Enhancing Diabetes Screening Among Oral Healthcare Professionals: A COM-B Model and a Theoretical Domains Framework Approach

Abstract

Background/Objectives: Early detection of undiagnosed prediabetes (PD) and type 2 diabetes (T2D) could prevent or delay the onset of diabetes and its complications. The dental setting has been suggested as a location for expanding diabetes screening in primary care. This study aimed to investigate behavioural factors that influence an oral healthcare professional’s (OHP) participation in diabetes screening and their decision to refer individuals at a high risk of diabetes for medical follow-up and confirmatory diagnosis. These factors provide targets for future interventions to encourage screening implementation and increase referral guideline compliance. Methods: This qualitative study utilised OHPs who had participated in a diabetes screening trial in Victoria, Australia. Qualitative, semi-structured interviews were conducted by telephone or videoconferencing and transcribed and analysed thematically. The themes identified were deductively mapped onto the Capability, Opportunity, Motivation, and Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). Results: In total, eight interviews were conducted (seven dentists and one oral health therapist). Five COM-B domains were identified: reflective motivation, automatic motivation, social opportunity, physical opportunity, and psychological capability. Nine TDF domains were associated with issues related to knowledge, the environmental context and resources, memory, attention and decision processes, skills, social influences, beliefs about consequences, emotion, beliefs about capability, and social influence. Conclusions: This is the first study to investigate the factors influencing an OHP’s participation and decision making in diabetes screening and referral processes in the dental setting. The results demonstrate that OHPs need more education and training to screen for diabetes in dental clinics. This study represents the first step in developing interventions to target these factors and improve the effectiveness of diabetes screening in the dental setting.

1. Introduction

It is estimated that 10% of the global population (537 million people) has diabetes [1]. In Australia, approximately one in twenty people (1.3 million) has diabetes [2], and one in six people has prediabetes (PD)—blood glucose levels higher than normal but below the threshold for a diabetes diagnosis [3]. Without intervention, it’s estimated that 5–10% of people with PD will progress to type 2 diabetes (T2D) each year [4]. Additionally, one in four individuals with T2D is thought to be unaware that they have the condition [5].

Since up to half of the people with T2D have complications at diagnosis [6], opportunistic screening has been advocated to detect asymptomatic individuals with diabetes in order to implement early interventions to delay or prevent the onset of diabetes and its associated complications [7].

Diabetes screening typically uses a non-invasive risk assessment to identify those at a high risk for T2D, followed by biochemical testing for positive cases to confirm diagnosis [8]. One such tool is the Australian type 2 diabetes risk assessment tool (AUSDRISK), a short questionnaire developed to estimate the risk of progression to T2D over five years [9]. Participants identified as ‘intermediate risk’ or ‘high risk’ by the tool are advised to undergo further testing to determine their glycaemic status [8].

To increase diabetes screening rates, utilising additional primary care locations, such as the dental setting, has been suggested to opportunistically screen for the disease [10]. Previous studies investigating the feasibility of diabetes screening within dental settings have found that the process is generally acceptable to OHPs [11], the dental patients offered screening [12], and the medical professionals (GPs) responsible for diabetes diagnosis [13].

Screening for PD and T2D in the dental setting is not a single step, but instead represents a pathway comprising multiple steps, which, if completed, results in the diagnosis of an individual’s glycaemic status (Figure 1). If any of the steps in the screening steps are interrupted, the protocol is not completed, and the patient’s diagnosis remains unknown.

This study builds on the “Identification of type 2 diabetes and prediabetes in the oral healthcare setting clinical research trial” (iDENTify) that developed and evaluated the use of the private dental settings for identifying individuals with undiagnosed PD and T2D [15]. The iDENTify study highlighted two issues in the screening process, leaving the glycaemic status of over 75% of at-risk participants unknown. Firstly, nearly half of the individuals who screened positive were not referred by their OHP to their GP for further assessment, contrary to the screening guidelines [15]. Secondly, three quarters of participants who were referred did not comply with the referral advice to attend medical follow-up. The non-referral of individuals identified at a high risk of diabetes represents a missed opportunity, which potentially has significant implications on the effectiveness of diabetes screening in the dental setting.

