ORIGINAL ARTICLE

Y-W Kuo M Yen S Fetzer L-C Chiang Y-IL Shyu T-H Lee H-I Ma

Authors’ affiliations: Y-W Kuo, Department of Nursing, Asia University, Taichung, Taiwan M Yen, Department of Nursing and Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan S Fetzer, Department of Nursing, College of Health and Human Services, University of New Hampshire, Durham, NH, USA L-C Chiang, School of Nursing, National Defense, Medical Center, Taipei, Taiwan Y-IL Shyu, School of Nursing and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan T-H Lee, College of Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan T-H Lee, Department of Neurology, Chang Gung Memorial Hospital, Taoyuan, Taiwan H-I Ma, Department of Occupational and Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Correspondence to: Miaofen Yen, PhD, RN, FAAN National Cheng Kung University, No. 1, University Road Tainan 70101, Taiwan Tel.: +886 6 2353535, ext. 5823 Fax: +886 6 2377550 E-mail: [email protected]

Dates: Accepted 31 January 2015 To cite this article: Int J Dent Hygiene 14, 2016; 82–91 DOI: 10.1111/idh.12138 Kuo Y-W, Yen M, Fetzer S, Chiang L-C, Shyu Y-IL, Lee T-H, Ma H-I. A home-based training programme improves family caregivers’ oral care practices with stroke survivors: a randomized controlled trial. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

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A home-based training programme improves family caregivers’ oral care practices with stroke survivors: a randomized controlled trial Abstract: Objectives: Stroke survivors experience poor oral health when discharged from the hospital to the community. The aim of this study was to evaluate the effectiveness of a home-based oral care training programme on knowledge, attitude, self-efficacy and practice behaviour of family caregivers. Methods: A randomized controlled trial was conducted. The experimental group consisted of 48 family caregivers who received the home-based oral care training programme, and the control group consisted of 46 family caregivers who received routine oral care education. The outcomes were measured by the Knowledge of Oral Care, Attitude towards Oral Care, Self-Efficacy of Oral Care and Behaviour of Oral Care before the training programme, and at one and two months afterwards. The data were analysed using mixed model ANOVA to determine differences in the outcomes between the two groups. Results: The findings demonstrated that the intervention group had more knowledge (t = 8.80, P < 0. 001), greater self-efficacy (t = 3.53, P < 0.01) and better oral care behaviour (t = 11.93, P < 0.001) than the control group at one and two months, with statistically significant differences in oral care knowledge, self-efficacy and behaviour outcome over time. The attitude of the intervention group towards oral care practice was generally positive (mean of baseline and two month = 12.9 and 14.7), but no significant difference in attitude change between the control and intervention groups (t = 1.56, P = 0.12). The treatment interaction effect was significant for the family caregivers’ behaviour of oral care at one and two months of the intervention for both groups. Conclusion: Our individualized home-based oral care education can achieve significant improvements in oral care knowledge and selfefficacy among family caregivers of stroke survivors, and it can sufficiently empower them to modify their oral care practices in a home-based healthcare environment. Key words: daily oral care practice; family caregiver; home-based health care; oral hygiene; stroke survivors.

Introduction Cerebral vascular accidents (CVA), also called strokes, were the second most frequent cause of death worldwide in 2011 (1). Approximately 33 million people had previous strokes and are still living (2). At any one time, over 300 000 people across the globe are living with moderate to severe disabilities as a result of strokes (3). Stroke survivors have been

