F EATURE A RTICLE
Factors Affecting Caregivers’
Perceptions of Residents’ Oral Health in Long-Term Care
Facilities in Taiwan
Yen-Ping Hsieh, PhD Shou-Jen Lan, DDS, MPH, PhD Ying-Chia Huang, MD, PhD Chiao-Lee Chu, PhD, RN Yu-Hsuan Chen, BS Shin-Han Wu, BS Chih-Yu Liu, BS Tsuei-Ping Hung, BS Ching-Yu Peng, BS Ya-chin Chen, BS
The purpose of this study was to investigate the differences between resident oral care policies provided by 2 types of long-term care (LTC) institutions. The study also investi- gated factors affecting LTC institutional care- givers’ perceptions of the residents’ oral health. Overall, 103 completed question- naires were returned. Of these, 44 were from senior citizen welfare institutions, and 59 were from nursing homes. The variables af- fecting these perceptions included institution type and whether the residents attended hos- pital dental clinics or consulted a hospital doc- tor regarding oral health problems. The research results showed that institution type and whether an oral careerelated profes- sional was available in an institution were cor- related with an increase in institutional caregivers’ perceptions of oral care. (Geriatr Nurs 2012;33:350-357)
T
he provision of oral care for residents in long-term care (LTC) facilities is an impor- tant issue. A number of studies have indi- cated that poor oral health may increase the risk of stroke, heart disease, and pneumonia for residents in LTC institutions who are already af- flicted by certain diseases.1-6 Studies have also verified that LTC residents’ chewing ability, oral condition, denture condition, and oral hygiene all affect their quality of life.7-10There are 2 types of LTC institutions in Taiwan.
The first comprises senior citizen welfare institu-
tions, which are managed by the Department of Social Affairs. These institutions mainly provide services to senior citizens with chronic diseases who require nursing services. Data from 2011 in- dicate that there are 1053 senior citizen welfare institutions in Taiwan.11Most of these facilities are managed by the private sector (86.9%), fol- lowed by juridical persons (10.4%). The second type comprises nursing homes that are managed by the Department of Health. In 2011, 408 nursing homes in Taiwan12provided services mainly for persons with stable disease conditions or severe disabilities and those in need of technical and general nursing care. In other words, the degree of disability of residents living in nursing homes is more severe than that of those living in senior citizen welfare institutions. Most of these institu- tions are managed by the private sector (86%), with 14% managed by the public sector. Both in- stitution types in Taiwan are primarily managed by the private sector.
Although the evaluation items of oral care for residents have been established in institutional accreditation systems, the regulations governing the establishment of LTC institutions in Taiwan do not stipulate the requirements for establishing relevant oral health equipment, staffing, and training. Consequently, the baseline for managing the oral health of residents in the 2 types of insti- tutions is consistent.
Caregivers in LTC institutions play an impor- tant role in the promotion of oral health for their residents; however, studies have indicated that
caregivers are deficient in oral careerelated edu- cation. After caregivers are provided with oral care-related educational training, their knowl- edge and skills improve, which is helpful for re- ducing the incidence of respiratory infections in residents.13-18 Therefore, caregivers’ oral caree related knowledge and skills is important and beneficial for the maintenance and improvement of residents’ physical and psychological status.19 Significant differences have been found be- tween the oral healtherelated educational train- ing courses provided by caregivers in relevant existing studies and that in the LTC system that is under development in Taiwan. First, a dental hygiene system has not been developed in Taiwan, and there are no professional dental hygienists guiding the LTC caregivers who pro- vide oral healtherelated educational training courses. Second, dentists are the main promoters of oral health in Taiwan. In 2010, there were 6209 dental clinics in Taiwan,20translating to a ratio of 5 practicing dentists for every 10,000 people.21Al- though national health insurance has been estab- lished in Taiwan, oral healtherelated systems have yet to be developed in LTC institutions. As a result, dentists’ promotion of oral health for residents in LTC facilities is an unpaid volunteer service, resulting in low incentive for dentists to see patients in LTC facilities.
Therefore, owing to a limited number of oral health professionals and the lack of oral health systems in LTC facilities, the maintenance or pro- motion of residents’ oral health in more than 85%
of private LTC facilities is dependent on each fa- cility’s self-implementation of oral care policies.
