 |
The Experiences and Perceptions of Unit Managers in Facilitating Oral Health in Adults with Intellectual Disability
Mary-Anne Simon, Margaret Cullen-Erickson, Chris Lloyd and Glenys Carlson
Abstract
This qualitative research investigated the experiences and perceptions of unit managers regarding their involvement with oral health management of adults with intellectual disability. Semi-structured individual interviews were conducted with eight participants working in four different area offices of a metropolitan disability service, whose experience as unit managers ranged from 1 to 17 years. Key themes identified in the interview data focused on unit managers' views of the oral health of this group, the support roles involved in the oral health of adults with intellectual disability, the priority of oral health, the experiences of the participants within the oral health system, and the strategies for supporting adults with intellectual disability in oral health management. Implications of the findings included the need to improve education for all persons involved in the oral health of adults with intellectual disability, to encourage a collaborative approach to oral health by workers within accommodation support services and the oral health system, and to enable adults with intellectual disability to maximally participate in their own oral health management.
Introduction
Oral disease is a major health problem for adults who have an intellectual disability (Faulks & Hennequin, 2000; Pratelli & Gelbier, 1998; Scott, March, & Stokes, 1998). The prevalence and severity of oral disease in this group are higher compared to the general population (Beange, 1996; Tesini & Fenton, 1994). High rates of dental caries, missing teeth, a high prevalence of periodontal disease, prolonged detainment of primary teeth, misaligned or additional teeth, and malocclusion are all indicators of poor oral health in adults with intellectual disability (Chiang, 1991; Gordon, Dionne, & Snyder, 1998). Poor oral health impacts negatively on nutrition, digestion, the ability to chew and enjoy food, facial shape and speech (Jurek & Reid, 1994; Scott et al., 1998). Under-diagnosis and differential oral health treatment contribute to the poor oral health of adults with intellectual disability (Cullen-Erickson, 1994; Cumella, Ransford, Lyons, & Burnham, 2000; Gordon et al., 1998; Reichard, Turnbull, & Turnbull, 2001). They have the right to the same advantages of good oral health as experienced by the rest of the community, including the possession of healthy, aesthetic and functional teeth and gums (Davies, Holloway, & Worthington, 1988; Scott et al. 1998; Tesini & Fenton, 1994).
Oral health may be affected by the limited understanding some adults with intellectual disability have of the importance of oral health management (Lindemann, Zaschel-Grob, Opp, Lewis, & Lewis, 2001), difficulty in communicating oral health needs (Faulks & Hennequin, 2000), anticonvulsant medications that impact upon gum health (Marshall & Bartold, 1999), and a fear of oral health procedures (Gordon et. al., 1998). Physical restraint and general anaesthesia (GA) are commonly used in treatment settings with adults who have fear and communication difficulties (Burtner & Dicks, 1994; Tesini & Fenton, 1994). Little has been written about alternative strategies to alleviate fear and overcome communication barriers with adults with intellectual disability within the oral health management context (Gordon et al., 1998).
People without disability usually manage their own oral health. Oral health management for individuals with intellectual disability often involves other people, such as employees within supported accommodation services (Beange 1996; Malmstrom, Santos-Teachout, & Ren, 2001). Supported accommodation is any living arrangement based in the community, providing people with an intellectual disability with support from paid workers (Young, Sigafoos, Suttie, Ashman, & Grevell, 1998). As part of this role, support workers may provide assistance with daily oral hygiene or accessing an oral health service. Within supported accommodation, organisational factors such as the challenge of recruiting, training and retaining high-quality support workers have been identified as impacting upon the oral health of residents (Ford & Honnor, 2000).
Unit managers are responsible for managing staff and overseeing the oral health management process for adults with intellectual disability (Disability Services Queensland, 2001). The knowledge, attitudes and beliefs these staff have about oral health management, impact upon the oral health outcomes of adults with intellectual disability (Beange, 1996; Davies et al., 1988; Faulks & Hennequin, 2000). Awareness of factors and strategies unit managers perceive to influence oral health management will assist in identifying how positive oral health outcomes for adults with intellectual disability can be best achieved.
Previous studies have focused on a variety of participant groups, including dental professionals (Bickley 1990; Cullen-Erickson 1997), parents of children with intellectual disability (Cullen-Erickson 1994), individuals living within institutions (Gabre & Gahnberg, 1994; Pregliasco et al., 2001) and support workers (Faulks & Hennequin, 2000). A study involving a participant group similar to this research interviewed 75 care managers working in residential homes for adults with an intellectual disability about their experiences obtaining dental services for the adults (Pratelli & Gelbier, 1998). The main barrier to care was reported to be the adults' reluctance to accept treatment. Improved communication between support workers of adults with intellectual disability and service providers within the oral health system was suggested.
The aim of this research was to identify strategies, which contribute to optimal oral health for adults with intellectual disability, by exploring the experiences and perceptions of unit managers about oral health management. Oral health management involves those activities carried out by an individual, or for an individual, which assist a person to achieve and maintain an optimal level of oral health. This may involve personal oral hygiene procedures, professional dental services and involvement in any other activity which acts to contribute to the maintenance of a healthy, aesthetic and functional set of gums and teeth (Cullen-Erickson, 1994; Davis, 1987). Being aware of strategies and understanding the factors unit managers perceive to influence the oral health management process will assist personnel working with this group to achieve desirable oral health outcomes for adults with intellectual disability. An increased understanding of the role of unit managers in this process was also expected. The research questions used in this study to determine how optimal oral health of adults with intellectual disability can best be achieved were:
- What are the unit managers' experiences with respect to the oral health management of adults with intellectual disability?
- Who does the unit manager believe has a role in the oral health management of adults with intellectual disability?
- What values, attitudes and priorities do unit managers place on oral health?
- What are the strategies unit managers believe to be effective in facilitating optimal oral health for adults with intellectual disability?
Method
Traditional social research in the area of dentistry has been characterised by the use of surveys, which provide participants with a structured, predetermined format in which to respond (Faulks & Hennequin, 2000). With a growing emphasis on education and prevention in the oral health arena, there is recognition of the benefits of exploring people's perceptions and how these may affect health-related behaviour (Nettleton, 1986). The qualitative approach used in this study enabled a detailed exploration of unit managers' perceptions and experiences within the focus area, as well as an indication of the priority participants place on oral health (Krefting, 1991; Patton, 2002; Pope & Mays, 1995).