OHPs are exposed to an increasing number of evidence-based guidance on many aspects of oral healthcare. But the availability of clinical guidelines does not guarantee their use, with research on oral health guideline adherence finding compliance to be low [16]. There are currently no studies exploring the factors that influence an OHP’s decisions to comply with referral guidelines for medical follow-up as part of a diabetes screening protocol. This study firstly aims to identify factors that influence an OHPs’ decision to screen eligible patients for PD and T2D during a routine dental examination. The second aim is to identify factors influencing an OHP’s decision on whether to follow the screening referral guidelines or not. Understanding the determinants of these behaviours enables the development of future strategies that aim to improve diabetes screening participation and referral rates.

2. Materials and Methods

2.1. Theoretical Frameworks

To inform the development of interventions that encourage OHPs to adopt diabetes screening in private dental settings and to increase their compliance with referral guidelines, this study utilised the COM-B model of behaviour, and the Theoretical Domains Framework (TDF).

The COM-B model is the first hub of the Behaviour Change Wheel (BCW). The BCW offers a systematic guide for developing effective behaviour change interventions by connecting factors that influence behaviour with appropriate intervention functions and policy categories that then enable the selection of behaviour change techniques [17]. The COM B model (Figure 2) proposes that the key factors that influence a person performing a behaviour are capability (physical and psychological), opportunity (social and physical), and motivation (reflective and automatic) [17]. Physical capability (C) is described as the individual’s physical strength, skills, and stamina, and psychological capability (C) represents their knowledge and the necessary thought processes to perform a behaviour. Opportunity (O) is defined as the external factors that either facilitate a behaviour or reduce its likelihood to occur. Opportunity has two components: social opportunity, which is the cultural norms and social cues and influences that encourage or discourage a behaviour, and physical opportunity, which constitutes environmental cues and resources [18]. Finally, motivation (M) is the conscious and unconscious processes that drive and enable behavioural change. Motivation is divided into reflective motivation, which involves conscious thought processes such as planning, intentions, and evaluations, and automatic motivation. Automatic motivation encompasses habit, instinct, impulses, and desires [19]. For behaviour to change, there needs to be a change in one or more of capability, opportunity, and motivation, and these can provide targets for behaviour change interventions.

The COM-B model is further enhanced by the Theoretical Domains Framework (TDF), which encompasses 128 psychological constructs from 83 behaviour change theories [20], aiding in understanding and targeting factors influencing behaviours, particularly in primary healthcare and oral health research regarding screening and preventive practices [21]. In oral health research, the TDF has been previously used to investigate the factors influencing oral health preventive behaviours by OHPs [22].

Figure 2. The capability, opportunity, motivation, and behaviour model and the Theoretical Domains Framework (TDF) adapted from [23].

Figure 2. The capability, opportunity, motivation, and behaviour model and the Theoretical Domains Framework (TDF) adapted from [23].

2.2. Research Design

This study used a qualitative research design. It commenced with the identification and detailed description of the target behaviours. The subsequent step involved analysing the capability, opportunity, and motivation needed to perform the chosen behaviours and the COM-B diagnosis [17].

The target behaviours selected for this study were as follows:

1

The OHP’s inviting all eligible patients attending a routine dental consultation to participate in a diabetes risk assessment.

2

OHPs complying with the AUSDRISK diabetes screening guidelines and referring all patients identified as intermediate and high risk for T2D to their GP for further investigation.

The target behaviours were then specified using the Action, Actor, Context, Target, Time (AACTT) framework (

Table 1. Target behaviour 1. The OHP offers information and screening invitation (implements a diabetes risk assessment) to all eligible individuals.

Action	The OHP undertakes a diabetes risk assessment for all eligible patients
Actor	OHPs working in a private dental setting
Context	Private dental setting
Target	Patients attending a routine dental consultation (non-emergency consultation)
Time	At the beginning of a routine consultation

and

Table 2. Target behaviour 2. Compliance to AUSDRISK referral guidelines.