This study suggests that only the self- implementation of oral care policies by LTC facilities can provide direction for the future establishment of oral care systems in LTC facili- ties. This study has 2 purposes: to investigate 1) whether oral care policies vary according to facil- ity characteristics and 2) whether the oral care policies of LTC facilities have any effect on the caregivers’ perceptions of their residents’ oral conditions.
Setting and Sample
In 2010, there were 56 LTC facilities (34 senior citizen welfare institutions and 22 nursing homes) in Taichung City.11 Telephone calls were placed to all 56 LTC facilities, and 22 facili- ties were willing to participate in this study
(13 senior citizen welfare institutions and 9 nurs- ing homes). All of the participating facilities were managed by the private sector. The question- naires were distributed to the LTC facilities that were willing to participate, and they all agreed with the contents. Ten questionnaires were dis- tributed to each facility, thus, 220 questionnaires were distributed.
Inclusion criteria for the caregivers were that they had to be Taiwan citizens, had to personally provide residents with physical care, and were willing to participate in the questionnaire survey.
Foreign caregivers and those who refused to par- ticipate in the study were excluded. The question- naires were distributed from September to November 2010.
Overall, 103 questionnaires were returned, for a return rate of 46.8%: 59 completed question- naires were returned from the nursing homes (a return rate of 65.5%), and 44 completed ques- tionnaires were returned from the senior citizen welfare institutions (a return rate of 33.8%).
Most of the caregivers (95) were female (only one was male), and their mean (SD) age was 42.1 (10.9) years. Most of the caregivers (57.3%) served in the nursing homes, whereas 42.7%
served in the senior citizen welfare institutions.
Most of the caregivers (48.5%) were high school graduates, whereas 22.3% were college or gradu- ate school graduates. Most of the caregivers were nurse’s aides (71.8%), and 20.4% were nurses (Table 1).
Measurement and Methods
This study developed self-edited questionnaire items according to the oral health-related data from the LTC institutions.22-25 After the questionnaire was developed, 3 experts (in- cluding dentists volunteering in LTC facilities for more than 6 years and nursing professionals familiar with the LTC facility care models) were invited to test and amend the questionnaire according to item importance, appropriateness, and comprehensibility. After the experts amended the questionnaire twice, the final version included 9 items concerning the implementation of oral care policies by facilities and 4 items concerning the caregiver’s perceptions of oral care for the residents.
Among the 9 items concerning the facilities’
implementation of oral care policies, 2 were
questions about the facilities’ self-implemented oral health examinations for residents and the number of actual daily instances of caregivers as- sisting the residents in brushing their teeth and rinsing their mouths to help us understand the fa- cilities’ practical measures for implementing oral health policies. The other 7 items are shown in Table 2. Among these items, 4 were questions about the facilities’ implementation of their oral health policies (Items 1, 3, 6, and 7 in Table 2), and 3 were questions about the facilities’
relevant resources for managing residents’ oral care (Items 2, 4, and 5 inTable 2). The caregivers’
responses to the items in Table 2 were either
“Yes” or “No” to evaluate whether oral care poli- cies were implemented in facilities.
The following 4 items were used to measure the caregivers’ perceptions of oral care for their residents: “the current oral condition of the resi- dents,” “the importance for residents to undergo oral examinations semiannually,” “the impor- tance of oral health to the residents,” and “the res- idents’ oral health is relevant to their physical health.” These items were used as the basis for understanding caregivers’ perceptions of the res-
idents’ oral health. A 5-point Likert scale, with scores ranging from 1 (not important at all) to 5 (very important), was applied. The Likert scale was primarily used to measure attitudes and sub- jective or objective perceptions. Existing studies on oral health perceptions were also comprehen- sively used.26-28
The total score of the previously mentioned 4 items (20 points maximum) was used to measure the caregivers’ perception of oral care. Correla- tion coefficients were used to test the correlation between these 4 items and the total score, and a significant correlation was found between all 4 items and the total score.29The correlation of Item 1 was .478, suggesting that it was moder- ately correlated with the total score. The scores of the other items were all ..80 (highly corre- lated), suggesting that the total score shared high homogeneity with all four items. The total score was considered the overall caregiver per- ception. Moreover, reliability analysis was used to test whether the reliability of the 4 items, and the total score was acceptable. Cronbach’s a value was .795, suggesting overall acceptable reliability.
