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Oral Health Social Marketing Scoping Report of Key Findings NHS Portsmouth


Report structure

Executive Summary 1.  Background & Objectives 2.  Methodology 3.  Summary of Qualitative Findings

8 16x20cm 72dpi RGB JPEG 12 16

General Attitudes to Oral Health

18

Brushing Behaviours Barriers to Accessing Dentists Trust/Fear

22 26

Apathy Cost Time Access/availability

4.  Audience Segmentation 5.  Influencer Interviews 6.  Recommendations Regarding Interventions 7.  Other Ideas

34 43 50 55 59

68 70 79 94

This project was commissioned by NHS Portsmouth. Uscreates were commissioned for the project through competitive tendering. Many people have kindly participated in this study. All people have agreed to their opinions, pictures and footage to be shared in relation to furthering the project. However, neither the identity nor the affiliation of the people whose opinions appear in this report or on film may be revealed or used for purposes beyond this project or by any organisation other than Uscreates and NHS Portsmouth.


Executive Summary


Executive summary

– Whilst there was often low involvement with oral maintenance, some people thought about their teeth a lot. Oral aesthetics played a central role in people’s confidence, particularly with men 16x20cm 72dpi RGB JPEG – Claimed brushing behaviours were adequate, particularly amongst young families. But holistic oral health could be very poor – Key ‘push’ factors to visiting the dentist included being in a set routine, a free service, fear of losing teeth, not wanting kids to have the same issues, experiencing severe pain and discomfort, the chance to get a clean & polish and the positive influence of Mums, wives and girlfriends (for young men) – Despite impacting confidence, aesthetics were very rarely seen to be a push factor in visiting the dentist. Some people were also putting up with significant amounts of pain and discomfort and self-treating – An array of factors saw people leave the dental system and become ‘dentally isolated’. These could be life-stage/ situational factors, cost-based issues, traumatic experiences or simply small nudges (that provided an excuse to reject what was often perceived to be a negative experience) – The five key barriers to accessing dentists that emerged were: fear/trust, apathy, cost, time and access/availability. The same barriers came into play when people did not visit the dentist or missed appointments – Fear is a very powerful emotive barrier that sees people leave the dental system for decades. It manifests itself in five main areas; unknown costs, being worse off, potential pain, feeling out of control and feeling judged. Underlying this fear is often an inherent lack of trust in dentists


Executive summary

Executive summary

– Much apathy surrounds oral health and it was rarely seen to be a high priority. Apathy stems from an “if there’s nothing wrong, why bother” mentality, knowledge gaps about the16x20cm link between health and general health and 72dpioral RGB JPEG knowledge gaps for young families about when to take young children to the dentist. Mums, wives and girlfriends were sometimes seen to play a positive role in pushing men through the apathy barrier – Three different cost barriers became evident in accessing dentists; paying when there was nothing wrong, paying for a negative experience and confusion about the pricing structure. There was a huge amount of confusion about the pricing structure resultant of the blur between public and private, and the band system – Very few people truly did not have the time to go the dentist, but time is inextricably linked to other barriers – Access/availability is still a very real barrier in Portsmouth. There is some confusion about how to actually access a dentist as the system is inconsistent in many areas. While the Dental Helpline was spoken about very favourably by influencers, the service is not good enough given the barriers that many have had to overcome to reach it. Real commitment is needed to persevere in long queues on an 0845 number – The 2006 dental contract has created stress for some of the dentists in Portsmouth – stress for the dentist and stress between the dentist and the patient. Some influencers believed the contract had created a dichotomy between patient care and the business element and incentivised treating the dentally fit and affluent – Overcoming the behavioural barriers identified will require a mix of service-side changes, communication, events and training. Outputs from the co-design event included; customer service helpline improvements, a ‘dispel the myth’ pricing structure campaign, oral health packs for young men, the dental academy, ‘chomp’ event, ‘buddy’ system, better packaging of treatment pricing, communications training for dental practices, Sure Start oral health, social networking, viral / social media and the emergency dentist


The accessing dentists barrier hierarchy The accessing dentists barrier hierarchy

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR


Behaviour change

Behaviour change

PUSH

People – ‘consumers’

PULL

Dental profession – ‘businesses’

Due to the nature of the barriers, behaviour change is going to be required on both the people and service side, in order to meet the behavioural goals required of this study


1. Background & Objectives


Background

Background

– Oral health is much more than healthy teeth and a nice smile, it is also essential to the overall health and wellbeing of an individual. Poor oral health and untreated oral diseases can adversely affect basic human needs including the ability to maintain proper nutrition and even communicate. Emerging science also points to important associations between gum disease and other serious medical conditions such as cancer, heart disease and diabetes (Department of Epidemiology and Public Health, University College London, British Medical Journal) – The oral health of Portsmouth residents was recently identified as a key health issue that needed addressing, to reduce health inequalities, and improve the overall health and wellbeing of the community. The Oral Health Needs Assessment (OHNA, 2007) singled out Portsmouth as having far worse oral health than the areas that surround it, particularly with regards to young people – young men and children under 5. Approximately 44% (2007) of Portsmouth 5 year olds had evidence of decay/missing teeth/fillings compared to just 32% within NHS Hampshire and an England average of 38%. A 2008 dental survey, commissioned by Portsmouth NHS to understand the needs of adults, also showed many adults in the area tended to be very reactive to dental problems and there were issues in understanding how to access services. Further, there were marked variations by ward. – A DPP board (Dental Procurement Programme) was recently established to oversee and direct the procurement of three new dental practices across Portsmouth and alongside these service level changes, a need for research was identified to build on existing insight around oral health and provide a robust tool-kit to inform social marketing interventions to improve oral health and maintenance within the city.