Ya-Wen Kuo et al. Family caregiver oral care practice

found to have significantly poorer oral hygiene when compared to healthy community-dwelling elderly (4). More than half of all stroke survivors become dependent on other people for activities of daily living (ADL) (5), and it is estimated that over 25% of stroke survivors obtain assistance with ADL from family caregivers (6). Although oral care is one aspect of ADL that often requires assistance, a recent systematic review reported limited data on the efficacy of oral health promotion activities for stroke survivors (7). The poor state of oral health among stroke survivors in long-term care settings has been documented, with poor oral hygiene being linked to systemic disease, and vice versa, such as cardiovascular disease and nutritional problems. Oral health problems can also have an adverse effect on quality of life (8, 9). Research has also demonstrated that poor oral hygiene increases the incidence of pneumonia in a community, of hospitalization and of critically ill individuals (10–14). In addition, poor oral hygiene leads to dental caries, periodontal disease (15) and white-coated tongue (16–18), thereby predisposing individuals at high risk of stroke to respiratory infections (11, 12) and pneumonia (13, 14). Even though oral hygiene is important to overall health, it is often ignored during daily care provided by caregivers, and negative oral health beliefs were found among caregivers of the dependent elderly (19). Research by Junges et al. (20) reported the attitude of caregivers regarding oral health in a long-term care institution in Brazil, and the results showed that 75% of the caregivers performed teeth brushing as part of their routine, but only 21% performed cleaning of the mucosa with gauze. However, when asked whether they would motivate the independent elderly to perform oral hygiene, only 41.7% of the caregivers responded positively. Family caregivers often feel that they are unprepared to provide care and have inadequate knowledge to deliver sufficient care (21), and it has also been reported that the frequency of oral care is dependent on the caregiver’s training, and only when caregiver can provide regular oral care will there be the possibility of improving the quality of care (22). Therefore, more education, training and motivation that are received by a family caregiver can contribute to better attitudes and more positive behaviours towards oral care. Research has confirmed the influence of educational interventions to improve and understand the competence and confidence of family caregivers (23). Previous studies have evaluated the effectiveness of oral care training programmes delivered to the caregivers of dependent elderly residing in long-term care institutions (24, 25). However, home-based oral care training programmes delivered to family caregivers of stroke survivors who are functionally dependent and severely disabled have not yet been evaluated. Oral health education can improve periodontal health (7), which is essential for the overall wellness and quality of life of stroke survivors (26, 27). Researchers have recommended that family caregivers be trained in oral health for functionally dependent patients to improve the quality of care (28). An evidence-based intervention programme serves an important

method for training with family caregivers of stroke survivors. Thus, we established our home-based oral care training programme for family caregivers of stroke survivors by conducting a systematic review (29). Then, the programme was tested on family caregiver–stroke-survivor dyads recruited from three institutions of home health care. We hypothesized that after receiving the home-based oral care training programme (HOCP), the family caregivers would improve their knowledge, attitude, self-efficacy and behaviour relating to oral care.

Materials and methods The purpose of this study was to test the effect of an HOCP on family caregivers’ knowledge, attitudes, self-efficacy and behaviour related to the oral care of their dependent stroke survivors. Design

This randomized, controlled, single-blind trial was conducted to evaluate an HOCP for family caregivers of stroke survivors. The experimental group received an educational intervention focused on oral health, while the control group received routine care. The study was conducted between September 2012 and February 2013. Subjects and setting

The nursing directors of three hospital-based home healthcare institutions serving over 100 patients in central Taiwan were contacted for the screening of family caregivers. The family caregivers were eligible if their family member had experienced a stroke (ICD 9 430–438), had a Barthel index score of less than 60 and were unable to intake orally. The Barthel index score consisting of 10 items is used to measure performance in activities of daily living (ADL) of people with disabilities. The 10 items include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on a level surface, going up and down stairs, dressing, continence of bowels and bladder. The total score of the Barthel index score is 100, with a score of less than 60 indicating a severe disability situation for stroke survivors (30). The family caregivers were excluded if their stroke survivor had a confirmed diagnosis of pulmonary infection or a diagnosis of oral or tongue pathology. The family caregivers who were unable to open their stroke survivor’s mouth were also not eligible for this study; this is because stroke survivors with unstable conditions will increase intervention risk. Each family caregiver was actively caring for their stroke survivor for at least 8 h per day and was able to communicate in Mandarin or Taiwanese. Sample estimates were based on Cohen’s (31) suggested criteria for comparing the means of two groups. With a power of 0.8 and a = 0.05, a sample size of 26 family caregivers was required. Applying an estimated dropout rate of 25%, each group required 33 family caregivers. Further, the mortality rate for severe stroke survivors with home health care was also considered. Finally, the Int J Dent Hygiene 14, 2016; 82--91 |

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sample size was estimated based on three data collection times, and thus, we estimated the sample size as 50. Intervention procedure

In total, 171 family caregivers of stroke survivors were eligible for inclusion in this study. Each of the 171 family caregivers was contacted by phone and invited to participate, and 100 provided verbal consent. Once a list of consenting eligible family caregivers had been established, a computer-generated random number table was used to prepare the allocation schedule. A list of treatment assignments linked with the case number was generated with every other patient randomized into the intervention or control group. Participants allocated to the intervention group (N = 50) received the HOCP, and participants allocated to the control group (N = 50) received routine care. During this study, 6 participant family caregiver– stroke-survivor dyads were lost to follow-up due to later refusal to participate (N = 1) or death (N = 5). At the end of two months, 94 family caregivers–stroke survivors dyads (48 and 46 dyads in the intervention and control groups, respectively) were analysed in this study (Fig. 1). The control group received routine oral care including physical assessment, information on stroke and its consequences,

prevention and management options. Family caregivers were encouraged to maintain oral cleaning with cotton swabs by their routine care. The research protocol and delivery of the HOCP were conducted by a trained home healthcare nurse (HHCN) with 10 years of experience. This nurse was a qualified home healthcare nurse and received an integrated HOCP training from a dental specialist. Data collection was conducted by a trained research assistant with a nursing background. Written Informed consent was obtained from family caregivers. All data were collected from family caregivers at the stroke survivors’ homes. Approval to conduct this study was obtained from the Institutional Review Board of Changhua Christian Hospital (CCH IRB No. 111122). Verbal consent was obtained during the initial phone interview, and written informed consent was obtained during the first visit by the HHCN. Home-based oral care training programme

