| Summary: | Dental decay is a worldwide Public Health problem. In the last decade Oral Health professionals in the UK have focused on developing national and regional Oral Health programmes to reduce dental caries rates in young children. Smile4Life is an example of a regional programme, which has been implemented in North West England. Recent research suggests health programmes should have a conscious theoretical base and incorporate multi-sectorial approaches. A literature review was undertaken to identify the differences between the theoretical underpinnings used in Oral Health interventions compared to General Health interventions. This showed that Oral Health interventions have been predominately underpinned by educational approaches and used fewer approaches that consider organisational and environmental factors. However, the literature review did not identify barriers and facilitators to the use of theoretical underpinnings in real-life settings. To understand the barriers and facilitators to developing and implementing interventions in real-life settings, and how barriers and facilitators relate to the theoretical underpinnings identified in the literature review, semi-structured interviews were conducted with nine policymakers who were responsible for developing and ten implementers who were responsible for delivering Smile4Life. The analysis was undertaken using an inductive thematic analysis. The interview findings consist of an overall meta-theme and three themes. The meta-theme refers to ‘intra-group relationships and inter-group boundaries’. Intra-group relationships refer to the relations within the policymaker group or implementer group. The inter-group boundaries refer to divisions between the two groups that meant people within each group perceived themselves to be distinct from people in the other group. The first theme intra-group inclusion and inter-group exclusion outlines that within each group, individuals interacted with one another and had a shared sense of unity and group beliefs. However, there were boundaries between the two groups due to a lack of interactions and feelings of exclusion between the groups. The second theme, different knowledge, experiences, and beliefs identified that each group shared similar knowledge and experiences, but between the groups this knowledge was not shared. The third theme standardised or flexible implementation identified that due to the differences in knowledge, experiences, and beliefs between the groups, these differences prevented the formation of a shared vision of how to implement Smile4Life. The groups divisions led to the implementers making changes to the intended implementation strategy of Smile4Life. This research suggests that the implementers (middle managers) are important in the development and implementation of Oral Health programmes and potentially other interventions. Currently, theoretical underpinnings do not explicitly consider middle managers in the development and implementation of interventions. A set of Implementer Engagement Guidelines, underpinned by the Social Identity Theory, are presented that consider the engagement of middle managers in the development and implementation of interventions, to enable policymakers to develop future General and Oral Health programmes.
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