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This article questions an uncritical adoption of the evidence-based paradigm for interventions to improve oral health at a population level.
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A linear logic model that links the generation of research evidence with its use is overly simplistic.
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This article explores approaches to the evaluation of complex interventions in dentistry and how they can be embedded into policy and practice.
How Should We Evaluate and Use Evidence to Improve Population Oral Health?
Section snippets
Key points
Background
Half of the world’s population suffers from untreated oral conditions, affecting a total of 3.5 billion people in 2015; 2.5 billion people were affected by untreated caries in permanent teeth, 573 million children by untreated caries in deciduous teeth, 538 million people by severe periodontal disease, and 276 million people were affected by total tooth loss.1 Dental diseases produce large societal costs, both in terms of treatment costs and losses to productivity; for the twenty-eight
The challenge of generating the evidence
The process of generating robust research evidence has traditionally relied on randomized controlled clinical trials (RCTs) to empirically evaluate interventions.7 Any observed effect is pooled statistically and the evidence is then synthesized to create evidence-based policies.8 Research evidence is then either pushed from the research community (in guidelines or evidence summaries) or pulled by clinicians who are seeking evidence-based approaches to inform their approach to care. There are
Producing change in population oral health?
One of the key challenges relates to the relevance of the RCTs and the degree of their use to shape policy aiming to improve a population’s oral health. There is evidence that outputs from trials have had a direct impact on public health policy. Recently, Chestnutt and colleagues’32 Seal or Varnish? trial led to a near immediate cessation of a national sealant scheme across Wales in favor of a fluoride varnish scheme. They concluded that “in a community oral health programme utilising mobile
The application of theoretic approaches to help evidence use
Psychological theory is increasingly used to predict individual behavior change and improve the adoption of evidence.49 These theories set out to understand the proximal determinants of behavior including beliefs (cognitions), knowledge, and the attitudes and motivations that underlie an individual’s behavioral intentions and ultimately behavior.50, 51 The underlying assumption is that understanding behavior is enough to produce changes at scale.52 Such approaches have been used in dentistry in
What can implementation science offer?
Given the persistent and often intractable challenges of evidence-based health care, there has been a growing interest in the study of implementation processes and approaches to unpack the black box. Implementation research reinforces the assertion that evidence production does not naturally flow into evidence use. As discussed previously, people use tacit and collective knowledge to determine whether evidence is credible and whether it fits with their experience and practice.28 Evidence users
Discussion
This article argues that an uncritical adherence to the evidence-based paradigm is not always feasible, desirable, or ethical for complex health care interventions.74 In addition, it argues that evidence production is not enough to stimulate evidence use, particularly highlighting the importance of carefully considering the theoretic underpinnings of change and the role of the context for implementation.
There are several pragmatic steps that could be taken when designing trials of complex
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Disclosure Statement: The authors have nothing to declare.
Financial Disclosure: There are no known commercial or financial conflicts of interest or funding sources for any of the authors.