The HOCP was theoretically guided by the PRECEDE-PROCEED model for planning, implementation and evaluation of the programme. According to the most recent version of the model by Green and Kreuter (32), this model prescribes nine phases in planning, implementing and evaluating health promotion pro-

Eligible caregivers (n = 170) Agree to participate (n = 100) Randomized

Experimental group (n = 50)

One month after initial visit

Telephone follow-up (2 weeks after second visit) Two months after initial visit

84

Control group (n = 50)

Initial visit (n = 50) Baseline data assessment, oral care overview based on the oral care educational pamphlet, discussion of basic oral care procedures, providing oral care products, teaching relevant strategies, demonstration, return demonstration, providing the reminder mechanism for oral care and follow-up

Initial visit (n = 50) Baseline data assessment, provide the routine oral care with swabs

Second visit (n = 48) Excluded from analysis (n = 2) -Refused to participate (n = 1) -Death (n = 1) Providing the positive reinforcement strategies, confirm the reminder mechanism for oral care, second time data assessment of oral care

Second visit (n = 50) No participant loss to follow-up. Social contact, second time data assessment of oral care

Consultation and encouragement to reinforce oral care practices

Third visit (n = 48) No participant loss to follow-up

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Social contact

Third visit (n = 46) Excluded from analysis (n = 4) -Death (n =4)

Fig. 1. Flow chart of study.

Ya-Wen Kuo et al. Family caregiver oral care practice

grammes. The PRECEDE portion of the model comprises five of the components that included social, epidemiological, behavioural and environmental, educational and ecological diagnosis, and administrative and policy assessments. The PROCEED portion of the model includes implementation, process evaluation, impact evaluation and outcome evaluation. The PRECEDE-PROCEED model provides a comprehensive structure for assessing health and quality of life needs and has been successfully employed to promote community health and for other public health interventions (32). The meaning of the educational programme depends on its effects, which are influenced by the appropriate uses of educational models. The PRECEDE component includes the factors affecting behaviours which are categorized into predisposing, enabling and reinforcing factors. Based on the results of a needs assessment of family caregivers, an appropriate environmental and educational intervention was implemented in the intervention group. Changes in the predisposing factors (knowledge, attitude and self-efficacy, sample characteristics for family caregivers: age, education, relationship and providing care time), enabling factors (educational pamphlet, education class, tool of toothbrush and tool of tongue clean), reinforcing factors (getting influences and support from family caregivers and health providers) and especially preventive behaviours were assessed by questionnaires immediately, one month and two months after the intervention activities. The family caregivers were educated and encouraged oral care that included the nature of the task; the frequency with which the task was to be performed; the hours of care provided each day; the skills, knowledge and abilities to perform tasks; the extent to which the tasks could be made routine and thus incorporated into daily schedules and the support received from other family members (28). The HOCP (Table 1) (15,28,29,33–36) included an oral care overview (a 20-min oral care health and disease verbal presentation based on an oral care educational pamphlet), discussion of basic oral care procedures and the risks, face-to-face education at the family caregiver’s home, provision of oral care products that included a dual action tongue cleaner (Sunstar American, Inc.) and a finger toothbrush, teaching strategies for the family caregivers that included assessment, method, skill, frequency and time of oral care, demonstrations, return demonstrations and a reminder mechanism with daily record sheets for oral care and follow-up phone calls. In this training programme, the family caregivers’ feelings about providing oral care were taken seriously, because most family caregivers often feel unprepared to provide care, have inadequate knowledge to deliver proper care and receive little guidance from the healthcare providers (28). The control group was encouraged to maintain their routine oral care practices (included oral cleaning with cotton swabs) during the two months of the intervention period. After the two months of the intervention period, the HOCP was also provided for the family caregivers in the control group. The measurements as described below were made in the outcome measure section.