Participants
Eight unit managers working in a metropolitan region within the accommodation support services of Disability Services Queensland were recruited for this study. Individuals who had worked within the unit manager role for less than 12 months were excluded. Recruitment initially involved convenience sampling followed by snowball sampling. Purposive stratified sampling was employed throughout recruitment, to include participants of both gender, and with varying ages, years experience in the unit manager position, and employment location. There were four male and four female participants, who worked across four different area offices within the regional service, and had between 1 and 17 years of experience as a unit manager. Participant recruitment was concluded when no new information was forthcoming, and saturation of themes had been achieved (Nettleton, 1986). This study received ethical clearance from the University of Queensland and Disability Services Queensland.
Data Collection Methods
In-depth semi-structured interviews were used due to the exploratory nature of the research. This allowed for the emergence of themes from information rich sources (Britten, 1995; Patton, 2002). Open-ended questions comprised the majority of the interview (see Appendix 1). The development of the interview schedule involved review of previous studies in the research area and input from two of the researchers with experience in accommodation services. The interview schedule was piloted with the first participant, who provided feedback regarding clarity and comprehensiveness of the questions.
Data Collection Procedures
After receiving an information sheet about the study, potential participants were contacted to ascertain their willingness to participate. A copy of the interview questions and a consent form were sent at this stage. All interviews were conducted in local offices of Disability Services Queensland. The commitment for each participant involved an interview of approximately one hour's duration and a review of a list of themes, which arose from the data analysis.
A low-key approach was adopted by the researcher during the interview process, interjecting only to seek clarification or expansion where necessary. With consent from participants, interviews were audiotaped and field notes containing informal observations and insights were recorded following each interview (Britten, 1995).
Data Analysis Procedures
Audiotapes and fieldnotes were transcribed. The coding process involved the research team reading the transcribed data, searching for recurrent thematic categories, and allocating code words to each category. A coding tree was developed to illustrate links between categories within the data. Entering the interview data into files within the computer software program N-Vivo facilitated the coding process (Qualitative Solutions and Research, 1999). Data in each thematic category were then synthesised and summarised. Similarities and differences between participants' experiences were noted, with particular focus given to strategies identified by participants as facilitating optimal oral health for adults with intellectual disability. Quotations of participants' statements were selected to illustrate specific experiences and perspectives.
Rigour
A number of strategies were employed to facilitate rigour in the research process. Paraphrasing was used during interviews to ensure the interviewer had correctly understood the participant's responses, and that the participant had understood each question (Britten, 1995). To allow for consistency in the research process, one researcher completed interviews with all participants, using the same interview schedule. Participant checks of a summary of the major findings followed completion of all interviews, allowing for feedback and comments (Krefting, 1991). These participant checks supported the overall findings. Credibility was facilitated by keeping a field journal to record experiences, reflections, comments and hypotheses as they emerged (Krefting, 1991). Two of the researchers who were experienced in qualitative methodology were involved in "colleague checking" throughout the research process (Krefting, 1991). At the data analysis stage, for example, four interviews were independently coded by members of the research team to identify key themes. Discussion was then held to review this list of themes and to check consistency of coding. Decisions made at this stage were based on consensus between team members. These four interviews were then re-coded, and the other interviews coded, using the finalised theme list.
The researcher who conducted the participant interviews has had limited experience with the participant group, which can be considered beneficial in qualitative research as it enables participants to ̉tell it as they see it" without interviewer-based influence (Patton, 2002). Other members of the research team have had extensive experience working in the health and disability services areas. The research team takes the stance that the oral health of adults with intellectual disability is strongly associated with a person's overall health and well-being.
Findings and Discussion
The major themes, which emerged from the interviews with the unit managers will be compared and contrasted in this section, along with reference to relevant literature. The themes to be discussed include support roles involved in the oral health management of adults with intellectual disability, the oral health status of this group, the causes and results of poor oral health, the priority of oral health, the experiences of adults within the oral health system and strategies for achieving optimal oral health for adults with intellectual disability.
Oral Health Management and Support Roles
The participants viewed oral health management as a component of the adults' overall health and well-being. Activities considered to be involved in oral health management were: daily oral health management, which included teeth-brushing, flossing, using mouthwash, gum care, eating healthily, and having a regime to manage oral health. Activities occurring within the oral health system included dental check-ups and treatment; oral health preparation, such as education prior to oral health activities; and management of oral health problems, which involved being vigilant to the possibility of oral health issues and responding when they arose.
The people identified by participants as having a role in the oral health management of an adult with intellectual disability included the adults themselves, support workers, unit managers, the specialist team (occupational therapist, speech therapist, psychologist) and other resource people, service providers within the oral health system, family members (who are often the person's Statutory Health Attorney), the general practitioner and advocacy groups. Most participants identified support workers as having the driving role with respect to supporting oral health management of adults with intellectual disability. "They're the ones identifying the problems... they're advocating for people, they're supporting, so, yes, they've got a big role actualy... because they're the ones having the hands on, all the time." (Participant 2)
The adults themselves were also considered to have an important role in their own oral health, being encouraged to participate to their maximum potential. To enable support workers to be sensitive to variations in the ability and participatory levels among the adults, unit managers indicated support was provided on an individualised and least restrictive basis. "So if people can brush their own teeth and if they can use a mouthwash and if they can use floss, then we encourage them to do that." (Participant 7)
Participants viewed the unit manager's role with respect to oral health management, as that of an overseer who makes sure the adults' oral health needs are taken care of, such as ensuring regular dental check-ups occur. They identified themselves as having a "distant" role from the adults, mainly supporting the support workers in their role. This support took on many forms, such as providing education, extra resources or personnel, maintaining staff's motivation about oral health, and being aware of support workers' issues and facilitating a problem solving approach to these. For example, prior to a support worker accompanying an adult to the dentist, the unit manager "might be able [to give] extra staff, it might be about talking through what sort of questions you're going to ask the dentist before you go, covering an understanding of why they're going." (Participant 3)
While the literature acknowledges the important role primary caregivers such as support workers have in the oral health management of adults with intellectual disability (Cullen-Erickson, 1994; Cumella et al., 2000), the presence of an individual to coordinate and advocate for oral care, such as a unit manager, is also considered to be a major predictor of success in oral health management (Tesini & Fenton, 1994). The role of the unit manager, the adult and the support worker should be valued in the oral health management process, as all have the potential to contribute to better oral health outcomes for adults with intellectual disability.