Uscreates were asked:

Uscreates were asked:

To undertake research to inform future social marketing interventions targeting young males (16-35) and young families (children under 5) accessing local dental services, and improving their personal oral hygiene, to ultimately reduce health inequalities and improve overall health and wellbeing


Behavioural objectives

More specifically Uscreates sought to identify the triggers and barriers to the following behavioural challenges amongst the target groups: – An increase in regular tooth-brushing, 
 with a 1450 fluoride toothpaste – An increase in awareness and use of the Portsmouth Dental Helpline – An increase in new/unique patients attending dental appointments – An increase in new/unique patients attending dental appointments non-reactively – A decrease in the number of people missing appointments

Behavioural objectives


2. Methodology


The research program Jan ‘10 to March ‘10

1. Desk Review / 
 Visual Analysis

2. RANTBOX / COFFEE-CUBE

The research program Jan ‘10 – March ‘10

3. Ethnographic 4. Influencer in-depth interviews interviews

5. Mystery shopping


The research program Jan ‘10 to March ‘10

The research program Jan ‘10 – March ‘10

1. Desk review and visual analysis •  A local and national literature review, drawing on the experience of similar projects and research, as well as analysis of the oral health category, was conducted. The results of this can be found on the blog http://oralhealthports.wordpress.com/ 2. The RANTBOX / COFFEE-CUBE touring ‘diary room’ •  n=86 x 10/15 minute ‘rants’ with young men and young families across Portsmouth (individuals not group sittings) •  Participants entered the box in groups of 2 to 7 •  Three RANTBOX (young men) and three COFFEE-CUBE (young families) sessions were held at various sites •  Sites included the Paulsgrove Healthy Living Centre, Cascades Shopping Centre, Highbury College, Mountbatten Leisure Centre and Guildhall Square •  Discussions centred around relationships with teeth, oral hygiene and going to the dentist •  Participants were given complimentary football tickets or £5 love-to-shop vouchers as a thank-you 3. Ethnographic in-home interviews •  n=12 structured in-depth interviews x 1.5 hours •  Interviews were conducted with a mixture of young men and young families who had not been to the dentist for between 3 and 20 years 4. Influencer interviews •  Up to 30 minute interviews were conducted with key contacts in the oral health field •  Interviews were confidential but included representatives from local dental practices (n=2 dentists and n=5 receptionists), the Portsmouth Dental Helpline (n=3 representatives), the dental academy (n=1), the dental committee (n=1) as well as health workers (n=2), an oral health promotions officer (n=1) and a Sure Start representative (n=1) 5. Mystery shopping •  The Uscreates team (using pseudonyms) made various attempts to join the dentist using the Portsmouth Dental Helpline, NHS direct and contacting the dentist direct, in order to better understand and evaluate the system


MAIN FINDINGS


3. Summary of Qualitative Findings


RANTBOX / COFFEE-CUBE highlights

RANTBOX / COFFEE-CUBE highlights


3. Summary of Qualitative Findings General Attitudes to Oral Health


Health and beauty blur

Tan = Good Health

Health and beauty blur

White Teeth = Youth

The literature review pointed to an increased blur between health and beauty with sales of whitening toothpaste having increased by 15% in the last 2 years. The desire for very white teeth was mainly only witnessed amongst the youngest men we spoke to. Some older men and families were actually opposed to this; “no need for pearly white teeth, that’s just wrong” % Source: Mintel ‘Britons put Hollywood smile ahead of hygiene


Relationship with teeth

Relationship with teeth

Young men (under 18)

Young families

Men SINKS and DINKS 
 (single income no kids / double income no kids)

Care about / motivated by: This age group tended to have few oral health problems and were most motivated by having fresh breath (for girls) and white teeth Influenced by: They had lots of influences on their oral hygiene including friends (peer pressure), facebook (photos always going up there), mums (still often buying their toothpaste or making them attend their free dental appointments) and girls (eager to impress)

Care about / motivated by: Men were most worried about losing their teeth and having ‘a nice smile’ (this was less to do with whiteness and more to do with structure). They were likely to have had some problems by this age and some were currently experiencing pain Influenced by: Girlfriends, wives and sometimes mum (even up to age 40!) still heavily influenced both brushing behaviours and dental visits

Care about / motivated by: Young families were most worried about aesthetics (again, less whiteness & more teeth structure). They were likely to have had some problems and some were currently experiencing pain. There was a strong sense they did not want what had happened to them to happen to their kids “I want something better for my own kids” Influenced by: Females in young families tended to make the oral health decisions, had few influences and lacked information

Whilst there was often low involvement with oral maintenance, some people actually thought about their teeth a lot  


Oral aesthetics were really impacting people’s confidence “If a girl looks at me, I will look away, I can’t smile at her. But a lot of my friends have missing teeth too”

“Teeth are really important to me, you know when I smile and that. That’s why I don’t have a lot of photos, because I got dodgy teeth and it bugs me and that. People take the mick”

Oral ‘aesthetics’ were really impacting people’s confidence

“If you’re out with people and you wanna laugh, sometimes you will hold yourself back because of the state of your teeth. Some people with bad teeth don’t come out of their shell”

“Sometimes I smile with my mouth closed, they’re always going up on facebook…”

Teeth aesthetics often played a central role in a persons confidence, particularly with men. However they were rarely doing anything about this. Aesthetic work was believed to be something sorted out in childhood. Otherwise it was considered too late – “It’s too late to sort out my teeth”  


3. Summary of Qualitative Findings Brushing Behaviours


Brushing behaviours

Brushing behaviours

Young men (under 18)

Brushing once or twice a day Most claimed to brush for about two minutes Mouthwash use was prevalent in-line with desire for fresh breath Mums often still bought toothpaste “Girls will think you’re minging so I brush twice a day when I go out”

Men 
 (SINKS/DINKS)

Young families

Brushing once or twice a day (mornings sometimes not enough time and evenings too much hassle)

Kids loved brushing when younger - as got older tended to become more difficult

A few brushing three times a day. And flossing too

Many techniques were being used songs, brushing together, timers etc

Mouthwash occasionally used as a substitute

Kids sometimes encouraged adults!