Action	The OHP refers all patients with an AUSDRISK score ≥ 6 (intermediate/high risk) to a GP
Actor	OHPs implementing a diabetes risk assessment
Context	Private dental setting
Target	Dental patients screened for diabetes
Time	Immediately following a diabetes risk assessment

). Specifying the target behaviour is a key step in clarifying who needs to do what differently, identifying influences (barriers and facilitators) on the behaviour and in developing interventions to encourage behaviour change [24].

2.3. Participation and Recruitment

Following approval by the University of Melbourne (Ethical approval no: 22246), the 76 OHPs who participated in the iDENTify study [18] conducted between September 2018 and March 2020 were invited to participate in this study.

Data Collection

Participants were provided with a plain language statement and a consent form via email, and written or verbal consent was obtained prior to the commencement of the interviews. Semi-structured interviews were conducted to identify the OHP’s barriers and facilitators to participation in diabetes screening and, where indicated, compliance to the guidelines for medical follow-up. The interviews explored the OHP’s knowledge of PD and T2D, their perceptions and experiences with implementing the screening protocol, and their reasons for deciding to either follow the referral guidelines or deviate from the guideline recommendations. Interviews were conducted using Zoom, a Voice over Internet Protocol (VoIP)-mediated technology, or on the telephone using a digital audio recorder. Additionally, contemporaneous field notes were taken during the interviews.

Data collection concluded when data saturation was achieved. Data was collected between June 2022 and December 2022.

2.4. Data Analysis

The interviews were then transcribed verbatim by an encrypted artificial intelligence system (Otter.ai). Transcripts were subsequently checked for accuracy, and any identifying information was removed by the primary researcher (AP).

The interview transcripts and notes were imported into NVivo (V.14) for data management. Following familiarisation with the data, the data was coded by AP using an inductive approach. A second researcher (either PL, RM, or ID) independently coded the data, enabling further refinement of the codes. The researchers presented their initial codes to one another, revising the initial codes to reach a consensus on a common interpretation of the data, to ensure consistency and reliability [25]. The resultant codes were then grouped together to generate initial themes. These themes were then further refined and reviewed until final themes were defined. The data was then analysed using inductive thematic analysis by employing Braun and Clarke’s six phases of thematic analysis [26] to understand the factors influencing the OHP’s participation in a diabetes screening programme (behaviour 1) and compliance to referral guidelines (behaviour 2).

The themes and subthemes that emerged from the data were categorised under the COM-B constructs of capability, opportunity, and motivation, and these COM-B constructs were then mapped to the relevant TDF domains. A COM-B “diagnosis” was undertaken to identify what needs to change in the OHP’s capability, opportunity, and/or motivation to ensure that all eligible dental patients are offered a diabetes screening, and those who screened positive are referred for medical follow-up.

3. Results

Eight OHPs participated in this study: seven dentists and one dental hygienist. Five participants were males, while three were females. Five worked in a metropolitan location and three in a rural location. Years in practice following graduation ranged from 10 to 51 years. The interviews were conducted, with seven using Zoom and one telephone interview.

Interview duration ranged between 21 min and 47 min (mean: 30 min).

Following the specified target behaviours, an analysis was undertaken to understand the key influences on screening participation and referral guideline compliance behaviours, using data generated from the qualitative interviews. Ten key themes were identified for the behaviours, and these were linked to the appropriate COM-B constructs and TDF domains (

Table 3. Themes, COM-B components, and TDF domains.