Oral Health Status of Adults with Intellectual Disability
Participants indicated they were aware of a number of oral health issues experienced by adults with intellectual disability, including bleeding and swollen gums, loosely set teeth, holes in teeth, and bad breath or halitosis. A number of participants had also supported adults who had missing teeth. When compared to adults without disability, participants felt this group's oral health "is not kept up to scratch the way it should be," and that generally people with an intellectual disability have "very poor oral health."
Participants questioned whether good oral health is a reasonable expectation for adults with intellectual disability, with particular reference to a perceived limitation in the oral health management performed by a support worker.
It's difficult. I think there's probably a perception that if everyone was vigilant in cleaning people's teeth, then they should probably be as good as anyone else in the community. But I guess as research has shown... you can probably only get to 80% efficiency that you get yourself. So I think it's a fairly difficult thing to get on top of and to maintain for people. (Participant 7)
A number of studies found better oral health outcomes for adults with intellectual disability who perform their own daily oral hygiene, when compared to those who are dependent on the support of another person (Carr, Sterling, & Bauchmoyer, 1997; Desai, Messer, & Calache, 2001; Faulks & Hennequin, 2000; Lindemann, et al., 2001). This highlights the importance of supporting adults to participate maximally in their own oral health management, and ensuring adults develop the self-help skills necessary for effective oral health management. This may include use of appropriate teaching strategies, modified techniques, practice and modeling.
Poor Oral Heath: Causes and Results
Participants identified a number of factors they believe contributed to the current oral health status of adults with intellectual disability. These factors included a lack of understanding of complete oral health management amongst family members, supported accommodation staff, and adults with intellectual disability (Pregliasco, et al., 2001); the difficulty adults and their support workers have in achieving complete oral health management (Carr, et al., 1997; Faulks & Hennequin, 2000); having a poor diet and taking anticonvulsant medications such as Dilantin (Hornick, 2002; Marshall & Bartold, 1999); difficulty communicating pain and other oral health issues (Disability Services Queensland, 2002; Tiller, Wilson, & Gallagher, 2001); and a reluctance by some dentists to provide services to adults with intellectual disability due a lack of understanding of their needs (Cumella, et al., 2000; Pratelli & Gelbier, 1998).
Participants attributed current resistance towards oral health management to dental experiences that were painful or stressful to "traumatic" past oral health experiences, such as the mass removal of teeth. These have been associated with fear and anxiety for adults with intellectual disability (Connick, Pugliese, Willette, & Palat, 2000).
There were two factors participants believed to have impacted on the adults' oral health, which were unique to this study. Firstly, participants felt support workers had difficulty advocating for adults when the dentist had decided on a treatment about which the support workers were unsure. "A lot of people tend to think medical professionals... dentists, doctors, whatever... they're God and we don't challenge them." (Participant 5). Secondly, in accommodation services, oral health management is provided reactively rather than proactively. Chiang (1991) stated that prevention should be the goal of a sound oral health care program. Participants' suggestions about the need to aim for proactive and preventative oral health management are discussed later in further detail.
Poor oral health can negatively affect the image an adult with intellectual disability presents to the community. "Not having teeth really makes it difficult for an adult in a community where so much is judged by a person's appearance" (Participant 1). Participants felt this emphasis on aesthetics had affected levels of acceptance by the general community, and had further contributed to low self-esteem amongst adults within this group. One participant indicated further implications related to this importance placed on image:
There's probably some correlation there with the amount of time that people are spent with [by supported accommodation staff]... this person's got pretty good teeth, and this person hasn't got real good teeth, you're less likely to sit there with them... so other areas of their development might well be impacted upon by the fact that they don't get the interaction that they should. (Participant 8)
Speech, eating and breathing difficulties, as well as bad breath, were reported to be the result of poor oral health.
Priority of Oral Health
Oral health was not high on the unit managers' daily agenda. Rather, it was seen as a component of their overall role of ongoing monitoring of health and well-being. Participants indicated the priority increased when behavioural or oral health issues arose.
I get more involved if there's actually an issue with one particular person... like when somebody right refuses to get it done, or if while brushing their teeth, they notice blood on the toothbrush or something. I guess I don't really give oral health much time on a daily basis.(Participant 7)
When compared with the priority participants placed on their own oral health, unit managers felt the priority of the adults' oral health was at least the same. One participant indicated a higher priority placed on the adults' oral health than his own. More variation was found between unit managers opinion about whether the priority they placed on oral health was appropriate. Some indicated "it's right as it is", whilst others felt it was not appropriate that oral health becomes a high priority only when issues arise.
It only becomes high when there's a problem. And that's probably not right, but that's my real life story at the moment. There's a whole heap of other competing demands... like huge amounts of paperwork... and unfortunately oral hygiene's not high on the list. So I suppose its that delegating, and you delegate that responsibility to the support workers and hope and trust that they're actually following through with it, and if there's issues then they'll bring them to your attention. (Participant 5)
The unit managers felt that support workers have a driving role in the oral health management of adults with intellectual disability, particularly in identifying and reporting oral health issues. It is important to explore the priority support workers place on oral health, as this has been found to affect the overall success of oral health management (Faulks & Hennequin, 2000). Whilst acknowledging the priority varied, participants stated that generally they thought support workers did not place a high priority on oral health. Attitudes of complacency amongst staff, a poor understanding of the importance and benefits of oral health management, and the historical low priority associated with oral health, were given as reasons for this low priority amongst support workers.
There are staff, for example, who used to work in the institutions where that was not the priority. To put it on them now that it is a priority, you will take care of somebody's teeth, as well as everything else, you're expecting the change of staff attitude to see at least it's an important part of the process. (Participant 4)
Participants felt the priority support workers placed on the adults' oral health varied depending upon a number of factors, including the time available within an eight-hour shift; the individual needs and communication abilities of an adult; if other areas needed attention, either on an individual basis or within the house; whether or not oral health issues were present; and the support worker's personal commitment to oral health. Tay (2002) found similar variation in the priorities, values and attitudes of support workers towards oral health of adults with intellectual disability. Thornton, Al-Zahid, Campbell, Marchetti, and Bradley (1989) indicated oral health can become a low priority for support workers if not properly monitored by someone who is responsible for overall care, such as a unit manager. Support workers need to be aware of the importance of oral health and the need for consistent, preventive oral health management in achieving improved oral health.
Experiences of Adults within the Oral Health System
The adults with intellectual disability were reported to attend dental check-ups regularly, either every 6 or 12 months, as well as on an emergency basis as required. The recommendation from the disability service in which the participants worked stated that people should visit a dentist bi-yearly for a routine check-up (Disability Services Queensland, 2002). Whilst not strictly in accordance with this recommendation, the attendance pattern in this group appears superior to findings from other studies, where adults living in the community reported being less likely to access dental care on a regular basis, and seeking care only when issues arise (Tiller, Wilson et al., 2001).