Statistical Analysis
The data were analyzed using SPSS (version 12:
SPSS Inc., Chicago, IL). A chi-square test was used to test whether there was a significant difference between the caregivers’ self-perceived implemen- tations of the institutions’ oral care policies for residents. Moreover, an adjusted residual was used to determine the differences in the imple- mentation guidelines for oral care between care- givers at different institutions. This study used multiple regression analyses to investigate the factors affecting caregivers’ perceptions of resi- dents’ oral health.
Results
Overall, 9 items were used to investigate the oral care policies implemented in the 2 facility types. First, the caregivers were asked questions concerning the number of oral health examina- tions implemented in the facilities and the num- ber of daily instances of assisting residents with brushing their teeth and rinsing their mouths.
On an average, the institutions assisted residents in undergoing oral health examinations 0.46 times (SD 0.87) per year. In the LTC institutions
Table 1.
Sociodemographics of the Participants
Characteristic N %
Gender
Male 1 1.0
Female 95 92.2
Missing 7 6.8
Job title
Nurse 21 20.4
Nurses aides 74 71.8
Missing 8 7.8
Served institutions
Nursing home 59 57.3
Senior citizen welfare institutions
44 42.7 Marital status
Not married 28 18.5
Married or common-law wife 108 71.5
Separated/divorced 15 10.0
Education level
Literate/elementary school 5 4.9
Primary high school 17 16.5
Senior high school 50 48.5
College or graduate school 23 22.3
Missing 8 7.8
in which tooth-brushing and mouth-rinsing poli- cies were implemented, the mean numbers of daily tooth brushing and mouth rinsing instances were 1.79 (SD 1.03) and 2.29 (SD 1.24), respec- tively. The t test showed no significant difference between the 2 facility types, suggesting that their oral care policies regarding oral health examina- tions and tooth brushing or mouth rinsing were similar.
Moreover, any differences in the 7 items con- cerning the implementation of oral care policies in these 2 types of facilities is shown inTable 2.
Using the chi-square test, we found significant differences in Items 1, 6, and 7. The use of the ad- justed residual showed that the frequency of im- plementation of these 3 oral care policies in the nursing homes was higher than that of the senior citizen welfare institutions.
Table 2.
Differences in Oral Care Policies Between the 2 Types of Facilities
Items
Institution Type
N c2
Nursing Home
Senior Citizen Welfare Institutions 1. Residents’ periodic oral health examination
No 26 (e2.2) 29 (2.2) 55 4.83*
Yes 33 (2.2) 15 (e2.2) 48
2. Residents’ oral health examination sites At the institution
No 55 42 97 0.23
Yes 4 2 6
At a dental clinic
No 34 26 60 0.02
Yes 25 18 43
At hospital
No 46 39 85 1.99
Yes 13 5 18
3. Rules on residents’ tooth brushing and mouth rinsing
No 2 2 4 0.9
Yes 57 42 99
4. Specially appointed dentists
No 39 34 73 1.52
Yes 20 10 30
5. Person with whom to consult about residents’ oral health problems Private or special doctor in the institution
No 42 27 69 1.1
Yes 17 17 34
Dental clinic near the institution
No 32 29 61 1.42
Yes 27 15 42
Hospital doctor
No 37 33 70 2.22
Yes 21 11 32
6. Promotion of oral health knowledge
No 8 (e3.5) 18 (3.5) 26 9.99‡
Yes 51 (3.5) 26 (e3.5) 77
7. Oral cleaning as the content of oral care programs for residents
No 6 (e2.7) 14 (2.7) 20 7.57†
Yes 49 (2.7) 28 (e2.7) 77
The parentheses in items 1, 6, and 7 were adjusted residual values.
*P\ .05.
†P\ .01.
‡P\ .001.
Overall, 4 items were used to measure the care- giver’s perceptions of oral care for their resi- dents. The mean score of “the current oral condition of the residents” was 3.20 points (SD 0.83), whereas the mean score of “the importance of oral health to the residents” was 4.10 points (SD 0.71). The mean score of “the importance for residents to undergo oral examinations semi- annually” was 4.20 points (SD 0.82), whereas the mean score of “the residents’ oral health is rele- vant to their physical health” was 4.27 points (SD 0.78). Overall, 4 questions addressed the caregivers’ perceptions of the residents’ oral health. The mean total score was 15.77 points (SD 2.33). These results show that caregivers’
oral health perceptions were significantly higher.