Themes from OHP Interviews	Target Behaviour *	COM-B Construct	TDF Domain
1 The OHP’s diabetes knowledge	1 and 2	Psychological capability	Knowledge
2 Risk assessment tool is easy to use	1	Physical opportunity Psychological capability	Environmental context and resources Memory, attention and decision processes. Skills Knowledge
3 Additional time required for risk discussion and referral	1 and 2	Physical opportunity	Environmental context and resources
4 No remuneration for screening	1 and 2	Physical opportunity	Environmental context and resources
5 The OHP–patient relationship	1 and 2	Social opportunity	Social influences
6 The OHP’s evaluation of diabetes screening outcomes	1 and 2	Reflective motivation	Beliefs about consequences
7 OHP’s clinical communication skills	1 and 2	Psychological capability Reflective motivation	Skills Knowledge Beliefs about capability
8 Referral decision based on the risk score alone or subjective	2	Psychological capability	Memory, attention and decision processes Knowledge
9 Professional roles and responsibilities	1 and 2	Social opportunity Reflective motivation	Social influences Social/professional role and identity
10 Interprofessional communication and collaboration	1 and 2	Social opportunity Reflective motivation	Social influences Social/professional role and identity

* Behaviour 1. The OHP offers information and screening invitation to all eligible individuals. Behaviour 2. The OHP refers all screen-positive individuals for medical follow-up.

).

3.1. The OHP’s Diabetes Knowledge

All OHPs in the study were aware of the impact diabetes has on the development and progression of periodontal diseases, particularly in patients with sub-optimal glycaemic control (COM-B construct: psychological capability; TDF domain: knowledge). However, only one OHP reported that the relationship between diabetes and oral health was bi-directional and that managing periodontal disease may improve glycaemic control and overall health.

“If you can improve periodontal health that should also be to some degree reflected in improvement in the sugar management that the body has to cope with.”

OHP3

Several OHPs reported that knowledge deficits about diabetes, its complications, and medical management reduced their confidence in their ability to effectively screen for diabetes (COM-B construct: reflective motivation; TDF domain: beliefs about capabilities).

“The actual disease itself I can’t really go into too much detail because I don’t know you know I’m not an expert on it.”

OHP8

3.2. The Risk Assessment Tool Is Easy to Use

All the OHPs acknowledged that the AUSDRISK screening survey is quick and easy to implement (COM-B construct: physical opportunity; TDF domain: environmental context and resources).

“It was all relatively quick. And I think in dental practice, it probably does need to be quite quick.”

OHP4

3.3. Additional Time Required for Risk Discussion and Referral

OHPs found that discussing the risk assessment result and its implications and organising medical follow-up were time-consuming and disruptive to the traditional dental consultation workflow (COM-B construct: physical opportunity; TDF domain: environmental context and resources).

“I think time would be a barrier, as well, because it does take time to actually get that referral across or spend the time to educate and talk to the patients.”

OHP4

“But the busy crazy world of a dental practice and sort of like, where do we find the five minutes to talk?”

OHP8

3.4. No Remuneration for Screening

The majority of OHPs reported the lack of remuneration for the additional time spent implementing the risk assessment protocol as a barrier to diabetes screening participation (COM-B construct: physical capability; TDF domain: environmental context and resources).

“If it was government funded, or insurance company funded, that would be probably something I think a lot of dentists would do.”

OHP2

3.5. The OHP and Patient Relationship

Several OHPs indicated social influences, such as having an established OHP–patient relationship, facilitated screening recruitment, risk discussion, and referral for individuals who screened positive. (COM-B construct: social opportunity; TDF domain: social influences).

“You’ve established a rapport with the patient, you’ve got their confidence, …. they will then interact with you in a much better way”

OHP7

3.6. The OHP’s Evaluation of Diabetes Screening Outcomes

All the OHPs acknowledged that early identification of asymptomatic individuals enables early interventions that may prevent or delay the serious consequences of T2D (COM-B construct: reflective motivation; TDF domain: belief about consequences). They also found their participation in screening satisfying and rewarding (COM-B construct: automatic motivation; TDF domain: reinforcement).

However, several OHPs voiced reservations as to whether asymptomatic individuals would change their health behaviours as a result of screening, thus undermining its effectiveness (COM-B construct: reflective motivation; TDF domain: beliefs about consequences).

“And my take on this…. is that there’s a huge amount of inertia in lifestyle changes. And then chronic healthcare, which is asymptomatic, there’s a huge inertia.”

