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Table 3 Context-mechanisms-outcome configurations (CMOCs): The building blocks for programme theories

From: Exploring the contexts, mechanisms and outcomes of a torture, abuse and dental anxiety service in Norway: a realist evaluation

CMOC

Context

Mechanism

Outcome

Number 1, relates to programme theory 1

TADA is a state-funded service. It delivers both anxiety treatment and dental restoration. For many of these patients, the cost of dental restoration is unaffordable. The 2020 annual budget for the service was 85 million Norwegian kroners (around 8 million euros).

Increased accessibility: a vulnerable group can access services they would otherwise be unable to afford. This makes it easier for these patients to improve their oral health.

Altered focus: The service shifts from private to public.

An immediate outcome for patients is increased accessibility to services and hence increased service uptake. There are ripple effects for patients including improved quality of life.

Number 2, relates to programme theory 2

National guidelines set by the Norwegian government are open to interpretation. Some patients are in difficult life situations and may not always benefit from the full CBT dimension of the TADA service. Patients are heterogeneous in character.

The TADA teams tailor their approach by learning what the patient needs and they search for local resources in order to meet these needs.

The service delivers treatment, improving the oral health of patients who follow the service pathway. Not all patients meet the clinical assessment criteria for of alleviation of dental anxiety.

Number 3, relates to programme theory 3

The Directorate of Health controls the service. There is a lack of common meeting arenas. There is a lack of explicit leadership and guidelines from the Directorate of Health. Poor communication exists across teams (nationally and regionally). County legislation affects service delivery.

TADA teams become self-reliant and protectionist in their work.

The individual TADA teams work cohesively as a team but separate from other teams in the region.

Number 4, relates to programme theory 4

There is an increased incidence and severity of torture methods in countries from which migrants have fled. Accounts from the Directorate of Health reveal that few torture survivors have applied for the TADA service. Teams have adjusted to accommodate patients more quickly. There is possibly a lack of sufficient advertisement for the TADA service. When fleeing from conflict areas and trying to resettle in a new country, individuals do not necessarily prioritise dental anxiety and/or dental restoration. This patient group undergoes a long asylum interview in which their backgrounds are checked, and they are asked to describe their torture experiences. Being asked to do so again may be exhausting.

The patients may find the asylum process overwhelming. Their dental health is not prioritised at this given time. Patients were unaware that such a service exists.

The service is unable to reach and accommodate patients who have suffered from torture.