Table 1. Home-based oral care training programme Session overview

Component

Oral care overview

An educational pamphlet related to oral care was provided to the family caregivers of the intervention group. Based on the oral care educational pamphlet provided to the family caregivers of the intervention group, a 20min verbal presentation was followed by a discussion of basic oral care procedures and risks. Two kinds of oral care products: intervention group were provided with two kinds of oral care products: a dual action tongue cleaner (Sunstar American, Inc.) and a finger toothbrush. Emphasize the importance of home-based oral care. Assist the family caregivers in planning and assessment the oral care of stroke survivors. Provide guidance for appropriate cleaning techniques of dentures, natural teeth and tongue. The HOCP emphasizes the need for well trained and skilled caregivers who have the knowledge, attitude and self-efficacy in stroke survivors. An ideal teaching of oral care would have several strategies that are listed below: 1 twice (after breakfast and before sleep) a day; 2 two minutes per time; 3 learning brushing sequence (from teeth to tongue); 4 learning tongue cleaning (distinguishing six regions, from left– middle–right of the anterior tongue to left–middle–right of the posterior tongue); 5 learning how to use the equipment (tongue cleaner and finger toothbrush); 6 checking the dental cavities; 7 confirming the method of toothbrush; 8 using the technique of Bass brushing and oral mucosa cleaning. The HHCN demonstrated the method of toothbrushing and tongue cleaning to the family caregivers. The HHCN provided return demonstrations of these techniques. Provide the daily record sheet for oral care. Telephone follow-up at one month to reinforce oral care practices. Family caregivers’ feelings about providing oral care were investigated and discussed during a 20-min conversation with the HHCN. Assessed by a trained research assistant with a nursing background. The Behaviour of Oral Care questionnaire was used based on the HOCP intervention protocol.

Discussion of basic oral care procedures and risks

Providing oral care products

Teaching content

Teaching strategies

Demonstration

Return demonstrations Reminder mechanism for oral care Follow-up

Assess oral care behaviour

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Outcome measurements

Family caregiver oral care knowledge, attitude, self-efficacy and behaviour were evaluated at baseline and at one and two months after the intervention in both the intervention and control groups. The measurements were made in the homes of the stroke survivors. Knowledge. A 44-item Knowledge of Oral Care (KOC) questionnaire was developed by the authors of this study. Twentysix items were derived with permission from the Carer’s Questionnaire developed by Frenkel et al. (24) which assessed caregivers in long-term care facilities. A total of eighteen items were generated as a result of a review of the literature on tongue cleaning and tongue coating (15,18,33–36). The content validity index was 0.95. The items required true/false responses, with each correct answer scoring one. In this study, the internal consistency (K-R 20) was 0.86. Attitude. A 19-item Attitude towards Oral Care (AOC) questionnaire was developed by the authors of this study. Thirteen items were obtained with permission from the Carer’s Questionnaire developed by Frenkel et al. (24), and 6 additional items assessed attitudes towards tongue cleaning. Each item was measured on a 5-point Likert scale from 2 for ‘strongly agree’ through zero for ‘no opinion’ to 2 for ‘strongly disagree’, to give a range of scores from 38 to 38. Negatively worded statements were reverse coded. In this study, the internal consistency (Cronbach’s a) was 0.83. Self-efficacy. Family caregiver Self-Efficacy of Oral Care (Self-E) was measured with a 34-item questionnaire. Twentysix items were modified from the Oral Health Self-Efficacy Questionnaire (OHSEQ) (37) and covered two self-efficacy domains: perceived competence (12 items) and level of confidence (14 items). Eight items were developed to measure perceived outcome expectancy. The subjects rated their selfefficacy in providing oral care on a 5-point Likert scale from 2 for ‘strongly agree’ through zero for ‘no opinion’ to 2 for ‘strongly disagree’, to give a range of scores from 68 to 68. Negatively worded statements were reverse coded. In this study, the internal consistency (Cronbach’s a) was 0.87. Behaviour. The family caregiver’s behaviour was assessed by a trained research assistant with a nursing background using the Behaviour of Oral Care (BOC) questionnaire, based on the HOCP (15, 18, 29, 33–36, 38). The assessment time including viewing the daily record sheet and observing the whole oral care process was about 15–20 min. The BOC includes 26 items: five items concerning time (including toothbrush time: after breakfast and before sleep) and frequency of toothbrushing (including toothbrushing, tongue cleaning and checking for tooth cavities twice a day), seven items about the method of toothbrushing (the Bass brushing technique), one item about brushing force, one item about brushing for at least 2 min per time, seven items concerning tongue cleaning (including sequence and area), four items about toothbrushing products (included cleaning solution, toothbrush, tongue clean tool and dental floss) and one item about oral mucosa cleaning. A score of 0 (no behaviour noted), 1 (partially) and 2 (adhered to

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protocol) was given for each item, with a total score ranging from 0 to 52. The content validity index of the BOC was 0.95. Statistical analysis

Data were analysed using IBMâ SPSSâ English version 19 software (SPSS Inc., Chicago, IL, USA) for Windows. Demographic data of the intervention, and control groups were compared using the chi-square test and Student’s t-test. SPSS mixed model ANOVA was performed to calculate differences between the intervention and control group with respect to knowledge, attitude, self-efficacy and practice behaviour at one and two months.