OHP2

OHPs recognised that encouraging those who screened positive to attend a medical appointment, in the absence of any signs and symptoms, was difficult and challenging (COM-B construct: reflective motivation; TDF: beliefs about consequences).

“So perhaps once people leave the office, the urgency is not there for them to get to the doctor, or they have nothing else going on medically, so they delay it.”

OHP4

The OHPs’ perceptions and beliefs about the outcome of diabetes screening strongly influenced whether screening was routinely offered to patients, and referral guidelines followed (COM-B construct: reflective motivation; TDF domain: beliefs about consequences).

“So, the one thing you must do to convince somebody of anything, is to be convinced yourself.”

OHP2

Some OHPs expressed reservations about the additional burden that diabetes screening places on dental patients at the conclusion of a dental consultation. Individuals undergoing screening were required to consider the risk results and their implications, in addition to receiving oral health messages, engaging in treatment planning discussions, and scheduling future appointments at the end of the consultation (COM-B construct: physical opportunity; TDF domain: environmental context and resources).

“When a person leaves a dental appointment, they’re sort of told you need to floss you know…. you need to clean a bit better…. you need to get on top of this toothpaste …. and then go see…. so, it’s like bombardment of things that this person has to do”

OHP8

3.7. OHP Clinical Communication Skills

Study participants acknowledged the importance of possessing effective clinical communication skills for every step of the diabetes screening pathway, from providing information to inviting eligible individuals to participate in the risk discussion and referral advice (COM-B construct: psychological capability; TDF domain: knowledge and skills).

“I think I do need a bit more training in communicating some of the basically bad news and inconvenience, communicating that more carefully”

OHP4

3.8. Referral Decision Based on the Risk Score Alone or Subjective

For the screening programme to be effective, it is important to maximise medical follow-up among those individuals who screen positive. All the OHPs reported following the referral guidelines as recommended in the AUSDRISK protocol (COM-B construct: psychological capability; TDF domains: knowledge and memory, attention and decision processes).

“I don’t think we deviated from it…. if the questionnaire…. gives it you know, two plus two equals four, that’s it, you gotta go. Next step is you go.”

OHP6

Several OHPs admitted their interpretation of the risk score, as well as their decision on whether medical referral was warranted, was influenced by their subjective perception of the patient, as well as whether they presented as the stereotypical candidate for T2D diabetes (COM-B construct: psychological capability; TDF domains: knowledge and memory, attention and decision processes).

“I think I really only looked at weight, and possibly any other inflammatory conditions that might tweak it…. I would look at people in their physical sense and say: Do you physically look like someone that would be at risk for type two diabetes?”

OHP1

The OHP’s subjective referral decision may have been based on incomplete knowledge about the pathogenesis of diabetes and its risk factors (COM-B construct: psychological capability; TDF domain: knowledge and memory, attention and decision processes).

3.9. Professional Roles and Responsibilities

In this study the majority of OHPs believed that diabetes screening was part of their professional responsibilities (COM-B construct: reflective motivation; TDF domain: social/professional role and identity) and aligned with their objective of improving the overall health of their patients.

“Because we’re not just dealing with teeth, we’re dealing with this whole person.”

OHP5

On the other hand, several OHPs expressed reservations about whether their patients would expect a dentist to screen for diabetes (COM-B construct: reflective motivation; TDF domain: social/professional role and identity).

“They’re shocked, because they’ve got us separate from the medical community.”

OHP1

A few OHPs described discomfort in obtaining a waist measurement from the patient, a procedure not routinely carried out by an OHP (COM-B construct: reflective motivation; TDF domain: social/professional role and identity).

“The waist measurement…. I think if that was a routine screening tool, it wouldn’t be something I would be comfortable doing on a regular basis.”

OHP1

Several OHPs also believed that GPs may consider screening for diabetes in a dental setting as intruding upon their professional boundaries (COM-B construct: reflective motivation; TDF domain: social/professional role and identity).

