PHYSICAL RESISTANCE DURING ORAL HYGIENE CARE
ARTICLE ABSTRACT The purpose of this study was to investigate perceived comfort levels, behaviors, and barriers reported by group home caregivers who provide oral hygiene measures to consumers with special health care needs (SHCN) who physically resist the care. A 24-item survey was sent to 884 caregivers employed at six care facilities in Iowa. Bivariate analyses and logistic regression models were used to analyze the data (alpha = 0.05). The overall response rate was 52%. An analysis of the data indicated that caregivers who felt more comfortable providing oral hygiene for consumers who physically resisted the care experienced a higher frequency of consumers not opening their mouths (p = 0.0003), pushing the caregiver away (p = 0.0002), moving their heads uncontrollably (p = 0.0004), spitting at (p = 0.0099), hitting and/or kicking the caregiver (p = 0.0011). Furthermore, these caregivers provided weekly direct care for a greater number of consumers (p = 0.0044), received oral care training from their current facility (p = 0.0424), brushed the teeth of uncooperative consumers at least 75% of the time (p < 0.0001), and felt “somewhat comfortable to very comfortable” flossing their teeth (p < 0.0001). The caregivers’ comfort level in providing oral hygiene measures to those consumers with SHCN who physically resist the care appears to be significantly associated with their training and experience working with this population.
KEY WORDS:
caregivers, group homes, special health care needs, dental care
Group home caregivers’ comfort levels regarding physical resistance during oral hygiene care Kayla M. Risma, DDS;1 Karin Weber-Gasparoni, DDS, MS, PhD;2* Sarah E. Swenson, BS, DDS;3 Ronald L. Ettinger, BDS, MDS, DDSc;4 Fang Qian, PhD5 1Pediatric
Dentist in Private Practice, Dubuque, Iowa; 2Associate Professor and Chair, Department of Pediatric Dentistry, College of Dentistry, University of Iowa, Iowa; 3Pediatric Dentist in Private Practice, Cedar Rapids, Iowa; 4Professor, Department of Prosthodontics, College of Dentistry, University of Iowa, Iowa; 5Adjunct Assistant Professor, Department of Preventive & Community Dentistry, College of Dentistry, University of Iowa, Iowa. *Corresponding author e-mail: [email protected] Spec Care Dentist 35(3): 123-131, 2015
Introd uct ion:
Dental care is the most common category of unmet healthcare services for consumers with special healthcare needs.1–3 Many of these consumers have “significant limitations in performing daily self-maintenance activities,” and depend on a family member or caregiver for daily oral hygiene.1 Currently, approximately 7 out of 10 individuals with special health care needs (SHCN) are children or nonelderly adults.4 As these children transition to adulthood, many move to community-based group homes where they can be more autonomous. This transition often poses a barrier to proper oral care as many of these young adults are still dependent on a caregiver for daily oral hygiene. Since these consumers with SHCN are at higher risk for gingivitis, periodontal disease, caries, malocclusions, and dental trauma,1 it is imperative that dental professionals address these barriers to attain adequate oral health for individuals with SHCN who live in group home settings.
Providing health care for consumers with special needs, by definition, requires a range of knowledge and accommodative measures that go beyond what is considered routine.1 These individuals may have a wide variety of physical, developmental, mental, sensory, behavioral, cognitive, and emotional impairments.4–6 The current literature lacks information on perceived comfort, behaviors, and barriers encountered by group home staff members who provide daily oral hygiene measures for individuals with SHCN who physically resist the care. However, there is abundant research regarding elderly populations who live in
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long-term facilities.7–20 In their study regarding oral care delivery for nursing facility residents, Chalmers et al.7 indicated that 80% of nurses’ aides reported residents not opening their mouths, biting the toothbrush, and refusing oral care. Other difficulties included kicking, hitting, spitting, and biting the nurses’ aide.7 Many of these barriers have also been reported in the SHCN population. Jobman et al.21 identified difficult behaviors in individuals with SHCN living in group homes, which included moving their heads uncontrollably, not opening their mouths, biting, spitting, and hitting the caregiver. It is reasonable to conclude
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that these behaviors contribute to the problem of unmet dental health needs among group home consumers with SHCN. Therefore, the purpose of this study was to investigate the perceived comfort levels, behaviors, and barriers reported by group home caregivers whose oral hygiene care was physically resisted by consumers with SHCN.