Most claimed to brush for about two minutes “i sometimes can’t be bothered to brush at night”

Claimed brushing behaviours were adequate, and particularly good amongst young families  

Many parents unaware of the time brushed for (some watched) “He loves brushing his teeth, he’s always asking to do it”      


Toothpaste

Toothpaste

– Mums, wives and girlfriends often made the toothpaste purchases – There was some awareness of fluoride but little awareness of levels of fluoride INSTEAD: – Some people had a favourite toothpaste - “I always use the one with the whitener and the fluoride” / “I always just use Colgate” / “I go with what I’ve always had” / “Aquafresh, it’s what I grew up with” – Some people were choosing toothpastes with everything - “I go for the ones with everything, including fluoride” – Some people were buying toothpaste based on perceptions of taste or freshness - “I use Colgate as when I changed I didn’t like the taste” / “I use it because it gives me the freshest feeling” – Children mainly used special toothpastes


Holistic oral health

“I’ve stopped drinking Coke completely, and only drink Fanta now. That’s not half as bad. If I buy a bottle, I’ll drink the whole thing by the end of the day, so I try to buy cans”

Holistic oral health

“He doesn’t always have this stuff you know. But he likes his Coke and his sweets and his Mum gives them to him when he’s good”

“I make sure he brushes first thing in the morning because he always has juice at night”

But holistic oral health could be very poor, and there was some confusion about what was ‘bad’ for you


3. Summary of Qualitative Findings Barriers to Accessing Dentists


Key motivators for accessing dentists

Key motivators for accessing dentists

– Being in a set routine (established when dental care was free) – The fact it was free – Not wanting kids to have the same issues – A fear of losing teeth – Experiencing severe pain / discomfort – The chance to get a clean & polish – Influence of Mums, wives, girlfriends  

NOT: –‘Minimal’ pain – Aesthetics

Before looking at the barriers to accessing dentists it was important to consider the motivators to going. Despite impacting confidence, aesthetics was rarely a motivator for going to the dentist and many were also putting up with pain for significant periods of time and self-treating


So when do people leave the dental system

So when do people leave the dental system…

LIFESTAGE / SITUATIONAL FACTORS

PRICE

TRAUMATIC EXPERIENCES

– Before 18, no routine established

– At 18, when it stops being free (significant numbers)

– Traumatic experiences – WOM or real i.e death, foreign dentists, pain, needles down throat etc). Will see people leave for decades

– When moving areas – Having kids - missed appointments with new priorities (taken off books) – Dentists retiring / going private

– Working, when it stops being free – Too expensive – Confusion about pricing structure

– Poor treatment (teeth growing back wrong, fillings falling out etc)

NUDGES

– Small nudges i.e. moody receptionist, not being told what is going on – because the dentist is generally perceived to be a negative experience, many looked for ‘excuses’ to leave the system, and a small nudge could be all that was needed

– An expensive experience

The above were the array of factors people cited for leaving the dental system. People who leave the dental system become list hoppers, emergency users or non-users


Key barriers to not going to the dentist

Key things ‘putting people off’ visiting: Sources: Adult Dental Health Survey Portsmouth

Key barriers to not going to the dentist

Barriers that emerged in qualitative research

Don’t know / Nothing

44%

Apathy

Cost

22%

Cost

 

Trust / Fear

Afraid 18%

Availability / Access

Availability

11%

Time

5%

Time

Barriers that emerged qualitatively were not ‘new’ but it was possible to fully explore there complexity and relationships. The same barriers came into play when people didn’t join the dentist or did not turn up for appointments


Barrier hierarchy Dentally isolated

Barrier hierarchy Trust /  fear   Apathy        Cost      Time   Access  /  availability   A7end  appointment  

Attending regular appointments

Regular appointments  

Some people experienced all these barriers, others just experienced one, as shown in the segmentation later


Barrier hierarchy

Barrier hierarchy Trust /  fear  

High level emotive barriers

Apathy      Cost      Time  

Lifestyle barriers

Access /  availability  

Service-side barriers

A7end appointment   Regular  appointments  

Some barriers were specific to the individuals, while others were created by problems on the service-side


Barrier hierarchy

Barrier hierarchy Trust /  fear   Apathy        Cost      Time   Access  /  availability   A7end  appointment   Regular  appointments  

When people missed appointments they reverted back to an earlier barrier (but often cited lack of time as a comfortable default)


Behavioural Theory

Barrier hierarchy

Maslow's hierarchy of needs (1943), Theory of Human Motivation

Access /  Availability   Apathy  /  Cost  /  Time   Fear  

This barrier hierarchy is loosely based on Maslow’s theory of human motivation (1943). He claimed people moved up the needs hierarchy sequentially, and lower level needs had to be satisfied before people would be motivated by any higher level need. For our purposes we have effectively inversed this hierarchy to accommodate overcoming barriers NOT being motivated. The more basic needs are at the base of Maslow’s motivational hierarchy, while it is the deeper, more complex emotive barriers that need to overcome when accessing dentists, before reaching any of the more functional access/ availability barriers,


Barrier hierarchy

Barrier hierarchy

The following sections explore the FIVE key barriers to emerge in the hierarchy. We need to think of these as hurdles people need to overcome

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR


3. Summary of Qualitative Findings Barriers to Accessing Dentists Exploring TRUST / FEAR

TRUST / FEAR


General trust issues

“I don’t really have friends, I have associates…”

General trust issues

“My neighbours keep telling lies about me… about drugs and parties and stuff”

“I mainly talk to my sister, if I talk to my sister, it won’t go no further”

“Friends get you into trouble…”

Some of the people we spoke to were living complex lives. For them trust was not something that was acquired easily and it was also easily broken. This context is important when considering the role of dentists within it


