Developing A Population Intervention To Promote Oral Health and Cancer Screening In Nursing Homes
Oral cancer will be diagnosed in an estimated 41,000 Americans in 2013. Nearly half of the incidence cases and 60% of the 8,000 deaths attributed to oral cancer occur in those over age 65. Early diagnosis—through screening—is key to survival. The Office of Oral Health of the Massachusetts Department of Public Health (MDPH, 2010) found that 34% of older adults in nursing homes have major to urgent dental needs with 25% of those individuals needing follow-up for soft tissue lesions, indicating they were at heightened risk for oral cancer and in dire need of screening. Oral cancer screening is a relatively simple and low cost cancer screening procedure, yet unlikely to be performed among this high risk population. The purpose of this study was to empirically identify a viable statewide intervention that would improve oral health and cancer screening in nursing homes.
We conceptualized this study using a framework integrating elements of the Health Belief Model, Transtheoretical Model, and Implementation Science. We worked with the MDPH, Harvard School of Dental Medicine, and Simmons School of Social Work to develop a sample frame of licensed long-term care facilities across the Commonwealth. A rigorous recruitment protocol yielded a study population of nursing home administrators eligible to participate in nine discrete focus groups (total participants = 34) during 2012. The interview guide had questions about the perceived benefits, barriers, motivation, and capacity of long-term care facilities to provide oral health care and oral cancer screening. During the two-phase analysis process, the research team individually and collectively examined each verbatim transcript in its entirety to determine salient topics and primary coding themes from a focused ethnography approach (Charmaz, 2006; Padgett, 2008). A further review utilized predetermined coding themes from the conceptual framework (Miles & Huberman, 1994). Discrepancies were resolved through a consensus approach
Findings indicate that while long-term care administrators are committed to provide oral cancer screening, competing demands for resources make screening a low priority issue. Other barriers include insurance regulations, funding, access to dental providers, and low knowledge about oral cancer risk among nursing home residents, family members, and staff. Participants reported that two factors would motivate them to elevate screening to a high priority: regulations and/or low-cost and easy access training for front line staff.
Conclusions and Implications
This paper suggests empirically grounded ways to implement oral cancer screening in nursing homes. Given the increasing interest in trans-disciplinary approaches to public health, social workers are uniquely positioned to address the barriers and to work across disciplines to develop training interventions for patients, families, staff, and specifically front-line providers who have the most contact with elders in long-term care facilities. Social workers also can provide educational opportunities that link oral health to general health for families, create alliances between nursing homes and dental programs, and monitor, evaluate, and disseminate health promotion strategies. Our findings provide formative data to support the development and testing of low-cost interventions across disciplines involved in the care of elders in residential facilities.