Methods
The survey instrument consisted of 24 questions related to caregivers working in group homes, which included demographics, amount of training on how to provide oral health care to consumers with SHCN (i.e., brushing and/or flossing), comfort levels, behaviors, and barriers to delivering oral hygiene measures to these consumers. The pilot study21 was first designed and then tested by 10 faculty members at the University of Iowa College of Dentistry in the Departments of Pediatric Dentistry, Preventive and Community Dentistry, and Prosthodontics, as well as by two group home staff. The study was then conducted among 129 caregivers of two Iowa group homes. Nine administrators of residential and intermediate care facilities within 70 miles of Iowa City were invited to participate in this study; however, three of them declined to participate. Paper surveys were delivered to six care facilities: Reach for Your Potential; Systems Unlimited; Prairie House; REM Iowa; Community Care, Inc.; and Handicapped Development Center. A cover letter explaining the elements of consent was attached to the survey instrument. Two months after the initial survey delivery, a second set of surveys was either mailed or hand delivered to each facility, depending on traveling distance. Consent was considered to be obtained if the respondent returned the survey. To allow study participants to feel comfortable while completing the survey, the names of the study participants were kept anonymous, both to our research team and within their care facility. For this study, individuals with SHCN are referred to as “consumers” since this terminology is
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utilized by the group homes surveyed in this study. This study was approved by the University of Iowa Institutional Review Board.
Sta t is t ica l a na ly s is
A four-point Likert-type scale question ranging from “very uncomfortable” to “very comfortable” was used to query study participants about their comfort level in providing oral hygiene care (i.e., brushing and flossing) to consumers with SHCN who physically resisted the care. Responses of participants were dichotomized into either “comfortable” or “uncomfortable.” Bivariate analyses were performed to determine whether a significant difference existed between the two groups regarding demographic characteristics, training, behaviors, and encountered barriers. The standard chisquare test, Fisher's exact test, and Cochran-Mantel-Haenszel chi-square test were used for categorical variables. A two-sample t-test or Wilcoxon rank-sum test was used, when appropriate, to compare the groups with respect to quantitative measures. A multiple logistic regression model was used to identify factors associated with caregivers’ comfort level while providing oral hygiene measures to consumers with SHCN who physically resisted the care. The variables, which showed significant association with the primary outcome (p ≤ 0.10), were considered as candidates for the final logistic regression model. Forward and backward procedures were performed in the stepwise logistic regression analysis. A p value of less than 0.05 was used as a criterion for statistical significance, and 0.05 ≤ p < 0.10 was used as a criterion for marginal significance. SAS for Windows (v9.3, SAS Institute Inc., Cary, NC) was used for all analyses.
Re s ult s
A total of 884 surveys were distributed to caregivers in six group homes. Four hundred and fifty-nine surveys were returned for a response rate of 52%. The final number of usable surveys was 457. One
survey was returned blank, and one caregiver declined to participate. Table 1 provides relevant characteristics for the 457 caregivers in this study. The mean age of caregivers was 32.1 years (SD = 12; range = 15–69 years) and 75% were female. Respondents reported a mean of 5.8 years working as a caregiver and an average of 3.6 years in their current group home. Caregivers provided daily care for an average of 10 consumers with a total of 32.4 hours a week of direct consumer care. Approximately one-third of consumers were reported to be incapable of brushing independently (32.2%) and another one-third required assistance when brushing their own teeth (37.4%). The vast majority of caregivers (81%) reported receiving some type of training on providing direct oral hygiene care to consumers with SHCN, while 65% reported receiving training from their current facility. However, about 46% expressed an interest in participating in further educational programs that provide training in either handling the uncooperative consumer or performing oral hygiene care. Nearly 56% of the caregivers rated their own oral health as “excellent” or “very good” and about 30% of the respondents needed dental care within the last 6 months. Among those who needed dental care, 59% needed a check-up and cleaning, 17% needed restorative treatment (fillings, extractions, etc.), and 5% needed emergency dental care. Table 2 depicts the perceived comfort levels, problems encountered, and barriers regarding oral hygiene care. Most caregivers felt “somewhat comfortable” to “very comfortable” providing oral hygiene care for cooperative consumers (89%). However, for consumers who physically resisted the oral care, only 61% of caregivers felt comfortable providing the hygiene measures. Regardless of how a consumer's cooperation level was perceived by the caregiver, the majority of caregivers never flossed the consumers’ teeth. Sixty-four percent never flossed the teeth of cooperative consumers and 68% never flossed those of uncooperative
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Table 1. Summary of relevant characteristics of caregivers providing oral hygiene care to individuals with special health care needs (SHCN).a Variable
Mean
Standard deviation
Age of caregiver in years
32.1
12.0
Number of years working as a caregiver
5.8
6.3
Number of years caregiver has worked at current location
3.6
4.8
Number of consumers caregiver provides direct care for on a weekly basis
10.0
12.1
Hours per week providing direct care
32.4
10.7
Percentage of consumers who are incapable of brushing their own teeth
32.2
31.7
Percentage of consumers who require assistance when brushing their teeth
37.4
31.6
Percentage of consumers who are independent and brush their own teeth
32.5
34.3
Frequency
Valid Percent
Reach For Your Potential
61
13
Systems Unlimited, Inc.
