Bringing oral healthcare to where people are: an implementation evaluation of an oral health education program on an inpatient mental health unit

Background In Canada, where access to healthcare does not ordinarily depend on ability to pay, oral healthcare has been the persistent exception. People living with serious mental illness are among those least likely to access oral healthcare. Oral health services have been integrated into existing healthcare settings, mostly as clinical treatment; however, the upstream work of education, prevention and promotion is less well documented. The Windsor Family Health Team's Oral Health Education Program (OHEP) brings upstream oral health services to people where they already receive care. Developed for primary care, it was subsequently delivered by a registered dental hygienist on an inpatient mental health unit at Windsor Regional Hospital. Methods We conducted a multi-source implementation evaluation, drawing on the RE-AIM framework, Proctor's implementation outcomes and the updated Consolidated Framework for Implementation Research to examine reach, adoption, acceptability, appropriateness and feasibility. Data came from patient questionnaires, a unit staff survey, and an interview with the program's Oral Health Educator. The study was originally designed as a prospective cohort evaluation, but too few participants completed follow-up questionnaires to support conclusions about change over time. Results Eighty-seven patients enrolled and three withdrew, leaving 84; 35 responded at 7 days, 38 at 30 days and 15 at 90 days. Participants included people adversely impacted by determinants of health: 9.5% identified as Indigenous, 52.4% reported an income below CAD $20,000, and 29.8% had been unhoused in the past year. Of 61unit staff surveyed, 88.5% had referred a patient to the program, 88.5% considered it well or very well integrated into the unit workflow, and 93.4% were satisfied or very satisfied with its implementation. Almost all responding patients said they would recommend it. The program was delivered two half-days each week, which limited how many patients could be seen. Conclusion Upstream oral health services were integrated into this inpatient mental health setting and reached people who face barriers to accessing oral healthcare. Study participant attrition is itself a finding, and points to compounding gaps in policy, practice, and what counts as evidence. This is an equity problem as much as a methodological one.