Dentists sometimes not trusted figures

Dentists sometimes not trusted figures

Some people really did not trust dentists, and there were many parallels drawn with the profession and car mechanics. “I feel like I do when I get my car fixed, they could spin you any old line�


Sources of fear

UNKNOWN COSTS •  Being told the right costs •  Being told the right course of treatment / over-selling •  Not understanding the cost structure

BEING WORSE OFF •  Poor treatment - experience and stories of teeth growing back wrong, fillings falling out etc

Sources of fear

PAIN (DEATH) •  Related to traumatic experiences, some only WOM death, needles down throat etc •  Instruments, treatment = pain and discomfort

BEING OUT OF CONTROL •  Panic attacks •  Totally In dentists hands •  Foreign dentists – things not being explained

BEING JUDGED •  Being looked down on •  Not being able to see what they’re doing •  Not being able to see what they’re thinking •  Being patronised •  Once teeth have got so bad, really hard to return (too late)

Most people are worried they’ll go, “what have you done to your teeth?”

Lack of trust translates into a fear of dentists. Fear is a very powerful emotive barrier that sees people leave the dental system for decades. This fear can stem from a lack of trust in dentist skills, treatment, bedside manner and charging structures


How far fear goes

“My teeth are knackered (laughs) I’ve hardly got any. I’ve got brittle teeth, so they break and don’t completely all come out, I’ve got bits of tooth in the gums. I have toothache everyday, I was up for about two weeks with it” Female, Mum, not been for 20 years, FEARFUL

How far fear goes…

“The pain of toothache, you seriously can’t get any worse than that. I often experience pain and just use paracetamol for that. It’s too late to sort out my teeth”

“I think about them all the time. Some people with bad teeth don’t come out of their shell. I just worry what they’ll say about the state of my teeth, I don’t think they’ll want to give me the help”

Male, not been for 19 years, FEARFUL

Male, not been for 20 years, FEARFUL

Fear is such a deep emotive barrier, it sees people putting up with significant amounts of pain and discomfort. Reluctant to admit to it, apathy can often mask a latent fear of dentists


Knock-on effects

Knock-on effects

“I’ve always had a thing for dentists, I think I got it off my Mum, as she is petrified of them. My Mum had a needle dropped down her throat. I’m concerned I’m passing my fear onto my daughter, as she already doesn’t want to go…”

This fear of dentists can become intergenerational and can therefore go on to affect whether young families will sign their children up to the dentist. If it is possible to encourage people who experience this barrier to at least take their children to the dentist, there could also be opportunities to tap into their personal fear at the same time


Don’t target fear with fear

Don’t target with fear

Bleeding

Puffiness

Recession

Bleeding gums during tooth brushing, flossing or any other time

Swollen and bright red gums

Gums that have receded away from the teeth, sometimes exposing the roots

Targeting fear with fear is not a good idea. These people are fearful anyway and often reject this idea. Positive messages or normalising would work better


Combating trust / fear issues

“Since having that chat to your team at the healthy living centre, talking about my teeth and all the things like that, that has really urged me on a bit, sitting there thinking about what teeth I could have… so that’s why I joined that dentist” Male, not been for 20 years, FEARFUL

Combating trust / fear issues

“I was recommended the hospital emergency dentist. At the hospital you’re in better, safer hands, they know what to do, they take more time and care. I’ve been telling everyone about it, they explained everything and reassured me”

Trust / fear issues can be overcome. For one respondent it was the opportunity for a friendly, positive interaction and a chance to reflect on his fear. For another, it was the emergency dentist, and the perception he was in ‘safer hands’


Fear summary

– Complex lives can equal complex trust – Dentists are sometimes not perceived to be trusted figures (by people who have experienced or just heard about poor treatment plans, expensive treatment or mistakes) – This lack of trust in dentists can translate into a powerful emotive barrier; fear – Fear manifests itself in five main areas; the unknown costs, being worse off after going, potential pain, feeling out of control, feeling judged – Fear can see people leave the dental system for decades and enduring significant amounts of oral discomfort – Trust / fear issues can be overcome. One respondent went on to book an appointment at the dentist, after a friendly and positive interaction about his oral health, and a chance to reflect on his fear

Fear - summary


3. Summary of Qualitative Findings Barriers to Accessing Dentists Exploring APATHY

APATHY


Barrier hierarchy

Barrier hierarchy

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR


Other priorities

HEALTH

Â

Other priorities

KIDS, FAMILY, PARTNERS, SOCIALISING

Respondents were asked to hierarchise the most important things in their lives. General health was always a high priority but in some cases this importance was not actually being acted upon. Oral health was however rarely a high priority. There is often very low engagement with this territory although, as discussed, people often think about about their teeth, particularly if aesthetics or pain are perceived to be a problem, or they have young children


What fuels apathy

What fuels APATHY

– Huge knowledge gaps about link between oral health and general health –“If nothing wrong, you don’t need to do anything” – Apathy sometimes masks fear - willing to put up with significant amounts (both pain and aesthetics) – Mums claimed to lack knowledge and information about when to take children to the dentist and what to do with regards to oral health. This fuelled apathy, if not being told, can’t be very important

There is very limited knowledge about the link between oral health and general health. This leads many to adopt an apathetic approach to oral health if there is perceived to be nothing wrong, or no pain and discomfort are experienced (even if something is actually known to be wrong). Some people were also willing to put up with significant amounts of pain / loss of confidence, when apathy masked a latent fear of dentists


The emergency dentist – a doubleedged sword

The emergency dentist – a double-edged sword

“Why go when you haven’t got a problem? I think it’s best to go when you do have a problem. I can always go to the emergency dentist if I need to…” Male, 27

The emergency dentist can fuel apathy for some (but also help them overcome trust issues)


The role of mums, wives and girlfriends

“The only time I go the Dr or dentist is when my Mums drags me there” Male, 26

“My girlfriend found 
 me a dentist” Male, 24

“I don’t think about my teeth much, only when my Mum nags me” Male, 33

“My girlfriend nags me to brush properly in the morning, and this is slowly affecting my behaviours. It’s a good thing, I don’t mind” Male, 28

The role of mums, wives, girlfriends

Mums, wives and girlfriends often played an influential role in pushing men through the apathy barrier, and may provide an opportunity for targeting. According to the Dental Helpline, most of the calls were from mums (of kids up to 35 years old!)