202
44
REM Iowa
36
8
Community Care, Inc.
23
5
Prairie House
16
4
Handicapped Development Center
119
26
Male
114
25
Female
337
75
5
1
Location staff
312
70
Onsite supervisor
58
13
Other
70
16
7
2
High school diploma
216
48
Two year college degree
87
20
Four year college degree
122
27
Graduate degree
15
3
Variable Employment facility
Gender
Job description Office supervisor
Education Some high school
Ever received training on how to provide direct oral health care (i.e., brushing and flossing) for consumers with SHCN Yes, only by verbal training
85
19
Yes, only by hands-on training/demonstration
49
11
Yes, by verbal and hands-on training/demonstration
30
51
No, I have not received any training
89
19
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consumers. The following were problems encountered during delivery of oral hygiene care: 40% of consumers did not open their mouths; 34% pushed the caregiver away; 30% moved their heads uncontrollably; 26% hit and/or kicked the caregiver; and 40% completely refused oral care in at least one in four encounters. In cases when a consumer physically refused oral care, 49% of caregivers reported never continuing delivery of the oral hygiene measures, and 83% of caregivers stopped the oral care and attempted again at a later time. In general, the greatest percentage of caregivers “strongly disagreed” to “disagreed” that the following were barriers to providing oral care to consumers: not being able to devote enough time to oral care (62%); and lack of additional staff to help (63%), knowledge (63%), training (57%), or confidence in providing oral hygiene care (61%). When asked if the consumer who physically resisted oral hygiene care was a barrier, 40% of caregivers “disagreed” to “strongly disagreed,” and 32% of caregivers “agreed” to “strongly agreed.” Table 3 presents the bivariate (unadjusted) results for those variables which showed significance in the bivariate analyses and then were entertained as candidates to develop the final logistic regression model. When compared to their analog counterparts, caregivers who felt comfortable about providing oral hygiene care for physically resistant consumers were significantly more likely to provide direct care for a greater number of consumers per week (11 vs. 9 persons, p = 0.0044) they also had received both verbal and hands-on training (70.4% vs. 50.7%, p < 0.0001) had training at their current facility (66.7% vs. 49.0%, p = 0.0005), flossed the teeth of cooperative consumers 25–100% of the time (67.8% vs. 57.3%, p = 0.0362), and brushed the teeth of consumers, both cooperative and uncooperative, 75–100% of the time (67.1% vs. 52.0% p = 0.0018; 75.0% vs. 45.6%, p < 0.0001) respectively. Higher comfort levels in brushing and flossing the teeth of consumers with SHCN were associated with a greater likelihood of feeling comfortable with providing oral
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hygiene measures for consumers who physically resisted the care (p < 0.0001 in each instance; Table 3). Caregivers who experienced a higher frequency of consumers’ behavior problems, such as not opening their mouth, pushing the caregiver away, moving their head, spitting and hitting the caregiver, were more likely to feel comfortable with providing oral hygiene measures to the consumers who physically resisted the care. Moreover, caregivers who felt comfortable about providing oral hygiene measures for the consumers who were physically resistant were more likely to continue the oral care or attempt again at a later time (p < 0.05 in both instances; Table 3). Bivariate analysis of the data found that gender, age, education, and job position of the caregiver were not significantly associated with the comfort levels of the caregivers who provided oral hygiene care to physically resistant consumers. Caregivers’ opinions regarding barriers while providing oral hygiene measures were also not significant. However, it is worth noting that the number of hours caregivers reported providing direct care for consumers with SHCN on a weekly basis approached a marginally significant value (p = 0.0545; Table 3).