Many participants expressed a belief that during visits to the oral health system, adults with intellectual disability are treated differently to adults with no disability. Some unit managers also felt these differences had resulted in a poorer standard of care for this group as compared with the general population. Check-ups of shorter duration, the use of "socially unacceptable" practices such as lying over the top of adults, and a preference for certain oral health treatments over others, were all mentioned by participants as experiences of adults within the oral health system. While these are unconfirmed experiences, other studies have found similar results with respect to differential treatment based on a person's disability (Gabre, Martinsson, & Gahnberg, 2001; Pregliasco et al., 2001).
Participants believed a preference for extraction as opposed to treatment of decayed teeth was common, without consideration of the consequences for an adult with intellectual disability. "Would it have been you or I who had attended, they would have encouraged a more rigorous and lengthy treatment plan, rather than just the removal." (Participant 8) Another participant indicated that whilst she had heard of instances where adults had received dentures, she felt crowns and bridges were almost unheard of in the oral health treatment of adults with intellectual disability. Tesini and Fenton (1994) stated that routine restorative dentistry procedures can usually be completed for individuals with disabilities with little or no modification. Accommodation support staff should be encouraged to advocate for adults within the oral health system.
Participants reported that most of the adults they supported did not have private health care cover and were more likely to access low-cost services such as public hospitals and university training dental schools. Some participants expressed a belief that more effective and efficient oral health treatment could be provided through the private system. Participants indicated a preference for the private system based on beliefs that it provided shorter waiting lists, an ability to make a specific appointment time, better attempts by service providers to communicate effectively and develop rapport with adults, and selection of "appropriate" treatments by dentists for the adults. "We're talking about her going from having the rest of her teeth removed, to maintaining them and developing better standards of oral hygiene. That was a significant thing, allowing her to go through the private sector." (Participant 1)
Malmstrom et al. (2001) stated that being of a lower socioeconomic status and receiving treatment through the public system may affect the oral health treatment decisions made for this group, such as the decision to keep or extract teeth. Scott et al. (1998) however, indicated that the extra time and personnel often required in treating this group are more likely to be available in the public sector. Advocating changes to the public oral health system and better access private to oral health services were suggested.
Seven of the eight participants reported the use of GA and other restrictive practices in the treatment of adults with intellectual disability within the oral health system. Most participants indicated they felt dentists administered GAs automatically at the commencement of treatment sessions, using them as a behavioural management strategy. "There seems to be a general perception that all people with intellectual disabilities won't be able to cope with any procedures in visiting a dentist, so there's generally the knock out solution that everyone goes and has a General first." (Participant 1) There were mixed feelings amongst the unit managers as to whether or not they were comfortable with this practice. Some believed there was need for a GA in the oral health treatment of adults with intellectual disability. Others felt it was not possible for a dental appointment to happen without one, although indicated they felt the use of GA to be quite intrusive. In contrast one participant disagreed with the automatic use of GA, describing their use as "detrimental". This participant felt they should only be used after alternatives had been considered for managing an adult's behaviour, which was often a manifestation of fear of the dental environment. Alternatives to GA suggested by this participant included:
"Can they handle it?" [the dentist asking this at the beginning of an appointment], looking at the way they [dentist] deal with the person rather than how the person copes with things, are they acting appropriately in the procedure, doing everything the person needs, are they looking at other milder forms of medication to sedate them before a General, those issues (Participant 1)
Pratelli and Gelbier (1998) reported that their care manager participants viewed it as bordering on assault to force treatment under GA, unless adults were in pain or there were other needs. Further research into the use of GAs with people with intellectual disability in oral health treatment is needed. Support workers need to be aware of the alternative ways of assisting adults to feel comfortable throughout a dental appointment, so they can then advocate for these alternatives to professionals working in this area. Encouragement of alternatives would be consistent with a least restrictive approach.
Implications for Practice
Strategies for Achieving Optimal Oral Health for Adults with Intellectual Disability
Oral Health Strategies for Adults within Supported Accommodation
Collaborative planning
Cooperation and collaborative planning of the oral health management of adults with intellectual disability were suggested as important to the success of the process.
A positive experience that came out just recently was that we actually got together with staff from the hospital...the head dentist, myself, the health liaison person... we went there, they showed us around the hospital, we had a conference with the head doctor and the head nurse, and we came up with some strategies that we're able to work on. Having that conference and being shown round... and we're saying 'Oh, this is what we believe should have happened' and they took all that into consideration. That was absolutely great... and that's what we need more of. (Participant 5)
Input from both staff within both the oral health system and the accommodation service may assist in achieving complete oral health management. Participants suggested accommodation staff could effectively contribute to the planning process by providing accurate and relevant information about an adult's oral health, and educating dental professionals about the nature of a person's disability and ways to encourage acceptance of treatment. In turn, it was indicated that dental professionals could facilitate the process by providing feedback about what information is most useful, and discussing resources and equipment available to assist in the oral health management of this group. People with an intellectual disability have a greater need than most for comprehensive and coordinated care (Lennox, Beange, & Edwards, 2000). Tiller et al. (2001) suggested that forming alliances between community support teams and dental services may reduce the level of extractions this group receives and increase restorative care.
Team meetings
Fortnightly team meetings attended by supported accommodation staff were viewed by participants as an important opportunity for discussing the health and well being of each adult with intellectual disability. One participant indicated that whilst she hoped any oral hygiene issues would be raised by support workers in this context, "it's not something that's there on the agenda." (Participant 5) Oral hygiene must be strongly emphasized as a vital aspect of the total health care for adults with intellectual disability and receive appropriate attention in the group home setting (Thornton, et al., 1989). The low priority unit managers felt support workers place on oral health, as well as their personal low priority, may be associated with this current absence of direct prompting within team meetings.
Education for accommodation support staff
Participants believed an increase in the quality and quantity of support worker education would improve this group's ability to perform effectively in their role related to oral health. "Increased education... that's the crux, that's the bottom line. That's not about telling people [support workers] what to do, its about telling them how to do it, and showing them, helping them to do it." (Participant 5) Training for support workers was reported by participants to currently involve an initial induction followed by 18 months on-the-job experience. A number of unit managers felt oral health required more attention within this initial training. Ongoing and compulsory oral health training in the format of yearly "refresher" courses were also suggested by unit managers for this group. This suggestion was made by support workers themselves in Tay's study (2002).
