Sorrell, Caitlin
(2025)
A feasibility study for a randomised control trial on the effects of engagement with a dental anxiety online peer support group.
PhD thesis, University of Nottingham.
Abstract
The study presented in this thesis aimed to evaluate the feasibility of a Randomised Control Trial (RCT) on the effects of engagement with a Dental Anxiety (DA) Online Support Group (OSG) in an adult population. The purpose of a feasibility study is to ascertain whether an RCT should be conducted, can be conducted, and if so, how it should be conducted.
Background
DA is a common phenomenon, with an estimated 54% of the population in England reporting moderate to extreme anxiety. It is a condition that is more likely to affect women, younger adults and people from lower socio-economic backgrounds. DA can lead to avoidance of routine dental appointments, shame and stigma, and poorer oral health outcomes, and this cycle can be self-perpetuating. There is evidence that the impact of DA can be wide-ranging, negatively affecting self-esteem, health-related quality of life, eating habits and even relationships. DA often starts in childhood and a variety of exogenic and endogenic factors have been suggested as potential causes. Ways of managing DA currently include pharmacological (for example sedation or analgesia) and psychological therapies (for example hypnosis or cognitive behavioural therapy). However, pharmacological therapies only address the symptoms and access to psychological therapies is limited.
In the context of healthcare, OSGs are virtual communities, often focused on a specific condition or illness, where peers can share their lived experience, exchange information, provide and receive both emotional and practical support. OSGs can use a variety of platforms (for example chat rooms, discussion forums or social media sites) and can be either synchronous or asynchronous, moderated or unmoderated. People who live with conditions that are rare or that carry stigma are more likely to be motivated to join an OSG, and the anonymous nature of OSGs may encourage disclosure. Most OSG users are readers (commonly referred to as lurkers in the literature) rather than active posters. Some of the potential negatives of OSGs are misinformation, negative content and negative online behaviours. There is some evidence that OSGs can support behaviour change and therefore promote health outcomes, however much of that evidence is qualitative, based on a self-selecting population of existing OSG users, or has methodological issues.
Systematic Review
Systematic reviews can help assess whether an RCT should be carried out on a specific topic. Therefore, a qualitative systematic review was conducted in accordance with JBI methodology to explore the experiences of users of OSGs for adults living with DA. Rigorous searches were conducted across seven databases but yielded only 2 papers. This limited number of papers shows that OSGs for DA are an under-researched area. Both studies were considered of sufficient quality to be included in the review but had some methodological limitations. Meta-aggregation led to five synthesised findings, most of which were rated as moderately dependable. These synthesised findings indicate that participation in an OSG can be a positive experience for adults with DA and help bring about positive cognitive and behavioural changes.
Methodology
Pragmatism is the chosen paradigm for this feasibility study, along with a concurrent mixed-methods design (where qualitative and quantitative data are collected in parallel) as this reflects the complexity of the topic and allows participants’ perspectives to be considered. Both pragmatism and mixed methods are well-suited to a feasibility study.
The protocol was developed with input from a Patient and Public Involvement (PPI) focus group and panel, who provided input on their lived experience of DA and who gave feedback on a draft protocol as well as on the participant-facing materials (e.g. advert, questionnaire, participant information sheet). Their input was taken forward and shaped the final protocol that was granted approval by the University of Nottingham’s Faculty of Medicine and Health Sciences’ Research Ethics Committee in April 2023.
The study aimed to recruit 38 adults with moderate to high DA, as measured by the Modified Dental Anxiety Scale (MDAS), within 3 months. This sample size was based on a review of the literature on sample sizes for feasibility studies and allowed for an attrition rate up to 33%, based on evidence that online interventions can have high attrition. Recruitment took place through social media, predominantly through Facebook. Participants were randomly allocated to either a Wait-List Control (WLC) condition or to the OSG condition and asked to use it in a naturalistic manner (with no frequency or amount of time mandated) for a period of six weeks. Their usage of the OSG was measured by capturing logon data daily. At the end of the six weeks, semi-structured interviews were conducted with participants allocated to the OSG to explore the acceptability of the OSG intervention. Thematic analysis was conducted on the transcripts from the interviews. Participants completed pre- and post- measures of DA (MDAS) and intention to attend routine dental care (Dentist Contemplation Ladder). Descriptive statistics were produced to analyse the data.
Results:
40 participants were recruited within 3 months and attrition was lower than anticipated at 7.5%. Reductions in the mean MDAS score (indicative of a reduction in DA) were seen in both the OSG and the WLC conditions but were greater in the OSG condition. Increases in the mean Dentist Contemplation Ladder (indicative of a greater readiness to attend an appointment) were seen in both the WLC and the OSG conditions but again were greater in the OSG condition. The effect size based on the MDAS indicates that a sample size of 72 would be required for a fully powered RCT.
Thematic analysis generated 4 themes: “Initiation” which examines the barriers and facilitators to accessing the OSG, “exploration” or how participants navigated the OSG, “engagement” and what fostered or hindered participants participation in the OSG, and finally “benefits and outcomes” that the OSG had fostered. Most participants were positive about the experience, with a small number rejecting the OSG, having decided early on that it did not meet their needs.
From a process perspective, there was variation in the level of usage of the OSG. Overall, the number of times participants logged on to the OSG was limited with a mean of 3.6 times over six weeks. Participants found the sign-up process and the measures simple and easy to complete. The phone or Teams call that formed part of the sign-up process was well received by participants and may have helped reduce the risk of imposter participants.
Conclusions:
The results of the study indicate that it is feasible to recruit sufficient eligible participants for an RCT after taking attrition into account. The usage of the OSG was acceptable to the participants in this study, although some participants engaged more than others. The MDAS would be an appropriate main outcome measure for an OSG, although both measures provided useful insight and were acceptable to participants. A full RCT is therefore both feasible and necessary to further understand the effect of OSGs on DA.
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