Apathy - Summary

– Oral health is often not a high priority – If nothing is wrong why do anything about it? – Apathy is fuelled by knowledge gaps about the link between oral health and general health and lack of knowledge / information on what to do for children with young families – Apathy sometimes masks fear – Mums, wives and girlfriends were seen to play an influential role in pushing men through the apathy barrier

Apathy - Summary


3. Summary of Qualitative Findings Barriers to Accessing Dentists Exploring COST

COST


Barrier hierarchy

Barrier hierarchy

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR


Exploration of cost barriers

Exploration of cost barriers

1. Paying when nothing wrong (linked to apathy) 2.

Paying for a negative experience (even if in pain / discomfort)

3. Unknown cost - huge confusion about what the cost is and who is eligible for exemptions

Three different cost barriers were evident from the research. There was huge amounts of confusion about the pricing structure (resultant of the blur between public and private and the band system)


Confusion over cost and eligibility

Confusion over cost and eligibility

“Most dentists are private, you just can’t get a dentist in Portsmouth”

“I think the normal dentist is like £12.50 for a check-up and the NHS is like £30?”

“I do worry but then they’ve made it all private haven’t they? 
 So I worry about the cost and everything”

“I though the NHS was free with a £6 donation if you were working? So do I receive free treatment on JSA or not?”

“I thought the NHS was all free and you couldn’t get treated if you were actually working?”

“I’m surprised at that, I thought it would cost much more?”

These quotes are from all across the target audiences

“I think my brother paid £200 the last time he went to the dentist. If I had to pay anything over £30, I’d rather just let it happen”


NHS Cost - Summary

Cost summary

If you are not exempt from charges, you should pay one of the following charges for each course of NHS treatment you receive: – Band 1 course of treatment - £16.50 This covers an examination, diagnosis (e.g. X-rays), advice on how to prevent future problems, a scale and polish if needed and application of fluoride varnish or fissure sealants. If you require urgent care, even if your urgent treatment needs more than one appointment to complete, you will only need to pay one Band 1 charge. – Band 2 course of treatment - £45.60 This covers everything listed in Band 1 above, plus any further treatment such as fillings, root canal work or if your dentist needs to take out one or more of your teeth. – Band 3 course of treatment - £198.00 This covers everything listed in Bands 1 and 2 above, plus crowns, dentures or bridges.

Although this banding system is simpler than previous costing structures, it is not simple enough or being communicated appropriately


3. Summary of Qualitative Findings Barriers to Accessing Dentists Exploring TIME

TIME


Barrier hierarchy

Barrier hierarchy

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR


Commitment issues!

“Lives are not structured how they used to be. They are too spontaneous, too reactionary…” Influencer Interview

For many, time-keeping and commitment were generally quite poor – a modern phenomenon? This not surprisingly trickles down to keeping appointments, dentist or other. During the research, some people were reluctant to commit to anything that wasn’t that day, or the next day. “Yeah I’d like to do it, but call me on the day”

Commitment issues!


Time

Time

– Time is linked to other barriers •  Often a suitable default barrier to mask fear – “I’m too busy…” •  Twinned with apathy i.e. far down the list of priorities •  Linked to access to dentists – However very few truly have time issues – possibly working Mums, extreme cases e.g. a fisherman we spoke to!

Very few people truly would not have the time to go to the dentist if they really wanted to and prioritised it. Instead time was inextricably linked to other barriers


3. Summary of Qualitative Findings Barriers to Accessing Dentists Exploring ACCESS / AVAILABILITY

ACCESS / AVAILABILITY


Barrier hierarchy

Barrier hierarchy

Some people have had to overcome many barriers to begin seeking out a dentist, so to reach this point and get knocked back can be significant

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR


The importance of the receptionist

The importance of the receptionist

For this reason it is really important the first encounter with the dental profession is a positive one. Often this can be with a dental receptionist who may not realise the significance of this role


Issues accessing – perceived or real?

– 28% reported difficulty accessing a dentist – Of 20% who had recently attempted to access, only ½ were successful – 68% would be more likely to go if they could make an appointment in the local area Sources: Adult Dental Health Survey Portsmouth

We know from the Adult Dental Health Survey (2008) that access was highlighted to be an issue, by the public, in Portsmouth, but were not sure at this stage whether this was perceived or real…

Issues accessing – perceived or real?


Access issues are real

“There’s a real lack of dentists in Portsmouth. The new surgeries are full before they’ve even opened, and the only way to get treated is getting luck with an appointment at a hospital at the weekend. I’ve tried the helpline, they say ring back tomorrow, or there’s nothing in your area, or they send you to Southampton General Hospital and that is too far and expensive and they only give you basic treatment…”

Access issues were very much real at the time of the research for this social marketing scope

Access issues are real


Access confusion

Access confusion

– Little consistency about how to sign-up with a dentist was evidenced in interviews and mystery shopping; some dentists you can register on the phone, some you have to go into the dentist, some you are not allowed direct contact with the dentist, some you are told to call the Dental Helpline etc – There is sometimes a mismatch between the NHS Choices website and reality (i.e. it says they are accepting fee-paying patients and they are not) – The batch system of releasing places can make it a lottery

There is some confusion experienced in how to actually access a dentist as the system was identified in this study to be inconsistent in many areas


Redefining ‘access’

OUR VIEW:

Redefining ‘access’ TARGET AUDIENCE VIEW: – Many will not travel further than immediate area (even for emergency) – Paulsgrove IS Portsmouth to many residents i.e. they never leave that particular area – Some don’t have cars – Too fearful to travel particularly with kids in tow i.e. which buses? where to go when got there?