Results Sample characteristics

Ninety-four of the 100 family caregivers enrolled in this study provided data at each of the three measurement periods (Fig. 1). In the experimental group, one family caregiver refused to participate at one month, and one patient died within the first month. In the control group, four patients died within two months. Forty-eight family caregivers, including 32 women, comprised the intervention group, with a mean age of 52.7 (standard deviation, SD = 11.29) years. Most family caregivers had a senior high school education (33.3%). Most family caregivers of intervention group were nearly evenly divided among spouses (31.3%), daughter (27.1%) and son (25%), with 16.7% others. Forty-six family caregivers (27 women) comprised the control group, with a mean age of 53.9 (SD = 16.74) years. Among the family caregivers who completed the survey for the control group, 32.6% family caregivers had a senior high school education and the major family caregivers were the spouses (32.6%). The baseline characteristics (gender, education, family relationship, daily care time and age) were similar between the two groups (Table 2). Outcome variables

Descriptive characteristics at baseline, during the study period and at the end of the study are shown in Table 3. At baseline, subject knowledge, attitude, self-efficacy and behaviour of the oral care indicators between the two groups were not significantly different. The family caregivers who received HOCP training reported significantly improved oral care knowledge (23.4 – 32.6 – 31.8), attitude (12.9 – 15.8 – 14.9), self-efficacy (30.3 – 38.9 – 52.4) and behaviour (15.3 – 43.8 – 45.4) from baseline to one and two months, respectively (Table 3). In addition, the intervention group demonstrated significant differences in each variable score compared to baseline at one month. In the control group, the knowledge score of tooth care decreased on average from baseline to one and two months (22.1 – 21.9 – 20.5). After two months, the knowledge score of tongue care decreased slightly (10.0 – 9.2 – 8.1), and the

Ya-Wen Kuo et al. Family caregiver oral care practice

Table 2. Demographic characteristics of the family caregivers with stroke survivors (n = 94)

Gender Male Female Education Elementary Junior Senior College + Caregiver relationship Husband Wife Son Daughter Other Time of daily care Over 8 to 16 h Over 16 to 24 h

Experimental Group (n = 48)

Control Group (n = 46)

n

%

n

%

v²

P

16 32

33.3 66.7

19 27

41.0 59.0

0.64

ns

12 12 16 8

25.0 25.0 33.3 16.7

12 6 15 13

26.1 13.0 32.6 28.3

5.60

ns

3 12 12 13 8

6.3 25.0 25.0 27.1 16.7

8 7 9 9 13

17.4 15.2 19.6 19.6 28.2

5.90

ns

13 35

27.2 72.9

18 28

39.1 60.9

3.37

ns

Experimental group

Age (years)

Control group

Mean

SD

Mean

SD

52.71

11.29

53.91

16.74

attitude towards oral care, oral care self-efficacy and behaviour of oral care remained unchanged from the previous month (Table 3). The mixed model ANOVA analysis showed statistically significant differences in three outcome variables (knowledge: t = 8.80, P < 0.001; self-efficacy: t = 3.53, P < 0.01; behaviour: t = 11.93, P < 0.001) between the intervention and control groups over time. The attitude towards oral care did not differ significantly between groups (t = 1.56, P = .12). The intervention group had more knowledge, better attitude and greater self-efficacy and demonstrated better oral care behaviour than those of the control group. The group 9 time interaction was significant for oral care knowledge after one month of the intervention (P < 0.001), as were self-efficacy oral care (P = 0.001) and behaviour of oral care (P < 0.001) at one and two months of the intervention for both groups (Table 4).