Participants felt that increased education would raise the profile of oral health. Specific educational needs suggested for support workers included defining complete oral health management and its importance for adults with intellectual disability; support workers' role in the process; effective advocacy and support for adults within the oral health system; options for how to provide hands on assistance, such as modeling or using a hand-over-hand technique in daily care; departmental guidelines regarding oral health management; and products that can be used in supporting the oral health of adults. Other areas may include emphasising the importance of prevention and daily maintenance (Tesini & Fenton, 1994), and identification of simple oral health issues (Pregliasco, et al., 2001). Dental professionals, resource staff within accommodation services, practical demonstrations, videos, and sharing of ideas amongst support workers were all suggested as educational sources. Previous studies have shown better oral health amongst adults who received assistance from support workers who had received training in teeth brushing, than those who did not receive training (Lange, Cook, Dunning, Froeschle, & Kent, 2000). Increasing the quality and quantity of support worker education may contribute to improvements in the oral health of adults with intellectual disability.
Review of supported accommodation staff's workloads and responsibilities
A few participants indicated the need for a review of the current responsibilities and workload of unit managers within supported accommodation services. Participants felt that due to a large amount of time being spent in the office completing paperwork and other administrative duties, they were less able to keep their finger on the pulse and were highly reliant on support workers to monitor the adults' oral health. "There's more time actually spent here [in the office] than there is actually doing stuff in houses where... that's where we should be, I should be there checking up." (Participant 5) In their discussion of the oral health needs of adults with intellectual disability, Tesini and Fenton (1994) suggested that the presence of an individual to coordinate and advocate for daily oral care is a major predictor of success in preventive oral health management. Encouraging more direct involvement of unit managers in the oral health of this group may assist in preventing oral health issues in adults with intellectual disability.
Other staffing changes suggested by participants included increasing input from resource staff into the supported accommodation houses. This resource group included occupational therapists, psychologists, speech pathologists, health liaison officers and residential program officers. "We need more people on the go, we need more people educating staff, being able to develop plans. I think extra staff at that program officer level would help, or psychology or occupational therapy level would help." (Participant 6) Unit managers acknowledged the important role these staff have in the preparation, motivation and education aspects of oral health management. Resource staff may be involved with other accommodation services staff, adults with intellectual disability and their family members, as well as staff within the oral health system. The number and type of resource staff currently employed varied between area offices of the disability service involved in this study. Regardless of this, participants felt the group's input had contributed to a number of positive oral health experiences for adults, and that increased involvement could contribute to more adults experiencing such optimal oral health outcomes.
Departmental guidelines and capturing information
Participants acknowledged that there were a number of written departmental guidelines in place regarding oral health management of the adults living within supported accommodation. While these were given various titles, the guidelines featured within these documents outlined requirements such as the regularity of dental appointments, when daily oral health activities were to occur, and staff expectations with respect to support. Individualised documents were also present in some area offices, featuring information such as a personal oral health checklist and relevant historical information. Described as fairly comprehensive documents, the feedback from participants was largely positive regarding the impact these documents had had on the oral health of adults with intellectual disability; "I think the Health and Well-Being Manuals certainly have gone a long way to addressing needs in oral hygiene." (Participant 3)
The process of recording oral health information was raised by a number of unit managers as an area in need of improvement. For example after a dental appointment, information is generally only recorded about the oral health procedures; participants indicated little focus is given to recording an adult's level of comfort or feelings during the session.
What's probably going to be helpful is that we become better at recording situations that we've gone through, recording instances in people's lives a little better, so that we have that information on hand. If the person's not able to communicate themselves it's probably more important... so that people trying to support them in the future have a history to fall back on. (Participant 7)
One participant felt that improving the way information is captured, and having an individual's oral heath history available, would allow for a more proactive approach to oral health. A need for improved documentation amongst persons working within residential facilities for people with intellectual disability was identified in a study involving general practitioners and their experiences in providing services to this group (Lennox, Diggens, & Ugoni, 1997).
There was some inconsistency between area offices regarding awareness of written guidelines, and how oral health information was documented. Being well informed of a person's oral history and having ready access to guidelines could assist in oral heath management, by ensuring support is comprehensive and occurs within the context of historical impacts.
Oral Health Strategies for All Adults with Intellectual Disability Involve the person.
Participants indicated that adults with intellectual disability should be allowed input into their oral health management, and that their choices should be considered in planning processes. These could include choices about toothbrush colour, toothpaste flavour, when daily oral care should occur during the day, which dental service to access, and whether to use the public or private system. While it was believed encouraging input would facilitate greater cooperation from the adults, some unit managers felt that there were instances where an individual's input should be dependent on his or her decision-making ability.
Just because a person can make decisions about some things, doesn't mean they can make decisions about everything. 'Your choice is root canal treatment, or whatever, which one?'... don't go there. [We need to] communicate in the language the person knows and understands, limiting choice to a small number of real and achievable choices, identifying to people the risks attached. (Participant 8)
The importance of providing adults with information about the consequences of their choices, in a manner they can understand, was raised by this participant as part of the process of ensuring informed choice. Being given the opportunity to make choices has been suggested as a critical variable in the overall life satisfaction of individuals within this group (Kelly & Walsh, 1996). Encouraging adults to participate in choices regarding their oral health management, and ensuring support is provided in a least instructive and most informative manner, may enable adults with intellectual disability to have improved oral health and satisfaction with this component of their lives.
Education for staff within the oral health system
A review of the current education provided for staff working within the oral health system, with respect to adults with intellectual disability and oral health management was indicated to be needed by a number of participants.
Any changes... ? If there was more work done around training dental practitioners, around issues specifically relating to adults with intellectual disabilities. Not just the medical model side of things, but also the value of a person's life and promoting of a person's value through the way you speak to them, and the way you treat them. Not just looking at them as a person with an intellectual disability. (Participant 1)
Particular educational needs identified by unit managers for this group included awareness of the specific issues and needs related to adults with intellectual disability, how to effectively communicate with this group, how to determine an adult's comfort level during a treatment session, and how to address feelings of anxiety or fear if present. Current lack of understanding in many of these areas, particularly poor awareness of interpersonal and communication skills, may be associated with the reluctance of some dentists to provide services to this group. Having increased knowledge in treating individuals with intellectual disability was associated with increased willingness to treat this group amongst dentists in a Kansas study (Reichard et al., 2001).