Dental Practices Portsmouth (2008), NHS Portsmouth

Our view of access also needs to be re-defined. Many will not leave their immediate areas. There is more fear associated with getting to the dentist, particularly with young children


Portsmouth Dental Helpline

Portsmouth dental helpline

MYSTERY SHOPPING EXPERIENCE – Told mobile would be charged (although no amount stipulated)

“I wouldn’t ring an 0845 number as I don’t have the money…”

– Queue, no holding music (concerned had been cut off? But hadn’t) – 10.5 minutes before got through – Given 3 potential dental surgeries (subsequently chose the closest) – Told to phone back for chosen surgery in 3 weeks to be put on waiting list. Waiting list then going to be 4/5 weeks once on – Told could not phone dentist direct

Considering the barriers we now know some people have had to overcome to reach this point, the Dental Helpline needs some improvements to optimise its effectiveness at getting people back into the system. While the Dental Helpline was spoken about very favourably by influencers, the service is not good enough. The above charts Uscreates experiences of trying to use the service with a pseudonym. Some of the most vulnerable people we spoke to did not have money on their phones to call us, so even the 0845 number is an immediate barrier. While a 10.5 minute queue is not always the case, if this experience had been a member of the public, who had overcome a number of barriers to get here, would they have waited to get a dental home?


Access - Summary

Access summary

– Some people have had to overcome many barriers to reach this point so to get knocked back is significant – There is huge confusion about how to actually access an NHS dentist, with many inconsistencies in the system – Our view of ‘access’ needs to be redefined. Many will not leave their immediate areas – While the Dental Helpline was spoken about very favourably by influencers, the service is not good enough and needs significant improvements to optimise its effectiveness at getting people back into the dental system. Real commitment is required to wait 10 minutes on an 0845 number


4. Audience Access Segmentation


Segments

SEGMENT NAME: FEARFUL

Segments

SEGMENT NAME: IF IT AINT BROKE, DON’T FIX IT

SEGMENT NAME: FREEBIES

SEGMENT NAME: ARMCHAIR ACCESSERS

Dentally isolated

Trust / Fear Apathy Cost Time

Apathy Cost Time

Cost

Access / availability

Access / availability

Access / availability

Access / availability

Attend appointment

Attend appointment

Attend appointment

Attend appointment

Regular appointments

Regular appointments

Regular appointments

Regular appointments

Attending regular appointments

Where different groups of barriers come together, different segments emerge. As people experience all or some facets of the barriers explored, we believe it is important to tackle and target the barriers, and not the individual segments. All, for example will experience elements of access / availability barriers


5. Influencer Interviews


Influencer interviews

Influencer interviews

Up to 30 minute interviews were conducted with key contacts in the oral health field. Interviews were confidential but included:

– local dental practices (n=2 dentists and n=5 
 receptionists) – the Portsmouth Dental Helpline (n=3 representatives) – the dental academy (n=1), – the dental committee (n=1)

– health workers (n=2) – oral health promotions officer (n=1) – sure start representative (n=1)

The views of dentists were very hard to access. However all dentists were emailed about the program of research, by two sources, and told they could submit their views if they wished The following details the thoughts, feelings and experiences on the service-side Please note, this may not be representative of opinions throughout Portsmouth as only the views of those willing to contribute have been included, and it was a partially self-selecting group


The 2006 dental contract

WHY WAS THE DENTAL CONTRACT CHANGED?

The 2006 dental contract WHAT CHANGED?

End ‘drill and fill’ – where dentist paid for each treatment

Fixed contract now measured in UDA’s (units of dental activity)

Encourage dentists to spend more time on preventative work e.g. teaching how to care for teeth

UDA targets need to be met (or penalties) Free to choose whether to use NHS, private or both No charges for missed appointments

The 2006 contract saw some Portsmouth dentists leave the NHS system


The 2006 dental contract = stress

The 2006 dental contract = Stress

“Everything is quicker which means more stress for the dentist and more stress for the patient. You need to make sure an appointment doesn’t go over 26 minutes or you won’t make a profit. I feel like I’m living on a treadmill…” Influencer Interview

“These contracts cause stress for the practitioner and stress between the dentist and the patient. Of course you care about them as patients but the new contract creates this dichotomy between the business element and patient care…” Influencer Interview

The 2006 contract has also increased stress for some of the dentists who have stayed


A system that isn’t delivering against what it set out to do? “There is no financial incentive to do a scale and polish, as it’s in band 1. Doing it properly can take 20 minutes” Influencer Interview

A system that isn’t delivering against what it set out to do?

“There’s no incentive to do preventative work at all, and there’s no time to explain about hygiene. You can’t treat patients properly” Influencer Interview

“One or ten fillings the dentists gets paid the same, so a new patient who needs a lot of work you’ll effectively get penalised for” Influencer Interview

“The new NHS system incentivises dentists treating the dentally fit and affluent”


Missed appointments have become a real problem

Missed appointments have become a real problem

MISSED APPOINTMENTS COST SOUTH-EAST HAMPSHIRE DENTISTS £365,000 FROM APRIL 2006 TO APRIL 2008 = 16,000 MISSED APPOINTMENTS Source: 23rd April 2008 – Dentists Fury Over Missed Appointments

“This week 10 appointments have already been missed. We have consistently missed targets…” Influencer Interview “Snow this year has caused real problems, bad weather affected appointments and we won’t have time to make that back up” Influencer Interview “Even with SMS and telephone, it doesn’t help. I used to phone 80% on the day of the appointment and still some failed to attend, I think fear got the better of them” Influencer Interview “Particularly for those on benefits there is no commitment to it as there is no monetary value to it. It costs nothing, so it is worthless” Influencer Interview

To charge or not to charge? There were mixed views on whether bringing back charging would help with missed appointments. Some claimed it had worked before, others claimed people just refused to pay and then never returned


The Portsmouth Dental Academy

– Dental unit been there 5 years with 25 chairs – Opening new centre in September 2010 with 20 more chairs and 80 KCL students – Want to get people ‘dentally fit’ and then back into the system

The Portsmouth dental academy

“NHS dentists are on a treadmill. Sometimes 40 to 50 per day to meet their targets. Kids need time and they don’t have the time for this. This is where the dental academy could help. It could give them time to get used to dentists, allow time for wriggling etc” Influencer Interview (Oral Health Promotions)

– Very holistic focus but want ‘rich’ student experience – reaching dentally-phobic, dentally-isolated, those with significant oral health issues, children etc – FREE service

There was some support for the dental academy. Is the dental academy a potential ally, if we make sure they get people back into the system with a ‘dental home’?