Discussion The findings of this study indicate that a structured homebased oral care training programme for family caregivers of stroke survivors can positively influence the knowledge, attitude, self-efficacy and behaviour of oral care. The family caregivers in this study were predominately female, which is expected as more men experience stroke (39) and there is a traditional cultural expectation of women being the family caregivers in Taiwan. At baseline, the family caregivers had low knowledge, attitude, self-efficacy and behaviour scores. Stroke survivors continue to experience significant

t

P 0.41

0.68

impairments after discharge, and these findings suggest that family caregivers may be poorly prepared for the full extent of caregiving responsibilities (40). Most stroke survivors are discharged home, and their family caregivers receive personalized risk reduction information on cholesterol, blood pressure, medications (41), rehabilitation, nutrition and community resources (42). However, oral care practices are not typically included in discharge information for family caregivers with stroke survivors in Taiwan, and the information given is usually limited to oral cleaning with cotton swabs. Previous studies (43, 44) on improving oral care practice for long-term care have shown that toothbrushing is appropriate as the standard of good oral care and using a swab does not remove plaque as effectively as a toothbrush. Further, oral care practices are rarely regularly observed by HHCN. The control group in this study benefited from both discussions with the primary HHCN during monthly visits and the raised awareness of oral care by the HHCN programme provider. The improvement in oral hygiene knowledge, self-efficacy and oral care behaviour from baseline to one month may reflect a short-term Hawthorne effect. The two-month decline in oral healthcare knowledge was likely due to the lack of reinforcement, as most family caregivers had little experience. Oral care of the tongue declined after two months in the control group, while self-efficacy and specifically the level of confidence increased from baseline. The control group was not provided with oral care products, so it is not surprising that product knowledge decreased at two months. The findings of Int J Dent Hygiene 14, 2016; 82--91 |

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Table 3. Changes in outcome variables from baseline, one month and two months intervention outcomes for family caregivers (n = 94) Intervention (n = 48)

Control (n = 46)

Variables

Baseline Mean (SD)

One month Mean (SD)

Two month Mean (SD)

Baseline Mean (SD)

One month Mean (SD)

Two month Mean (SD)

KOC (0–44) Denture care Teeth care Tongue care AOC ( 38–38) Self-E ( 68–68) Competence Level of confidence Outcome expectancy BOC (0–52) T&F Method* Products† Tongue‡ Mucosa§

23.4 3.9 8.5 10.9 12.9 30.3 11.1 10.5 8.7 15.3 3.8 3.7 3.4 3.3 1.2

32.6 4.6 10.5 17.5 15.8 38.9 15.1 12.6 11.2 43.8 8.4 15.3 6.5 11.9 1.8

31.8 4.5 9.8 17.6 14.9 52.4 19.2 19.2 13.9 45.4 8.6 15.7 6.9 12.4 1.8

22.1 3.4 8.7 10.0 12.3 28.3 11.0 9.4 7.9 16.4 3.8 4.1 3.6 3.5 1.3

21.9 4.3 8.4 9.2 12.9 32.2 13.3 10.0 8.9 25.15 6.1 7.9 4.4 5.0 1.7

20.5 3.6 8.4 8.1 12.9 33.2 13.2 11.2 8.9 24.22 6.2 7.9 3.5 4.74 1.78

(8.77) (4.42) (2.54) (4.86) (5.99) (11.35) (6.61) (3.93) (2.90) (7.94) (2.19) (3.08) (1.86) (3.33) (.75)

(7.23) (4.85) (4.52) (1.53) (7.11) (16.21) (7.55) (7.14) (4.07) (8.58) (2.09) (3.42) (1.56) (3.17) (0.49)

(7.29) (4.93) (4.74) (.99) (5.72) (14.46) (5.38) (7.93) (3.81) (9.20) (2.45) (3.59) (1.55) (3.25) (0.46)

(6.86) (3.59) (3.15) (4.28) (7.79) (14.5) (6.8) (6.06) (5.10) (7.7) (2.32) (3.76) (1.89) (2.71) (0.76)

(5.33) (4.35) (2.44) (2.81) (5.51) (11.91) (4.81) (5.34) (3.47) (7.74) (1.85) (3.27) (1.64) (3.52) (0.55)

(5.03) (3.99) (2.23) (2.12) (4.76) (8.34) (4.69) (3.43) (2.21) (8.73) (1.91) (5.04) (2.87) (3.74) (0.51)

SD, standard deviation; KOC, knowledge of oral care; AOC, attitude towards oral care; Self-E, self-efficacy of oral care; BOC, behaviour of oral care; T & F, time and frequency of toothbrushing. *Method of toothbrushing. † Toothbrush products. ‡ Tongue cleaning. § Mucosa cleaning.

