A MIXED METHODS IMPLEMENTATION STUDY ON A COMMUNITY-BASED ORAL HEALTH PROGRAM IN RURAL NEPAL

Author

• Amy Gray Szacilo

Year of Award

2026

Document Type

Dissertation

Degree Type

Doctor of Philosophy (PhD)

Degree Name

Public Health

Department or School/College

School of Public and Community Health Sciences

Committee Chair

Maja Pedersen

Commitee Members

Kimber McKay, Ethan Walker, Jessica Liddell, Donald Chi

Keywords

Community Health Services, Delivery of Health Care, Implementation Science, Nepal, Oral Health, Rural Health Services

Abstract

Background Nearly 3.7 billion people suffer from oral diseases globally and this burden disproportionately impacts rural and low-income communities. These disparities are particularly prevalent in Nepal, where the majority of oral health facilities are concentrated in urban areas, leaving rural communities with limited access to care. Community-based oral health programs can improve access to oral healthcare for rural communities. However, few studies have explored implementation contexts and outcomes of these programs.

Objective This package of three studies applied the Practical, Robust Implementation and Sustainability Model (PRISM) to evaluate the implementation of an augmented Basic Package of Oral Care (BPOC+) in Nepal to describe implementation contexts and outcomes.

Methods Study One applied a scoping review to assess existing literature on the BPOC as a multicomponent intervention. Studies Two and Three applied a sequential explanatory mixed methods design to quantitatively describe implementation outcomes within the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and qualitatively explore organizational and community perspectives through interviews and Photovoice methods to identify facilitators, barriers, and contextual influences on implementation. Study Three mapped qualitative findings from organizational staff and community members to RE-AIM outcomes.

Results Study One identified nine studies demonstrating multicomponent implementation of the BPOC, none of which applied theoretically informed models to explore implementation. For Studies Two and Three, organizational staff (n=22) were interviewed and for Study Three, a group of community members (n=10) participated in a Photovoice study. Collectively, Studies Two and Three identified multilevel influences on implementation and outcomes to include a community-engaged implementation strategy, organizational training protocols, positive perceptions among participants and stakeholders, public investment in oral health, participants’ care seeking norms and perceptions regarding oral healthcare, social diffusion of awareness, and several policy-level considerations.

Conclusion This dissertation shifts the lens of inquiry into oral healthcare from individual-level outcomes to encompass multilevel determinants of oral health influencing program outcomes. Findings support the need for community-engaged interventions addressing individual, structural, and systemic determinants. This research provides foundational knowledge that will inform improved implementation strategies for the BPOC+ in Nepal, and future iterations of community-based oral healthcare in other global rural settings.

Recommended Citation

Szacilo, Amy Gray, "A MIXED METHODS IMPLEMENTATION STUDY ON A COMMUNITY-BASED ORAL HEALTH PROGRAM IN RURAL NEPAL" (2026). Graduate Student Theses, Dissertations, & Professional Papers. 12682.
https://scholarworks.umt.edu/etd/12682