Table 1. Continued. Variable
Mean
Standard deviation
Received training from current employment facility on how to provide oral health care (i.e., brushing and flossing) for consumers with SHCN Yes
289
65
No
152
35
Interested in participating in an oral health program (both oral and hands-on training) on how to handle uncooperative consumers who resist oral care Yes
206
46
Interested in participating in an oral health program (both oral and hands-on training) on oral hygiene tips Yes
207
46
Interested in participating in an oral health program (both oral and hands-on training) on oral health education Yes
201
45
186
42
Excellent
94
21
Very good
163
37
Good
137
31
Fair
43
10
Poor
6
1
Yes
138
32
No
294
68
Not interested in oral health related courses at this time Yes How would you rate own oral health?
Needed dental care for yourself in the past 6 months
a
Due to missing data, not all variables add up to the total sample size population of 457.
Table 2. Responses of caregivers’ comfort level, behaviors, problems and barriers encountered.a Comfort
Very uncomfortable n (%)
Somewhat uncomfortable n (%)
Somewhat comfortable n (%)
Very comfortable n (%)
How comfortable do you feel providing the following oral health care for consumers? Brush the consumers’ teeth
42 (9)
17 (4)
81 (18)
307 (69)
Floss the consumers’ teeth
94 (22)
89 (21)
100 (23)
145 (34)
How comfortable do you feel providing oral health care for: Consumers who are cooperative with oral care
41 (9)
10 (2)
64 (15)
324 (74)
Consumers who verbally resist oral care
40 (9)
66 (16)
134 (31)
190 (44)
Consumers who physically resist oral care
68 (16)
Behaviors
Never 0% n (%)
99 (23) Sometimes at least 5% n (%)
Usually at least 50% n (%)
125 (30)
131 (31)
Almost always at least 75% n (%)
Always 100% n (%)
For your cooperative consumers, what percent of the time do you directly perform the following? Brush the consumers’ teeth
84 (19)
62 (14)
48 (11)
99 (22)
148 (34)
Floss the consumers’ teeth
277 (64)
61 (14)
36 (8)
26 (6)
32 (8)
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Table 2. Continued. For your uncooperative consumers, what percent of the time do you directly perform the following? Brush the consumers’ teeth
87 (22)
44 (11)
49 (12)
88 (22)
133 (33)
Floss the consumers’ teeth
259 (68)
42 (11)
23 (6)
21 (5)
39 (10)
Never 0% n (%)
Sometimes at least 25% n (%)
Usually at least 50% n (%)
Almost always at least 75% n (%)
Always 100% n (%)
Problems encountered
When you provide oral hygiene care, how often consumers: Do not open their mouths
126 (30)
168 (40)
78 (18)
37 (9)
12 (3)
Place hands over their mouths
269 (64)
102 (24)
34 (8)
9 (2)
8 (2)
Push caregiver away
194 (46)
144 (34)
56 (13)
16 (4)
12 (3)
Move their heads uncontrollably
183 (43)
125 (30)
64 (15)
34 (8)
15 (4)
Bite the caregiver
321 (76)
73 (18)
14 (3)
5 (1)
7 (2)
Spit at the caregiver
322 (76)
72 (17)
18 (4)
2 (1)
7 (2)
Hit and/or kick caregiver
290 (69)
105 (26)
13 (3)
6 (1)
6 (1)
Completely refuse oral care
209 (50)
169 (40)
28 (7)
9 (2)
6 (1)
104 (27)
105 (27)
47 (12)
25 (6)
107 (28)
Stop the oral hygiene care, attempt again later
67 (17)
74 (18)
74 (18)
77 (19)
112 (28)
Stop the oral hygiene care, seek assistance of another caregiver
102 (27)
92 (24)
78 (20)
48 (13)
62 (16)
What do you do when a consumer physically refuses oral hygiene care? Stop the oral hygiene care
Continue the oral hygiene care
187 (49)
69 (18)
65 (17)
31 (8)
32 (8)
Strongly disagree n (%)
Disagree n (%)
Neutral n (%)
Agree n (%)
Strongly agree n (%)
149 (36)
106 (26)
103 (25)
34 (8)
18 (5)
Lack of additional staff to help
132 (33)
122 (30)
101 (25)
42 (10)
9 (2)
Lack of knowledge on how to provide oral hygiene care
145 (36)
112 (27)
95 (23)
45 (11)
12 (3)
Lack of training on how to provide oral hygiene care
141 (35)
91 (22)
111 (27)
50 (12)
17 (4)
Lack of confidence in skills in providing oral hygiene care
142 (35)
106 (26)
105 (26)
42 (10)
13 (3)
Consumer physically resists oral care
88 (22)
75 (18)
115 (28)
86 (21)
44 (11)
Barriers encountered How much do you consider the following to be a barrier while providing oral care to consumers? Not able to devote enough time to oral care:
aDue
to missing data, not all variables add up to the total sample size population of 457.