Supervised Brushing

– “Daily supervised brushing with early years and kids centres” – “40 settings across Portsmouth” – “Based on Scottish model that really works” – “Evaluation next year but seems to be working really well” – “Creates a new skill-4-life / habit, gives them more exposure to fluoride” – “Trying to engage with parents too by chatting. Quite hard, many work and are busy” – “Service also flags really vulnerable children i.e. those with only stumps – for help”

Impacts of the supervised brushing may be related to the positive brushing behaviours Uscreates witnessed amongst the under 5’s? This is being evaluated soon All quotes direct from influencer interview

Supervised brushing


The Portsmouth Dental Helpline

The Portsmouth Dental Helpline

– 8 out of 10 referrals to the Dental Helpline come from the dentists themselves – Most calls to the helpline are from women - mainly Mums (sometimes with kids up 45!) – In the last year, 47% of calls to the helpline were emergency, 43% were registration and 10% were information

“There is a serious problem with the mentality of the people in Portsmouth. They will not travel. Even when people phone up the helpline for an emergency, they will not travel” Influencer Interview

“The Portsmouth Dental Helpline is fantastic and so is Kerry. It’s an awardwinning service…” Influencer Interview


6. Recommendations Regarding Interventions


Proposed interventions

We believe overcoming these behavioural barriers willRGB require 16x20cm 72dpi JPEG a mixture of service-side changes, communication, events, education and training. Outputs from the co-design event included:

- Customer service helpline improvements - ‘Dispel the Myth’- pricing structure communications campaign - Oral health packs for young men -  The dental academy -  Emergency dentist -  ‘Chomp’ event - ‘Buddy’ system - Better packaging of treatment pricing - Communication training for dental practices -  Sure Start Oral Health -  Social networking -  Viral / social media

These ideas are brought to life and explored in more detail below…


Proposed interventions

16x20cm 72dpi RGB JPEG

Please note these recommendations are only concepts and not final material. Where images have been used to represent and illustrate these concepts, they may be from other services


Customer Service Helpline Improvements

AIM: Service-side changes to optimise the effectiveness of the current system at getting people back into the dental system 16x20cm 72dpi RGB JPEG – An on-line booking facility option – A free-phone number (or better information about the cost of the call) – More call operators (answering calls more quickly) – A ring back service – 24 hours service for emergencies – Entertainment i.e. hold music / fact of the day / myth-busters – Health promotion / brushing tips while waiting – More immediacy i.e. For non-urgent cases a 7-day rule. Only dental surgeries that can take someone on within one week will make the books – A ‘thank you’ or ‘well done’ at the end of the conversation to reward for making an appointment / contacting dentist – A ‘travel pack’ option sent out after booking appointment detailing nearest parking to dentist / bus routes / bike routes / cab prices etc to target views of ‘access’ and widen dental options available – Option for ‘dental tour’ of surgery before appointment

Which barriers? TRUST / FEAR

ACCESS / AVAILABILITY


‘Dispel the Myth’ - Pricing Structure Communications Campaign AIM: To clarify the current confusion with the pricing structure and the associated fears about unknown costs – While changes to the national pricing structure are beyond the scope of his study, it is possible to clarify it locally 16x20cm 72dpi RGB JPEG – Call to action to phone the Dental Helpline (i.e. number given) – Factual but appealing posters / leaflets in surgeries / at bus shelters / at health centres etc

Fact?

I think my brother paid £200 the last time he went to the dentist..

It will not cost you more than £16.50 to get a check up on the NHS tomorrow

Which barriers? TRUST / FEAR

COST


Oral Health ‘Packs’ – Young Men

AIM: To retain young men in the dental system at 18 – Boys at 18 to receive two potential packs; a ‘Teeth MOT pack’ on their birthday and a ‘Pulling Pack’ at Freshers week 16x20cm 72dpi RGB JPEG – Packs could include information on pricing structure / importance of carrying on with appointments, breath freshener, £5 discount vouchers on first check-ups, refer-a-friend schemes, kiss-ometer etc – Opportunity to link into football club / rugby club?

Which barriers? COST

APATHY


The Dental Academy – Dental ally for the most dentally isolated AIM: To reach the truly dentally isolated, get them dentally fit and finally into a dental home – Win-win opportunity to target the most dentally isolated, fearful, under 5’s etc with an entirely free service, where the 16x20cm 72dpi RGB JPEG time will be taken to address any high-need problems, explain what is being done etc – However, very important a ‘dental home’ is arranged for individuals / families on ‘discharge’ – Clear pathway so patients do not become reliant on the service – Focus should not just be on the academy

SO LONG as they are referred to a dental home once ‘dentally fit’

Which barriers? COST

TRUST / FEAR

ACCESS / AVAILABILITY


The Emergency Dentist

Combating trust / fear issues

AIM: To reach the truly fearful, build trust, get them dentally fit and find them a dental home – Opportunity to direct the most dentally isolated / fearful with an entirely free service, where the time will be taken to address any high-need problems, explain what is being done etc and start the process of building trust – However, very important a ‘dental home’ is arranged for individuals / families on ‘discharge’ – Clear pathway so patients do not become reliant on the service