the control group at two months represent the baseline education and illustrate the importance of longitudinal assessments of the effects. The predisposing factors of the PRECEDE-PROCEED model include knowledge, attitude and self-efficacy. The impact of the HOCP was evidenced by the significant improvement in each variable score after one month. Knowledge of tongue care increased over 60% at one month and was the greatest contribution to the increase in knowledge. Many micro-organisms are found in the mouth. Tongue coating is associated with the number of salivary bacteria (14, 45) and has even been implicated in the development of pneumonia and pneumonia-related health problems (15, 17, 46). However, tongue cleaning is not usually included in routine guidelines or nursing education curricula. Therefore, it is essential for all HHCN to receive evidence-based education and to instruct family caregivers in routine oral care to improve patient outcomes. Oral care behaviour improved significantly in the intervention group at one month and persisted at two months. Brushing another person’s teeth can be difficult and especially challenging for family caregivers when the patient is unable to actively participate or cooperate. While attitude towards oral care increased early in the study, the 73% increase in self-efficacy was impressive. The improvement of family caregivers’ knowledge in caring for stroke survivors might influence attitude towards care of older adults (47). The short-term effect of the HOCP in the field improved attitude score with family caregivers from positive at one month to decline at two months that may be affected by the enhancing self-efficacy. 88

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Bandura described three important components of self-efficacy: a person’s estimate of her/his own capability to perform in the particular environment; a person’s feelings of increased confidence in accomplishing a particular task; and a person’s belief system that allows an individual to have control over her/his thoughts, feelings and actions (48). There were sustained improvements in the scores of self-efficacy in the intervention group over time. The simple daily record sheet for oral care and telephone follow-up calls of encouragement may have boosted self-efficacy. Providing information, educating and promoting self-efficacy among family caregivers are key processes to achieve patient-focused, family-centred care. Models of health education programming include incentives and feedback received from others that encourage learner behaviour (32). The HOCP created a non-threatening opportunity to discuss challenges around oral care with telephone follow-up calls as the reinforcement. Long-term follow-up may be needed in the future studies to identify the effect of the sustainability of the programme. The differences between the control and intervention groups after two months attest to the impact of the HOCP. The oral care knowledge of the intervention group, which was similar at baseline to the control group, was nearly double that of the control group at two months. Specifically, the oral care method scores of the family caregivers who received the intervention were twofold higher than those of the control group, and tongue care was performed three times more often by the intervention group. The control group demonstrated that when knowledge does not influence attitude or self-efficacy, there is

Ya-Wen Kuo et al. Family caregiver oral care practice

Table 4. Mixed model (n = 46) groups

ANOVA

analysis of variance results for KOC, AOC, Self-E and BOC between the intervention (n = 48) and control 95% CI

Outcome variable KOC Intercept Group 1 (Group 2) Time 0 (Time 2) Time 1 (Time 2) Group 1* Time 0 Group 1* Time 1 AOC Intercept Group 1 (Group 2) Time 0 (Time 2) Time 1 (Time 2) Group 1* Time 0 Group 1* Time 1 Self-E Intercept Group 1 (Group 2) Time 0 (Time 2) Time 1 (Time 2) Group 1* Time 0 Group 1* Time 1 BOC Intercept Group 1 (Group 2) Time 0 (Time 2) Time 1 (Time 2) Group 1* Time 0 Group 1* Time 1

b

SE

t

P

Upper

Lower

20.54 11.29 1.54 1.37 10.02 0.64

0.92 1.28 1.47 1.31 2.06 1.83

22.40 8.80 1.05 1.05 4.87 0.35

0.00 0.00 0.30 0.30 0.00 0.73

18.72 8.74 1.36 1.21 14.0 4.24

22.36 13.84 4.45 3.95 5.96 2.97

12.89 1.98 0.61 0.02 1.41 0.87

0.91 1.27 1.24 1.11 1.74 1.56

14.19 1.56 0.49 0.02 0.81 0.56

0.00 0.12 0.63 0.98 0.42 0.58

11.10 0.52 3.06 2.18 4.84 2.20

14.68 4.49 1.84 2.22 2.02 3.95

14.70 4.51 3.67 0.33 4.43 4.43

0.91 1.28 1.18 0.99 1.65 1.39

16.09 3.53 3.11 0.33 2.68 3.18

0.00 0.001 0.002 0.74 0.01 0.002

12.90 1.99 5.99 1.64 7.68 7.18

16.50 7.03 1.35 2.29 1.17 1.68

23.30 21.28 5.67 3.43 24.51 4.18

1.27 1.78 1.69 1.46 2.37 2.05

18.29 11.93 3.35 2.35 10.34 2.04

0.00 0.00 0.001 0.02 0.00 0.04

20.79 17.77 9.01 0.55 29.18 8.23

25.81 24.79 2.34 6.32 19.84 0.14

SE, standard error; CI, confidence interval; KOC, knowledge of oral care; AOC, attitude towards oral care; Self-E, self-efficacy of oral care; BOC, behaviour of oral care; Experimental group = Group 1, Control group = Group 2, Baseline data = time 0, One-month data = time 1, Two-month data = time 2.