Table 4 displays results from the final multiple logistic regression model, which explored significant factors associated with caregivers’ perceived comfort while providing oral hygiene measures to consumers who physically resisted the care. The significant predictors in the final models included training from the current facility on providing oral health care
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for consumers with SHCN (p = 0.0424), percentage of time spent brushing the teeth of uncooperative consumers (p < 0.0001), comfort level for flossing the consumers’ teeth (p < 0.0001), comfort level for providing oral hygiene care for the cooperative consumers (p < 0.0001), and frequency of the consumer pushing the caregiver away (p = 0.0076).
Caregivers who reported feeling comfortable providing oral hygiene measures to consumers who physically resisted the care were: (1) 1.76 times as likely to report receiving training from their current facility on how to provide oral health care for consumers with SHCN compared to those who did not receive training; (2) 3.71 times as likely to brush
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Table 3. Results of bivariate analyses for the factors associated with caregivers’ reported comfort in providing oral hygiene measures for consumers who physically resist the care.a,b Variables
Caregivers’ comfort levelc Comfortable N = 256
Uncomfortable N = 167
p Value
Practice characteristics of the caregiver Number of hours per week providing direct care for consumers with SHCN Mean (hours)
32.6
31.7
0.0545
9
0.0044
Number of consumers providing direct care for on a weekly basis Mean (person)
11
Ever received training on providing oral health care (i.e., brushing and flossing) for consumers with SHCN Yes, verbal and hands-on training/demonstration
152 (70.4%)
64 (29.6%)
Yes, verbal training or hands-on training only/ or no training
103 (50.7%)
100 (49.3%)
ARTICLE ABSTRACT The purpose of this study was to investigate perceived comfort levels, behaviors, and barriers reported by group home caregivers who provide oral hygiene measures to consumers with special health care needs (SHCN) who physically resist the care. A 24-item survey was sent to 884 caregivers employed at six care facilities in Iowa. Bivariate analyses and logistic regression models were used to analyze the data (alpha = 0.05). The overall response rate was 52%. An analysis of the data indicated that caregivers who felt more comfortable providing oral hygiene for consumers who physically resisted the care experienced a higher frequency of consumers not opening their mouths (p = 0.0003), pushing the caregiver away (p = 0.0002), moving their heads uncontrollably (p = 0.0004), spitting at (p = 0.0099), hitting and/or kicking the caregiver (p = 0.0011). Furthermore, these caregivers provided weekly direct care for a greater number of consumers (p = 0.0044), received oral care training from their current facility (p = 0.0424), brushed the teeth of uncooperative consumers at least 75% of the time (p < 0.0001), and felt “somewhat comfortable to very comfortable” flossing their teeth (p < 0.0001). The caregivers’ comfort level in providing oral hygiene measures to those consumers with SHCN who physically resist the care appears to be significantly associated with their training and experience working with this population.
