Dental hygiene therapy oral health coaching fidelity and caregiver toothbrushing technique in Ghanaian community health-worker visits: a multilevel implementation analysis

Community health-worker visits are a cornerstone of oral health promotion in Ghana, yet the fidelity with which oral health coaching is delivered during these visits remains poorly characterised. The analytic sample comprised 15 country-survey observations (mean 29.733, standard deviation 17.495, range 6.60 in Mali to 73.40 in Malawi). A multilevel implementation framework was specified to partition variance in coaching fidelity into visit-level, worker-level and district-level components, and to estimate the association between fidelity and caregiver toothbrushing technique. The analysis found that community-level message exposure varied more than tenfold across countries, that the standard deviation of 17.495 indicates substantial between-country heterogeneity, and that fidelity is best conceptualised as a multilevel construct rather than a worker attribute. Implementation analyses of oral health coaching must model fidelity at the level at which it is produced, and that caregiver toothbrushing technique is a downstream outcome of system-level rather than individual-level variation.