropriateness of conducting a meta-analysis. We anticipate that there will be limited scope for conducting a meta-analysis owing to the differences in intervention content, potential BCT’s and outcome measures across a small number of randomized controlled trials. However, we will summarise the data statistically where data available is sufficiently similar and of sufficient quality. Diversity across studies will be qualitatively assessed in terms of intervention (content, duration, frequency, provider and setting), participant characteristics, outcome measures and follow-up. If two or more studies are considered homogenous, we will analyze the statistical heterogeneity of the data using the Chi-square test and I2 statistic. The level of significance for Chi-square test will be set at P < 0.1. Values of I2 greater than 50% will be considered as indicative of substantial heterogeneity.28 In case of substantial heterogeneity, we will pool studies using the random effects model and in case of low or no heterogeneity, we will pool studies using the fixed effects model. Sensitivity analysis will be performed to investigate the effect of inclusion or exclusion of heterogenous studies. Evidence of publication bias will also be assessed.