“But their attitude is, he’s only a dentist, so therefore that they don’t consider we know anything”

OHP4

3.10. Interprofessional Communication and Collaboration

An OHP’s perception of their relationship with medical professionals was a common theme that arose during the interviews. As one participant observed, for diabetes screening to be effective, co-operation is required between the OHP and the medical professional (GP).

“There’s only so much I can do, you might need to see other professionals … so there’s no point in me being in charge, so you should go to your GP.”

OHP6

A barrier to diabetes screening was the infrequent communication between OHPs and GPs. OHPs admitted that they rarely contacted GPs about the patients they shared.

“I have never ever in my practicing career rung up a GP about diabetes”

OHP2

Conversely, they seldom received any communication from GPs (COM-B construct: social opportunity and automatic motivation; TDF domain: social influence and reinforcement).

“Never got a letter following that in terms of results…. whether it’s none of my business… hum… I don’t know.”

OHP5

Several OHPs believed a divide exists between the professions. Additionally, many of the OHPs presumed that GPs would not appreciate receiving a referral related to diabetes screening from an OHP (COM-B construct: social opportunity; TDF domain: social influence).

“Writing a letter back to a dentist is probably low on their priority. Because they’re very busy.”

OHP8

To encourage interprofessional collaboration and streamline the referral process, some OHPs suggested replacing the referral print letter with electronic communication (i.e., emails) or directly contacting the GP via a phone and advising them that their patient has undertaken a diabetes screening and requires further investigation (COM-B construct: physical opportunity; TDF domain: environmental context and resources).

“Seamless secure messaging platform with the GPs ideally. So, I think you just have to facilitate it and make sure there’s no…. inhibition in the process”

OHP2

The key barriers to offering diabetes screening to eligible dental patients and subsequently following the AUSDRISK referral guidelines are summarised in

Table 4. Key barriers and facilitators to diabetes screening and referral guideline compliance.

Barrier	Facilitator
Diabetes knowledge deficits	Risk assessment tool is easy to use
Referral decision subjective	Referral decision based only on the risk score
No renumeration for screening	Screening is an OHP’s responsibility
Additional consultation time required for screening	Established OHP–patient relationship
Perceived patient inertia to modify lifestyle	Professional satisfaction: screening is rewarding
Professional boundaries: concern about patient and GP perceptions	Benefits of early identification of diabetes
Lack of interprofessional communication

.

4. Discussion

Our study identified that the OHP’s psychological capability, physical and social opportunity, and reflective motivation need to change to increase the likelihood a clinician will routinely screen all eligible individuals for diabetes and follow the referral guidelines in the screening protocol.

In line with previous studies [27,28,29], the OHP’s psychological capability (TDF domain: knowledge) to screen was limited by knowledge deficits regarding diabetes pathogenesis, management, and the screening protocol. These knowledge gaps reduced their confidence to provide appropriate information to their patient during each screening step. For example, OHPs felt uneasy discussing the benefits of screening and early detection with patients due to limited knowledge of prediabetes management.

Furthermore, knowledge deficits resulted in some OHPs deviating from the protocol’s referral guidelines (TDF: knowledge and memory, attention and decision processes) by making referral decisions based on their objective assessment of the screening participant’s risk, rather than relying solely on the patient’s risk score.

In this study, several OHPs acknowledged the importance of effective clinical communication skills for initiating the screening process and when advising medical follow-up (COM-B constructs: psychological capability and reflective motivation; TDF domain: skills and beliefs about capabilities). Discussing the benefits and harms of disease screening, while considering patients’ values and circumstances facilitates joint, evidence-based health decisions between HCPs and patients [30]. Research suggests that HCPs can enhance participation rates in screening programmes by clearly explaining procedures and encouraging patient involvement [31,32].

