Supervised Toothbrushing Programmes: Understanding Barriers and Facilitators to Implementation.

Objectives: Supervised toothbrushing programmes (STPs), whereby children brush their teeth at nursery or school with a fluoride toothpaste under staff supervision, are a clinically and cost-effective intervention to reduce dental caries. However, uptake is varied, and the reasons unknown. The aim was to use an implementation science approach to explore the perspectives of key stakeholders on the barriers and facilitators at each level of implementation of STPs.

Methods: This qualitative study involved individual interviews and focus groups with a purposive sample of stakeholders involved at all levels of implementation of STPs: (1) policymakers; (2) providers of STPs; (3) nursery/school staff; (4) parents/carers; and (5) children (aged 2-6 years old) across England. Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR).

Results: A total of 159 stakeholders were interviewed (40 individual interviews and 17 focus groups) across all levels of implementation. Barriers and facilitators to STP implementation were identified across 35 of the 39 CFIR constructs. Four themes were identified that determined STP implementation: (1) acceptability of STPs; (2) external 'make or break' conditions; (3) the importance of engagement across the system; and (4) desire for centralised support.

Conclusions: This is the first study to qualitatively explore the barriers and facilitators to STP at all levels of implementation underpinned by an implementation science framework. The findings have strong implications for policymakers who wish to implement STPs, highlighting the need for careful consideration of the adaptability of the programmes, the role of formal and informal engagement systems, and the need for centralised support. This work has facilitated the co-design and piloting of a supervised toothbrushing implementation toolkit, which provides a central hub of resources and good practice to optimise implementation of STPs at scale.