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Improving the oral health and related health behaviours of adults experiencing severe and multiple disadvantage (SMD): evidence synthesis and qualitative stakeholder research


Sheena Ramsay (Principal Investigator)

This study involved colleagues from Newcastle University, University of Plymouth, UCL, NHS England, and charities (e.g. Fulfilling Lives Newcastle/ Gateshead), including experts by experience. 


This project aimed to identify effective and long-term interventions that can improve the oral health and related health behaviours (alcohol and drug use, smoking and diet) of people with SMD, with the goal of improving their overall health and wellbeing. We undertook a review of international evidence to identify interventions that are effective and cost-effective in improving oral health, substance use, smoking, and diet in adults experiencing SMD. The review also considered resource implications and issues around implementation and acceptability of interventions. We also conducted interviews with policy makers and practitioners (London, Newcastle Upon Tyne, and Plymouth) and with people with experience of SMD (from Newcastle/ Gateshead) to understand factors that influence implementation and sustainability of these interventions, as well as gaps in provision and opportunities for the future to improve the oral health and related behaviours of adults with SMD. 





Integrated services are effective for reducing substance use in SMD groups – these included work therapy and housing (both abstinence-contingent and non-abstinence contingent), intensive case management; and integrated programmes combining substance use and mental health support. 


Substance use interventions in individuals with severe mental disorders were cost-effective compared to usual care and resulted in abstinence.


Implementation, sustainability of interventions as well as access to them is dependent on a variety of factors spread across wider environment and policy level, organizational level, inter-personal level and individual level. 


Implementation, sustainability and access to interventions depended on: 

  • Availability of funding; integrated and cohesive services.

  • Inclusive and tailored services, presence of outreach services, physical space and structure, knowledge of interventions, availability of training for healthcare providers.

  • Presence of support workers, motivation among service providers, relationship between service provider and person with SMD.

  • Wider disadvantages of people with SMD, their motivation for seeking healthcare, fear of services as well as stigma.


Integrated care for people experiencing severe and multiple disadvantage. 


Involving people with severe and multiple disadvantages in designing health interventions aimed at them. 


Bringing services closer to people with severe and multiple disadvantages. 


Investing in physical infrastructure and training of health and social care providers to build psychosocial skill sets.


Commissioning research that is relevant for SMD groups. 

Find out more

Protocol paper for reviews

Protocol paper for qualitative study



John et al, (2024). Factors influencing implementation and sustainability of interventions to improve oral health and related health behaviours in adults experiencing severe and multiple disadvantage: a mixed-methods systematic review, BMJ Open. 

McGowan et al, (2024). Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness of interventions, Plos One.

Conference Abstracts





This research is supported by the National Institute of Health and Care Research (NIHR) Policy Research Programme (NIHR200415). The views expressed are those of the author(s) and not necessarily those of NIHR or the Department of Health & Social Care.

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