little change in behaviour. The influence of knowledge was therefore a key in convincing the intervention group to change their oral care behaviour through changes in attitude and selfefficacy. Home health care is preferred for many people with longterm illnesses. The HOCP increased the family caregiver’s behaviour towards oral care, and this supports the effectiveness of educational interventions for family caregivers of stroke survivors. In our study, development and implementation of the HOCP training using PRECEDE-PROCEED model led to the promotion of oral care behaviour. Although there are some oral care education programmes of that have been developed in people with disabilities in nursing homes (49), few of these programmes involve theory-based developments (50), and outcome measures lacked indicators of selfefficacy. Our results indicated that knowledge, attitude, selfefficacy and oral care behaviours all evinced improvement after home-based oral care training programme. Maintenance of these positive effects is likely to require ongoing long-term family caregiver support and encouragement. In addition, the family caregiver’s feelings, stress and burden for oral care require further investigation. A dental hygienist is a licensed

dental professional, and they have the training and education that focus on and specialize in the prevention and treatment of oral health and disease (51). The dental hygienists also could serve as an educator to improve access to care for stroke survivors with home care. The best practice guidance for providing an oral health assessment and education for stroke survivors by dental hygienists at home also requires further exploration in the future. The majority of stroke survivors following their stroke return home, where family caregivers play an important role in their care. Stroke family caregivers provide valuable care to stroke survivors, often at the expense of their own life and health (52). The ethical situation emerging between the family caregivers and the stroke survivors also needs to be considered carefully. Our study had several limitations. The lack of crossover is a weakness of the study design. Although we attempted to keep observer bias to a minimum using observers not involved in treatment assignments or patient care, interactions with HHCNs (who were aware of the training received) may have disclosed treatment assignments during assessments. Another limitation of this study is the lack of long-term follow-up. Int J Dent Hygiene 14, 2016; 82--91 |

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Ya-Wen Kuo et al. Family caregiver oral care practice

While the intervention effect persisted after two months, the effect duration remains unknown. It is encouraging that the experimental group continued to improve over time, suggesting that long-term maintenance by family caregivers is possible. A sham intervention may have confirmed a Hawthorn effect in the control group. Family caregivers are critical partners in the plan of oral care for stroke survivors. Clinical nurses and dental hygienists should be concerned with oral care issues that affect stroke survivor’s oral health and quality of care as the reliance on family caregiving grows. Patients being cared for at home should be assessed by a health provider to ensure that the family caregivers are providing quality home care and that oral care is being provided correctly. We suggest that home healthcare providers and dental hygienists should be actively involved in providing family caregivers with a home-based oral care training programme for regular care and that a home care manual should be provided for routine oral care. Educational reinforcement on a regular basis should also be implemented to reinforce knowledge and develop positive attitudes and self-efficacy.

Principal findings

HOCP appears to be a useful method for enhancing oral care behaviour in the home setting. The education of home-based oral care relies on the knowledge and self-efficacy of oral care among family caregivers and was found to be sufficient to empower them to modify oral care practices. Practical implications

This has long-term care and home care implications for oral health educational programme among family caregivers of stroke survivors.

Acknowledgements We acknowledge the contributions made by all of the hospitalbased home healthcare institutions, patients and family caregivers who participated in this study. The authors also thank neurologist Jiann-der Lee, dentist Po-Yuan Chen and family medicine physician Yu-Wen Yang for their professional advice. The authors have no conflict of interests to report. There was no external funding for this study.

Conclusions Knowledge, attitude and self-efficacy are prerequisites to change behaviours. A home-based oral care training programme can achieve significant improvements in oral care knowledge, attitude and self-efficacy among family caregivers, sufficient to empower them to modify their oral care behaviour provided to stroke survivors. A home-based oral care training programme should be implemented for family caregivers when stroke survivors are discharged home. Further, we suggest including dental hygienists as part of the care team for stroke survivors who receive home care. Dental hygienists can provide expertise and tools necessary to develop in home oral healthcare programmes for these patients. Collaboration between nurses, dental hygienists, physical and occupational therapists might also be an adequate interdisciplinary approach to consider when providing training to family caregivers.

Clinical relevance Scientific rationale for study

Stroke survivors experience poor oral health when discharged from hospital to the community, and thus, the aim of the study was to evaluate the effectiveness of a home-based oral care training programme on knowledge, attitude, self-efficacy and practice behaviour of family caregivers. Few reported intervention programmes involve the PRECEDE-PROCEED model for planning, implementation and evaluation of the programme. The HOCP entails identifying the predisposing, enabling and reinforcing factors, which leads to behavioural change. 90

| Int J Dent Hygiene 14, 2016; 82--91

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