Specifically, OHPs reported limited confidence in their risk communication skills, particularly in delivering unfavourable news to patients who screen positive for diabetes. In our study, some OHPs only “suggested” medical visits for patients at risk of diabetes, instead of providing strong recommendations when providing referral advice [33]. The language used by OHPs when advising medical follow-ups may influence a patient’s compliance to advice [34]. Laverty et al. observed that OHPs often minimise explicit risk talk, instead choosing to use “softer, less offensive, language” when providing risk information to their patients [33]. This highlights the need for additional training for OHPs in risk communication to improve screening effectiveness [10].

The routine clinical consultation follows a predictable sequence, comprising tasks that must be accomplished within a limited timeframe [35]. OHPs expressed uncertainty where the steps associated with screening would fit within this traditional dental consultation model. (COM-B construct: physical opportunity; TDF domain: environmental context and resources). Additionally, OHPs identified the risk discussion and medical referral as the most time-consuming tasks in the screening process. Disruption of the normal operation of the dental practice [36], the additional time needed to screen [37], and the lack of financial incentive [38,39] have previously been identified as obstacles to an HCP’s screening participation.

The OHP’s physical opportunity (TDF: environmental context and resources) to refer was limited by a lack of prior communication with GPs regarding patients’ co-management, as well as an absence of a formal referral pathway between professions. OHPs and GPs often have limited communication [40]. Guan et al. attributed this insufficient dialogue to a lack of knowledge, time constraints, and the absence of integrated health records [41]. Co-operation between OHPs and GPs is therefore essential for effective screening [42], emphasising the need for improved interaction between these professions. Interprofessional collaboration is not supported by all HCPs [43], and poor communication, as well as fragmented and uncoordinated care, has been recognised as an issue in interprofessional referrals [44].

Consistent with previous research [27], this study also found that the OHP’s social opportunity and reflective motivation (TDF domains: social influences and social/professional role and identity) to conduct diabetes screening was influenced by uncertainty as to whether patients, GPs, and colleagues would expect them to perform this task. For example, while OHPs found the risk assessment tool easy to implement (COM-B construct: reflective motivation; TDF domain: beliefs about capabilities), discomfort arose from the requirement to collect a waist measurement, an uncommon procedure in dental settings (TDF domain: social/professional role and identity).

OHPs also believed that GPs may disapprove of them screening for diabetes, perceive it as crossing professional boundaries, and not welcome a referral from an OHP. This finding is not surprising, since healthcare teams have historically worked within a hierarchal structure, with the GP customarily taking the leadership role [45]. Research investigating co-operation between medicine and oral health has found that OHPs perceive a divide and negativity between themselves and the medical profession [42]. Effective diabetes screening within dental settings requires coordinated efforts between OHPs and GPs, as dentists are responsible for referring high-risk patients for confirmatory testing. Clearly defining the tasks for diabetes screening among the healthcare team is needed to facilitate the referral process in the screening pathway.

Finally, it is important to understand an HCP’s evaluations of medical screening benefits and risks (COM-B construct: reflective motivation; TDF: beliefs about consequences and beliefs about capabilities), particularly in their role of advising and inviting eligible patients to participate [46]. While all OHPs recognised the health implications of diabetes and the benefits of early intervention, some expressed doubts about patients modifying risk factors after a positive screening. Previous research highlights HCP’s uncertainty regarding their influence on patient behaviour and concerns about patients’ willingness to address modifiable risk factors, presenting barriers to preventive measures in primary care [38].

The findings of this study regarding deficiencies in the knowledge and communication skills of OHPs align with research on the preparedness of new dental graduates entering the workforce [47]. Given the bidirectional association between oral health and broader health outcomes, it is crucial to integrate and/or emphasise diabetes knowledge and communication skill training in the educational curriculum for oral healthcare students, as well as the continuing professional development courses for graduates. By improving OHPs’ understanding of T2D/PD and screening processes, their psychological capability to engage in routine screenings, interpret and discuss risk results, and facilitate referrals will be significantly enhanced. Additionally, diabetes screening in the dental setting requires interprofessional co-operation to be effective. Consequently, dental education should promote interprofessional communication and cooperation. One way to achieve this is to include interprofessional education (IPE) for healthcare students to create a learning environment that emphasises collaborative practice and integrated patient care to facilitate improved health outcomes [48].