While a number of studies have revealed the need for increased education of dentists (Cullen-Erickson, 1997; Cumella et al., 2000) and dental hygienists (Bickley, 1990), education for other staff within the oral health system was suggested in this study. "Admin staff as well... need to have an understanding of this group." (Participant 5) Waiting in a reception area was identified as a particular difficulty for some adults. Having coffee and picture magazines available, and giving the adult a specific appointment time may assist them to feel at ease and prepare them to receive treatment.
Education for adults with intellectual disability
Informing adults with intellectual disability about the activities involved in comprehensive oral health management, about how to properly complete these, about the importance and benefits of oral health management, and about why dental appointments need to occur were identified by participants as areas needing attention. Providing a variety of educational media, and tailoring these to the individual needs of each adult, were also suggested. "Some people are audible, some people are visual, and some people are physical (learners), so it all really depends on the person. Whatever really works for the person, we should be making sure that we're doing it." (Participant 6)
Participants proposed that an increased understanding of oral health amongst adults with intellectual disability would result in improved participation and increased ability by these individuals in oral health management activities, as they would be able to see a justification for the activities they were completing. "I mean it's no good saying 'we want you to spray your mouth with mouthwash' without giving a reason as well, because what's the incentive for that person to do that?" (Participant 6) In light of the finding that better oral health outcomes for this group have been linked with those adults who perform their own oral hygiene (Faulks & Hennequin, 2000; Lindemann, et al., 2001), greater focus should be given to educational programs for adults with intellectual disability, particularly those which concentrate on increasing an individual's own ability to maintain an adequate level of oral hygiene (Francis, Stevenson, & Palmer, 1990). A suggestion from one participant involved using a revised version of the educational packages currently used in schools, changing the information so it is presented in "an adult way."
Having a proactive and preventative approach to oral health
The way oral health is addressed and conceptualized by the disability service was suggested by a number of participants as an area which a more proactive and preventive approach. "Wherever possible, and as much as possible, we [should be] proactive in our approaches. I'm extremely conscious that for many people with intellectual disabilities, many forms of oral health treatment or service are reactive forms" (Participant 8). Being proactive involved considering all components of oral health management, including the importance of maintaining a healthy eating pattern. Participants suggested that support workers needed to view oral health as much more than just ensuring dental appointments occurred at appropriate intervals; "it's about being more proactive around that... its being aware that if people have had medication in the past how that impacts upon their gums, their state of teeth, those sorts of things." (Participant 3) Other ways in which oral health management could be proactive were suggested, including talking to the dentist about their clothing, as white coats were viewed as contributing to adults' fear of the dental setting; planning and collaborating with oral health staff, as has been previously discussed; and educating adults and their families about oral health procedures and the consequences of each prior to dental appointments.
Desensitisation was mentioned frequently as being used with adults who were fearful of oral health management, both within the domestic and dental practice settings. Encouraging an adult to simply hold a toothbrush, massaging an adult's neck and face, and experimenting with various toppings on a toothbrush, including water only, chocolate sauce, salsa and finally toothpaste, were examples of desensitisation within a domestic setting mentioned by participants. Participants suggested desensitisation or "groundwork" prior to a dental appointment, for example doing "drive-pasts" of the dental clinic, enabling individuals to go back to the setting a couple of times before they actually sit in the chair, and organizing for the dentist to first meet the individual away from the clinic. The goal of desensitisation was for the adults to come to view these clinics as non-threatening, as well as the equipment, people and processes associated with them. People most commonly involved in these proactive ventures included occupational therapists, program officers and support workers.
Preventive oral health activities that adults were mostly involved in included teeth-brushing at least once a day, attending dental appointments every 6 to 12 months, and looking after their diets. Using mouthwash and dental floss appeared not to be undertaken by adults. One participant indicated "I doubt that the flossing would happen; I doubt the mouthwash thing would happen either." (Participant 5) It was felt that these activities were not undertaken because of the difficulty support workers have in assisting adults with these intrusive practices, as well as the limited understanding a number of adults have of how to appropriately complete these activities. Tesini and Fenton (1994) suggested that there is no other group in which the need for preventive oral health is greater, than persons with intellectual disability. Strategies for overcoming these barriers to achieving preventive oral health management need to be further investigated. Some suggestions for alternatives to traditional oral health equipment, made by participants in this study, are discussed in the next section.
Individualisation of oral health management
Participants suggested that the oral health needs of adults with intellectual disability need to be met with an individualised approach.
And that's part of that individualisation. Two people live together, one of them has no concept of how to manage their own oral hygiene, the other is quite skilled in that - they don't get the same service, they don't get the same treatment. (Participant 8)
Participants believed that deinstitutionalisation has led to an individualised approach the oral health of adults with intellectual disability. This has occurred because the ratio of support workers to adults had been reduced. Three to four adults are currently supported by one support worker, allowing for more intense and focused attention to daily oral health management. It has also occurred because adults now have the freedom of accessing dental services in the community, and have input into the decision about which service they access.
The fact that we have the option where people can go to their own dentist is a better option, because it becomes providing a service to the individual, so that then becomes better. The reason its a better system is because people get better treatment, in so much as it's more timely... it's about managing their health more closely to them. (Participant 3)
One participant shared a positive experience, which had involved the team adopting an individualised approach and doing some background research as to why a particular adult had a strong aversion to teeth-brushing. Contacting people who had supported the individual in the past, including family members and psychologists, enabled the team to create a link between the individual's current behaviour and a traumatic experience in the past. A desensitisation process was implemented focusing on the individual needs of this adult; this resulted in increased participation by the individual in daily oral health care. Doing further investigations, and adopting an individualised approach to oral health management, may allow for improvements in the oral health of other adults with intellectual disability.
Considering alternatives to standard oral health equipment was discussed as a way in which oral health management could reflect the needs of the individual, particularly those for whom the standard equipment did not appear to support good oral health. Alternatives to the standard mouthwash technique included using swabs dipped in mouthwash, applying wash by a spray bottle or a syringe, and making a game of it where support workers attempt to outlast an adult with mouthwash in their mouth. Electric toothbrushes were identified as "one of the big steps forward" for adults with intellectual disability and oral health. A comparative study of the effectiveness of electric versus standard toothbrushes in reducing gingival, debris and calculus scores, confirms a preference for electric toothbrushes for adults with intellectual disability; however, this was only for individuals who used the brush themselves (Carr, et al., 1997). No alternatives to dental floss were suggested by participants in this study. As dental floss is effective in controlling plaque and preventing periodontal diseases (Pichel & Curtis, 1994), alternative strategies to regular flossing technique needs to be investigated. The impact of irregular or non-existent flossing on the oral health of adults with intellectual disability could also be examined in future studies.