To investigate the relevant factors affecting caregivers’ oral health perceptions, 4 questions concerning their perceptions of residents’ oral health were used as dependent variables; care- givers’ ages, job titles, and education levels, as well as the institution type and its oral care poli- cies, were used as the independent variables in multiple regression analyses. The results are summarized inTable 3.
The results of the multiple regression analyses showed that there are statistically significant dif- ferences in variables by institution type, whether residents underwent oral examinations in hospi- tals, and whether caregivers consult a hospital doctor regarding the residents’ oral care prob- lems. These 3 variables explained 21.9% of the total variance of caregivers’ oral health percep- tions. Among them, the institution type affected
the maximum variance (as much as 9.5%) of the caregivers’ oral health perceptions.
The results of theb coefficient showed that the oral health perception of caregivers in nursing homes was higher than that of those in senior cit- izen welfare institutions. The perception of those in facilities in which residents could undergo oral health examination in hospitals was higher than that of those in facilities in which residents had to undergo oral health checks in nonhospital in- stitutions. The perception of caregivers who did not consult hospital dentists was higher than that of those who did consult them.
Discussion
This study investigated the differences be- tween the implementation of oral care policies between 2 types of LTC institutions and the rele- vant factors affecting the oral health perceptions of caregivers in LTC institutions. Because there is limited access to oral health professionals and a complete oral health system is lacking in the field of LTC, the results of this study could be used as a reference to develop and promote oral health policies in LTC facilities.
The research results indicated that the nursing homes performed better than the senior citizen welfare institutions in terms of the following 3 as- pects: offering periodic oral health examinations for residents, promoting oral healtherelated knowledge, and providing oral cleaning and rins- ing as part of the resident care program. This study suggested that the results correlated with
Table 3.
Regression Analysis Summary Form of the Factors Affecting Caregivers’ Oral Health Perception
Order of the Variables to Be
Analyzed R R2 AdjustedR2 R2Change F b
1. Nursing home vs. senior citizen welfare institutions
.308 .095 .085 .095 9.498* .298*
2. Residents undergo oral
examinations in hospital vs. not doing so
.391 .152 .133 .057 8.035† .266†
3. Consulting with the doctor in the hospital where residents frequently visit vs. not doing so
.467 .218 .191 .065 8.204‡ .260†
*P\ .05.
†P\ .01.
‡P\ .001.
the evaluation items for LTC facilities in Taiwan.
The number of oral evaluation items for residents in nursing homes was larger than that for residents in senior citizen welfare institutions in Taiwan. Therefore, the research result was con- sistent with the currently promoted evaluation items in LTC institutions. In other words, the care or relevant education provided by nursing homes is indeed superior to that provided by se- nior citizen welfare institutions. These result showed that although there are no professional dental hygienists in Taiwan, an oral care evalua- tion system with multiple items could enhance fa- cilities’ oral health programs for their residents.
Therefore, this study suggests that the establish- ment of an evaluation system consisting of an oral care index in places where there are no pro- fessional dental hygienists could enable facilities to implement complete oral care programs for their residents.
However, both facility types lacked oral caree related resources for their residents. Such a finding reflects on the lack of oral healthe related professionals and relevant resources in LTC facilities in Taiwan. This result is consistent with previous studies showing that it is difficult for LTC residents with higher degrees of disabil- ity to attend a dental clinic. Moreover, institu- tions seldom provide professional oral care equipment or cover relevant expenses.1,30,31 Consequently, this study suggests that it is necessary to establish a system concerning consultations and clinical visits as well as oral care education within the oral health policies for LTC facilities and oral health professional units.
The second purpose of this study was to inves- tigate whether the oral care polices in facilities affect caregivers’ perceptions of their residents’
oral conditions. The research result of the rele- vant factors affecting the caregivers’ perceptions of the residents’ oral health showed that the insti- tution type had the most significant effect. In other words, caregivers’ perceptions of the resi- dents’ oral health in nursing homes were higher than that of those of caregivers in senior citizen welfare institutions. This result was consistent with the earlier-noted idea that oral care policies for residents implemented in nursing homes could increase caregivers’ perceptions of their residents’ oral health.