A free, easily accessible, online resource that addresses diabetes and screening knowledge gaps (psychological capability) and supports and streamlines the screening process (physical opportunity) should also be available to OHPs. Studies exploring diabetes screening by HCPs indicate that improved educational resources can facilitate the adoption of diabetes screening by clinicians [49].

Currently there is no provision for the OHP to be compensated for the additional time required for screening and the subsequent disruption of workflow this causes. Research suggests that offering a reward for a behaviour can increase its frequency [50], and if cost is a barrier to the behaviour, providing an incentive can overcome this obstacle [51]. Therefore, we suggest that OHPs be eligible for a government or health insurance rebate when administering the diabetes risk assessment.

OHPs in this study expressed concerns about how their involvement in diabetes screening would be perceived by colleagues, patients, and GPs. To address this, a directive for screening for T2D/PD could be incorporated into clinical guidelines from oral health and diabetes organisations. Providing clear and concise recommendations for diabetes screening will enhance OHPs’ social opportunity and reflective motivation to conduct screenings. Previous studies on OHPs’ antibiotic prescribing behaviours indicate that clear clinical guidelines facilitate appropriate prescribing practices [52]. By emphasising that diabetes screening is part of the OHP’s responsibilities, these guidelines will support the entire diabetes screening pathway.

To ensure adequate follow-up of the risk assessment result, we propose developing a point-of-care clinical decision support system (CDSS) for diabetes screening in the dental setting. CDSSs are computer-based information systems developed to assist HCP clinical-decision making and have been used to encourage the implementation of clinical guidelines and promote evidence-based treatment recommendations [53]. When linked to the patient’s electronic health record, the CDDS tool could alert the OHP which individuals are eligible for PD and T2D screening and provide administrative assistance for monitoring patient progress in the screening pathway and issuing prompts and reminders.

This study has several limitations. Firstly, the study sample was recruited solely from Australian OHPs from the state of Victoria. The small, region-specific sample size restricts the generalisability of our findings. However, the aim of this study was to provide a comprehensive and nuanced understanding of OHPs’ diabetes screening experiences within the specific context of Victoria. Although the sample size of OHPs recruited for this study is relatively small, accounting for approximately 10% of the total OHPs who participated in the iDENTify study [18], data saturation was achieved, suggesting that the sample provided sufficient depth and richness in the data collected. The validity and transferability of our results may also have been impacted by self-selection bias, as OHPs may have volunteered to participate in the study based on a pre-existing interest in diabetes screening, thus creating a sample that may not be representative of our target population.

Despite these limitations, this study addresses an important evidence gap in our understanding of an OHP’s barriers and facilitators to routinely participating in diabetes screening, as well as their decision to refer individuals who screen positive for medical follow-up. Relatively few studies have investigated OHPs’ participation in diabetes screening; as such this would be the first study to explore the behavioural determinants of an OHP’s referral decisions following a diabetes risk assessment. Another strength of this study is the use of a theoretical framework to explore the target behaviours. This study adopted a systemic approach, connecting the constructs of the COM-B model and the TDF to the qualitative data we collected to better understand what needs to change in an OHP’s capability, opportunity, and motivation to perform the target behaviours. The results of this study provide the basis for developing future behaviour change interventions to increase the effectiveness of diabetes screening. Future research could explore other factors influencing OHPs’ practices in varied contexts to develop a more comprehensive understanding of the challenges and opportunities in oral healthcare delivery.

5. Conclusions

This study has provided a comprehensive examination of the determinants affecting the adoption of diabetes screening and referral practices among OHPs in dental settings. By applying the COM-B model of behaviour and the Theoretical Domains Framework, this study identified key areas for intervention, including education and training, that limit their capability, opportunity, and motivation to engage in diabetes screening and adherence to referral guidelines. The findings underscore the need for targeted interventions to enhance OHPs’ psychological capability, social and physical opportunity, and reflective motivation, ultimately improving patient outcomes in diabetes management.