Conclusion
This study has explored the experiences and perceptions of unit managers in the oral health management of adults with intellectual disability. The findings of this research are consistent with the existing literature in relation to the persons identified as having support roles in the oral health of adults with intellectual disability; the variability of the priority place on oral health amongst supported accommodation staff; the opinion that adults are treated differently within the oral health system as compared to the general population; and the association of better oral health outcomes for adults who perform their own oral health management.
Unlike previous research, this study identified the need to adopt a proactive approach to the oral health management of adults with intellectual disability. Improved oral health education for adults with intellectual disability, support workers, unit managers and oral health professionals may raise awareness of the importance of this area in the overall life satisfaction of adults with intellectual disability. Coordination and collaboration between the oral health and the supported accommodation systems was considered essential in the promotion of high standards of oral health. The implications of these findings indicate the need to determine the best method of providing education to each of these groups. Education for adults must be aimed at improving their own skills in completing daily oral health activities. Education for support workers, unit managers and oral health professionals need to address how to improve the oral health of this group, whilst ensuring this is done in a least restrictive and most comfortable manner.
The small number of participants in this research may limit the generalisability of the findings. By involving unit managers working in the accommodation support services of Disability Services Queensland only, the findings may also be organisation-specific and reflect the unique situation of this agency. However, the findings of this research are presented in sufficient detail to enable readers to evaluate the relevance to their situations (Krefting, 1991). Further research in the area of oral health and adults with intellectual disability could address the experiences of specialist and resource staff working within supported accommodation, who may have their own strategies for improving the oral health of this group.
Acknowledgements
We thank the unit managers who participated in interviews and to Dr Kryss McKenna for her helpful editing suggestions.
References
Beange, H. (1996). Caring for a vulnerable population. Medical Journal of Australia ,164, 159-160.
Bickley, S. R. (1990). Dental hygienists' attitudes towards dental care for people with a mental handicap and their perceptions of the adequacy of their training. British Dental Journal, 168 (9), 361-364.
Britten, N. (1995). Qualitative interviews in medical research. British Medical Journal, 311, 251-253.
Burtner, A. P., & Dicks, J. L. (1994). Providing oral health care to individuals with severe disabilities residing in the community: Alternative care delivery systems. Special Care in Dentistry ,14, 188-193.
Carr, M. P., Sterling, E. D., & Bauchmoyer, S. M. (1997). Comparison of the Interplak and manual toothbrushes in a population with mental retardation/developmental disabilities. Special Care in Dentistry, 14, 188-193.
Chiang, T. P. (1991). The Dental Needs of Adolescents with Down Syndrome. In C. J. Denholm (Ed.), Adolescents with Down Syndrome: International Perspectives on Research and Programme Development-- Implications for parents, researchers and practitioners. (pp. 129-135). Victoria, B.C.: School of Child and Youth Care, University of Victoria.
Connick, C., Pugliese, S., Willette, J., & Palat, M. (2000). Desensitization: Strengths and limitations of its use in dentistry for the patient with severe and profound mental retardation. Journal of Dentistry for Children, 67, 250-255.
Cullen-Erickson, M. (1994). Parents' experiences in assisting a person with an intellectual disability to achieve optimal dental health. Australian Occupational Therapy Journal, 41, 163-172.
Cullen-Erickson, M. (1997). Dentist's Perceptions of Service Provision to People with an Intellectual Disability. Unpublished master's thesis, University of Queensland, Brisbane, Queensland, Australia.
Cumella, S., Ransford, N., Lyons J., & Burnham, H. (2000). Needs for oral care among people with intellectual disability not in contact with community dental services. Journal of Intellectual Disability Research, 44, 45-52.
Davies, K., Holloway, P., & Worthington, H. (1988). Dental treatment for mentally handicapped adults in general practice: Parents' and dentists' views. Community Dental Health, 5, 381-387.
Davis, P. (1987). Introduction to the sociology of dentistry: A comparative perspective. Dunedin, New Zealand: University of Otago Press.
Desai, M., Messer, L. B., & Calache, H. (2001). A study of the dental treatment needs of children with disabilities in Melbourne, Australia. Australian Dental Journal, 46, 41-50.
Disability Services Queensland. (2002). Chapter 6-- Health Matters. Accommodation Support Manual.
Disability Services Queensland. (2001). Unit Manager. Job Description.
Faulks, D., & Hennequin, M. (2000). Evaluation of a long-term oral health program by careers of children and adults with intellectual disabilities. Special Care in Dentistry, 20, 199-208.
Ford, J., & Honnor, J. (2000). Job satisfaction of community residential staff serving individuals with severe intellectual disabilities. Journal of Intellectual and Developmental Disability, 25, 343-362.
Francis, J., Stevenson, D., & Palmer, J. (1990). Dental health and dental care requirements for young handicapped adults in Wessex. Community Dental Health, 8, 131-137.
Gabre, P., & Gahnberg, L. (1994). Dental health status of mentally retarded adults with various living arrangements. Special Care in Dentistry, 14, 203-207.
Gabre, P., Martinsson, T., & Gahnberg, L. (2001). Longitudinal study of dental caries, tooth mortality and interproximal bone loss in adults with intellectual disability. European Journal of Oral Sciences, 109, 20-26.
Gordon, S., Dionne, R., & Snyder, J. (1998). Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs. Special Care in Dentistry, 18, 88-92.
Hornick, B. (2002). Diet and nutrition implications for oral health. Journal of Dental Hygiene, 76, 67-82.
Jurek, G. H., & Reid, W. H. (1994). Oral health of institutionalized individuals with mental retardation. American Journal on Mental Retardation, 98, 656-660.
Kelly, J., & Walsh, P. G. (1996). Assessment of quality of life for adults with a learning disability in a community residence and in an institutional setting: How do they compare? International Journal of Practical Approaches to Disability, 20, 12-18.
Krefting, L. (1991) Rigor in qualitative research: The assessment of trustworthiness. American Journal of Occupational Therapy, 45, 214-222.
Lange, B., Cook, C., Dunning, D., Froeschle, M. L., & Kent, D. (2000). Improving the oral hygiene of institutionalized mentally retarded clients. The Journal of Dental Hygiene, 74(3), 205-209.
Lennox, N., Beange, H., & Edwards, N. (2000). The health needs of people with intellectual disability. Medical Journal of Australia, 173, 328-330.