Which barriers? TRUST / FEAR


‘Chomp’ Event (including health professionals) AIM: Fun event to engage people with oral health – Targeting fear of being judged with an “it’s never too late…” / “you are not alone” overriding message 16x20cm 72dpi RGB JPEG – Using influence of Mums, wives and girlfriends – Health bus or stand in shopping centre to include: – Oral health ‘tent’ for quick once over / provide a rough quotation for cost of work – ‘Familiarisation appointments’ i.e. no treatment etc / chance to sit in the chair – Dentist of the Year voting! Building trust and positive news stories around dentists – £5 off check-up / treatment vouchers – Information on local dentists – ‘Dispel the myth’ posters / leaflets – Incentives for wives, mums, girlfriends to bring someone along to their current dentist (i.e. free hair cut / vouchers etc)

Welcom to Cho e mp!

Which barriers? TRUST / FEAR

Pompey Den,st   of  the  Year   2010!  

APATHY


‘Buddy’ System

AIM: Service-side changes to target fear of pain, noise, being judged and being out of control – Double appointment slots made available i.e. for TWO people 16x20cm 72dpi RGB JPEG – Buy One Get One Free (BOGOF) offers – incentive structure to bring a buddy along to current dentist (i.e. free hair cut / vouchers etc) – Parents invited into sessions with kids – Headphones with music / stories for those with fear of noise

Which barriers? TRUST / FEAR


Better Packaging of Treatment Pricing

AIM: Service-side changes to simplify the costing structure of different treatment options – Bronze/silver/gold package options to denote problem (i.e. two fillings) and three potential costing solutions 16x20cm 72dpi RGB JPEG – Pricing card to be shown to all patients – Pricing card to be displayed outside surgery so prices visible before making appointment – Better publicity / communications plan – Clarity on what treatments would NOT be available on the NHS and the cost of private ‘upgrades’ – DOH approval?

Which barriers? TRUST / FEAR

COST


Communication Training for Dental Practices AIM: To educate dental practice staff on patient barriers and improve on their communication skills – Receptionist / dental nurse / hygienist / dentist training 16x20cm 72dpi RGB JPEG – Short presentation of research findings to different audiences – Significance of different roles explored – Skills development / role play exercises in terms of greetings, empathy, bedside manner, judgment, explanations of costing, explanations of procedures, health promotions etc – Training in ‘dental tour’ when join surgery (receptionist) – Incentive for taking part

Which barriers? ACCESS / AVAILABILITY

TRUST / FEAR

COST


Receptionist research

The importance of the receptionist

AIM: To understand returning / new patients better and learn from them – Receptionists to identify out what barriers caused absence – Receptionists to identify what triggered return – Survey


Sure Start Oral Health

AIM: Introduce Oral Health into Sure Start Program – Working with children and parents one-to-one addressing key oral health messages – Drop in dental clinics one day a month at Sure Start centres 16x20cm 72dpi RGB JPEG – Blow up dentist chair for play – Session potentially delivered by new post - Community Dental Officer – Community Dental Officer ability to source dental practices for parents during session – Extension of current role or new role?

Which barriers? APATHY

TRUST / FEAR

ACCESS / AVAILABILITY


Toothpaste Loyalty - Kids

AIM: To embed positive toothpaste choices in young children – Opportunity to do more around encouraging better toothpaste choices earlier – Based on the knowledge that brand behaviours in childhood often continue on into adulthood (reference?) – Maximise on what is important to them i.e. taste / freshness / ‘everything’ – Tackle the notion a special toothpaste is required for kids


Social Networking

AIM: Opportunities to engage people with oral health in light-hearted way – Awareness-raising push to support other elements of intervention – Kissometers, group brushing at football club, extreme cleaning etc – Reference to site in ‘pulling pack’ – Promotion to large audiences at Fratton Park / cinemas / Guildhall TV screen etc – Sustainability – people need to ‘sign-up’ to campaign so we have contact details

Which barriers? APATHY


Viral / Social Media

AIM: Use social media to support wives, girlfriends, Mums and friends to encourage loved ones to visit the dentist – Create facebook / smart phone apps which help partners and friends to nudge loved ones to visit dentist e.g. transform profile pictures to vision teeth in 3 – 15 years time or kiss-ometer ratings – Provide ways of sharing images virally to reach large audiences (like dancing elves)

Which barriers? APATHY

Visit dentist every 6 months

Visit dentist every 3 years

Never visit dentist


‘Street Dentists’

AIM: To come to the target with information / education and support – A regular service / community presence – Making information, education and support more accessible

Which barriers? TRUST / FEAR

APATHY

TIME


Raising the ‘value’ of appointments

The importance of the receptionist

AIM: To educate people on the value of having a dentist appointment – Embed onus on personal responsibility – Explain impact on others / waiting lists

Which barriers? APATHY


7. Other Ideas


Holistic Oral Health

AIM: To continue to educate on the impact of diet on good oral health – Focus on sugary drinks and snacks as well as time of eating / drinking / brushing


Moving House Print Campaign

AIM: To prevent people becoming dentally isolated when they move house – Based on the knowledge people are likely to DNA and leave the system, if they move – Message – “speak to the receptionist to make sure we are still the best dentist for you..” – Receptionists directing people to Dental Helpline


Education on the importance of oral health

AIM: Target knowledge gaps about the link between oral health and general health – Awareness-raising to allow the population to make an informed decision regarding the accessing of dentistry services

Which barriers? APATHY


Barrier hierarchy

ABILITY ACCESS / AVAIL

TIME

COST

APATHY TRUST / FEAR

NHS Portsmouth Oral Health: Scoping Report  

A report detailing the behavioural insight work and attitudinal segmentation affecting oral health undertaken by Uscreates for NHS Portsmout...