Allowing residents to receive oral examina- tions in hospitals has a positive effect on the
oral care consciousness of caregivers. When caregivers do not consult practicing physicians in hospitals about oral problems, there is a posi- tive effect on the caregivers regarding their oral care consciousness. Previous studies have indi- cated that a referral relationship is in place be- tween LTC institutions in Taiwan and nearby hospitals and that contracted doctors serving in medical institutions are often assigned to provide periodic medical service in LTC institutions.32,33 Past literature has indicated that the residents of LTC institutes seek hospital care mainly for urinary tract infections, rehabilitation, and respiratory illnesses.34,35This suggests that only a small percentage of residents at LTC institutes are able to seek oral care at hospitals. In terms of the samples in this study, only 17.4% of the residents attended dental clinics, which might be related to the medical care model provided for residents by LTC institutions in Taiwan.
Consequently, most LTC institutions have contracted with medical institutions to provide medical services.35 Therefore, this study pre- sumed that it would be less likely for LTC institu- tions to provide direct dental care services, leading to a lower likelihood of caregivers consul- ting with relevant hospital personnel about oral care issues.
These results show that the manner in which LTC facilities implement health policies is associ- ated with oral health resources and affects care- givers’ oral care perceptions. Therefore, this study indicates that more importance be attached to making a connection between LTC facilities and their neighboring oral health professional resources.
Study Limitations
The findings of this study must be interpreted with caution in the context of its design. First, the small sample size limits the generalizability of its findings. Second, this study did not directly assess the residents’ oral conditions in the LTC institutions, human resource deployment of insti- tution oral care policies, or institutions’ attitudes toward the residents’ oral care. These factors might restrict our interpretation of the care- givers’ perception level and the implementation of the facilities’ oral care policies. Third, because all the facilities willing to participate in this study refused to be a study site for analysis, this study did not conduct a questionnaire survey on them.
Although expert validity and reliability analyses were used to verify the questionnaire acceptabil- ity, the questionnaire might not conform to the current conditions of LTC facilities, because it was not used for testing. Future studies should use a larger sample size and conduct a question- naire survey to assess the factors affecting insti- tutions’ oral care policy planning.
Conclusions
This study verified that in facilities in which there are no professional dental hygienists or LTC oral care systems, it is important to stress caregivers’ implementation of facility oral care policies for their residents. The establishment of a detailed evaluation system for residents’
oral care in LTC facilities is beneficial for improv- ing the facilities’ oral care program implementa- tion. The facilities’ implementation of oral care and connection with resources also affect care- givers’ oral care perceptions. Therefore, future development of oral care policies in LTC facilities should ascribe importance to establishing a com- plete oral care evaluation system as well as making a connection between facilities and neighboring dental medical units or resources to improve their programs and their residents’
oral care.
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YEN-PING HSIEH, PhD, is an Assistant Professor in the Department of Healthcare Administration, Asia University, Taichung, Taiwan. SHOU-JEN LAN, DDS, MPH, PhD, is a Professor in the Department of Healthcare Administra- tion, Asia University, Taichung, Taiwan. YING-CHIA HUANG, MD, PhD, is an Assistant Professor in the De- partment of Healthcare Administration, Asia University, Taichung, Taiwan. CHIAO-LEE CHU, PhD, RN, is an As- sistant Professor in the Department of Healthcare Admin- istration, Asia University, Taichung, Taiwan. YU-HSUAN CHEN, BS, Department of Healthcare Administration, Asia University, Taichung, Taiwan. SHIN-HAN WU, BS, is an Assistant in the Department of Nursing, Jen-Ai Hospital, Taichung, Taiwan. CHIH-YU LIU, BS, Department of Healthcare Administration, Asia University, Taichung, Taiwan. TSUEI-PING HUNG, BS, Department of Healthcare Administration, Asia University, Taichung, Taiwan.
CHING-YU PENG, BS, Department of Healthcare Adminis- tration, Asia University, Taichung, Taiwan. YA-CHIN CHEN, BS, Department of Healthcare Administration, Asia University, Taichung, Taiwan.
0197-4572/$ - see front matter Ó 2012 Mosby, Inc. All rights reserved.
doi:10.1016/j.gerinurse.2012.03.002