Lennox, N., Diggens, J., & Ugoni, A. (1997). The general practice care of people with intellectual disability: Barriers and solutions. Journal of Intellectual Disability Research, 41, 380-390.
Lindemann, R., Zaschel-Grob, D., Opp, S., Lewis, M. A., & Lewis, C. (2001). Oral health status of adults from a California regional center for developmental disabilities. Special Care in Dentistry, 21(1), 9-14.
Malmstrom, H., Santos-Teachout, R & Ren,Y.-F. (2001). Dentition and oral health. In V. P. Prasher & M. P. Janicki (Eds.), Physical health of adults with intellectual disabilities (pp. 181-203). Oxford: Blackwell.
Marshall, R. I., & Bartold, P. M. (1999). A clinical review of drug-induced gingival overgrowths. Australian Dental Journal, 44, 219-232.
Nettleton, S. (1986). Understanding dental health beliefs: An introduction to ethnography. British Dental Journal, 161, 145-147.
Patton, M. (2002). Qualitative evaluation and research methods (2nd ed.). Newbury Park CA: Sage.
Pichel, M., & Curtis, N. (1994). Teeth and gums: An owner's manual. Gamma Publishing Oxford, Oxford, England.
Pope, C., & Mays, N. (1995). Reaching the parts other methods cannot reach: An introduction to qualitative methods in health and health services research. British Medical Journal, 311, 42-45.
Pratelli, P., & Gelbier, S. (1998). Dental services for adults with a learning disability: Care managers' experiences and opinions. Community Dental Health, 15, 281-285.
Pregliasco, F., Ottolina, P., Mensi, C., Carmagnola, D., Giussani, F., Abati, S., & Strohmenger, L. (2001). Oral health profile in an institutionalized population of Italian adults with mental retardation. Special Care in Dentistry, 21, 227-231.
Qualitative Solutions and Research. (1999). Nvivo Reference Guide. Melbourne, Australia: Qualitative Solution and Research.
Reichard, A., Turnbull, H. R., & Turnbull, A. P. (2001). Perspectives of dentist, families and case managers on dental care for individuals with developmental disabilities in Kansas. Mental Retardation, 39, 268-285.
Scott, A., March, L., & Stokes, M. (1998). A survey of oral health in a population of adults with developmental disabilities: Comparison with a national oral health survey of the general population. Australian Dental Journal, 43, 257-261.
Tay, Y.-C. (2002). Support workers' experiences in assisting adults with intellectual disability to achieve optimal oral health. Unpublished manuscript, University of Queensland, Brisbane, Australia.
Tesini, D. A., & Fenton, S. J. (1994). Oral health needs of persons with physical or mental disabilities. Dental Clinics of North America, 38, 483-498.
Thornton, J. B., Al-Zahid, S., Campbell, V. A., Marchetti, A., & Bradley, E. L. (1989). Oral hygiene levels and periodontal disease prevalence among residents with mental retardation at various residential settings. Special Care in Dentistry, 9, 186-190.
Tiller, S., Wilson, K. I., & Gallagher, J. E. (2001). Oral health status and dental service use of adults with learning disabilities living in residential institutions and in the community. Community Dental Health, 18, 167-171.
Young, L., Sigafoos, J., Suttie, J., Ashman, A., & Grevell, P. (1998). Deinstitutionalisation of persons with intellectual disabilities: A review of Australian studies. Journal of Intellectual & Developmental Disability, 23, 155-170.
Appendix 1. Interview Schedule
- Could you start by telling me about your role in overseeing the oral health of the adults with intellectual disability whom you are responsible for?
- Are there any experiences which stand out in relation to your involvement with oral health management and adults with intellectual disability?
Prompt: Are there any (other) effective experiences/challenges which stand out?
- What do you see as your specific responsibilities with respect to the oral health management of these individuals (direct service and organisational activities)?
- What factors do you feel have been the most significant in contributing to the effective oral health management experiences you have had (direct service and organisational)?
- What factors do you think have been the most significant in contributing to the challenging experiences you have had in this area (direct service and organisational)?
- Do you feel that any changes are required to help you in your work of overseeing the oral health management of adults with intellectual disability? If so, please explain such changes.
Prompt: This may include personal changes, organisational policy changes, worksite changes
- Can you think of any training or past experiences that have been useful to you in overseeing the oral health management of adults with intellectual disability?
- Do you ever draw on your own oral health experiences when considering the oral health needs of the adults with intellectual disability with whom you work?
- Amongst all of your everyday responsibilities, what priority do you feel should be given to oral health?
Prompt: Do you participate in activities on a regular basis with an aim to enhance your oral health?
- Do you feel that the oral health of adults with intellectual disability plays a role in their overall health and well-being? If so, how?
Prompt: Are the adults within this group encouraged to participate in activities on a regular basis which aim to enhance oral health?
What processes and guiding principles do you use in making decisions regarding the oral health management of adults with intellectual disability?
Prompt: What have you found helpful to say or do if you involve the adult with an intellectual disability in this decision making process? Have any family members or statutory health attorneys been involved in the oral health management decision making processes?
- Who do you believe (apart from yourself, if indicated earlier) has a role in the oral health management of adults with intellectual disability?
Prompt: Do you believe that the house-team members play a role?
- What processes do you believe these other people (who have a role in the oral health management of adults with intellectual disability) use in making decisions regarding the oral health management of adults within this group?
Prompt: How are the oral health needs of adults with intellectual disability prioritized by the house-team?
- Are there any factors relating to adults with intellectual disability in the area of oral health management that you would like to comment on?
- Do you know of other persons who share similar experiences to yourself in supporting adults with intellectual disability with their oral health management?
Submitted by
Mary-Anne Simon B.Occ.Thy., (Hons) is with the Division of Occupational Therapy, University of Queensland.
Margaret Cullen-Erickson B.Occ.Thy., M.Occ.Thy. is a Senior Occupational Therapist with Disability Services Queensland. Her research interests focus on oral health for people with an intellectual disability.
Chris Lloyd M.Occ.Thy., PhD is a Senior Lecturer with the Division of Occupational Therapy, University of Queensland. Her research interests focus on program evaluation for people with disability.
Glenys Carlson PhD was a lecturer and research supervisor with the Division of Occupational Therapy, University of Queensland at the time that this research project was undertaken.
Contact
Address for correspondence: Chris Lloyd, Department of Occupational Therapy, University of Queensland, St Lucia Q 4072 Australia. Email:
E-Mail: c.lloyd@shrs.uq.edu.au
Key Words
intellectual disability; adults; oral health; unit managers; supported accommodation
|