KEY WORDS:
caregivers, group homes, special health care needs, dental care
Group home caregivers’ comfort levels regarding physical resistance during oral hygiene care Kayla M. Risma, DDS;1 Karin Weber-Gasparoni, DDS, MS, PhD;2* Sarah E. Swenson, BS, DDS;3 Ronald L. Ettinger, BDS, MDS, DDSc;4 Fang Qian, PhD5 1Pediatric
Dentist in Private Practice, Dubuque, Iowa; 2Associate Professor and Chair, Department of Pediatric Dentistry, College of Dentistry, University of Iowa, Iowa; 3Pediatric Dentist in Private Practice, Cedar Rapids, Iowa; 4Professor, Department of Prosthodontics, College of Dentistry, University of Iowa, Iowa; 5Adjunct Assistant Professor, Department of Preventive & Community Dentistry, College of Dentistry, University of Iowa, Iowa. *Corresponding author e-mail: [email protected] Spec Care Dentist 35(3): 123-131, 2015
Introd uct ion:
Dental care is the most common category of unmet healthcare services for consumers with special healthcare needs.1–3 Many of these consumers have “significant limitations in performing daily self-maintenance activities,” and depend on a family member or caregiver for daily oral hygiene.1 Currently, approximately 7 out of 10 individuals with special health care needs (SHCN) are children or nonelderly adults.4 As these children transition to adulthood, many move to community-based group homes where they can be more autonomous. This transition often poses a barrier to proper oral care as many of these young adults are still dependent on a caregiver for daily oral hygiene. Since these consumers with SHCN are at higher risk for gingivitis, periodontal disease, caries, malocclusions, and dental trauma,1 it is imperative that dental professionals address these barriers to attain adequate oral health for individuals with SHCN who live in group home settings.
Providing health care for consumers with special needs, by definition, requires a range of knowledge and accommodative measures that go beyond what is considered routine.1 These individuals may have a wide variety of physical, developmental, mental, sensory, behavioral, cognitive, and emotional impairments.4–6 The current literature lacks information on perceived comfort, behaviors, and barriers encountered by group home staff members who provide daily oral hygiene measures for individuals with SHCN who physically resist the care. However, there is abundant research regarding elderly populations who live in
© 2015 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12103
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long-term facilities.7–20 In their study regarding oral care delivery for nursing facility residents, Chalmers et al.7 indicated that 80% of nurses’ aides reported residents not opening their mouths, biting the toothbrush, and refusing oral care. Other difficulties included kicking, hitting, spitting, and biting the nurses’ aide.7 Many of these barriers have also been reported in the SHCN population. Jobman et al.21 identified difficult behaviors in individuals with SHCN living in group homes, which included moving their heads uncontrollably, not opening their mouths, biting, spitting, and hitting the caregiver. It is reasonable to conclude
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that these behaviors contribute to the problem of unmet dental health needs among group home consumers with SHCN. Therefore, the purpose of this study was to investigate the perceived comfort levels, behaviors, and barriers reported by group home caregivers whose oral hygiene care was physically resisted by consumers with SHCN.
Methods
The survey instrument consisted of 24 questions related to caregivers working in group homes, which included demographics, amount of training on how to provide oral health care to consumers with SHCN (i.e., brushing and/or flossing), comfort levels, behaviors, and barriers to delivering oral hygiene measures to these consumers. The pilot study21 was first designed and then tested by 10 faculty members at the University of Iowa College of Dentistry in the Departments of Pediatric Dentistry, Preventive and Community Dentistry, and Prosthodontics, as well as by two group home staff. The study was then conducted among 129 caregivers of two Iowa group homes. Nine administrators of residential and intermediate care facilities within 70 miles of Iowa City were invited to participate in this study; however, three of them declined to participate. Paper surveys were delivered to six care facilities: Reach for Your Potential; Systems Unlimited; Prairie House; REM Iowa; Community Care, Inc.; and Handicapped Development Center. A cover letter explaining the elements of consent was attached to the survey instrument. Two months after the initial survey delivery, a second set of surveys was either mailed or hand delivered to each facility, depending on traveling distance. Consent was considered to be obtained if the respondent returned the survey. To allow study participants to feel comfortable while completing the survey, the names of the study participants were kept anonymous, both to our research team and within their care facility. For this study, individuals with SHCN are referred to as “consumers” since this terminology is
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utilized by the group homes surveyed in this study. This study was approved by the University of Iowa Institutional Review Board.
Sta t is t ica l a na ly s is
A four-point Likert-type scale question ranging from “very uncomfortable” to “very comfortable” was used to query study participants about their comfort level in providing oral hygiene care (i.e., brushing and flossing) to consumers with SHCN who physically resisted the care. Responses of participants were dichotomized into either “comfortable” or “uncomfortable.” Bivariate analyses were performed to determine whether a significant difference existed between the two groups regarding demographic characteristics, training, behaviors, and encountered barriers. The standard chisquare test, Fisher's exact test, and Cochran-Mantel-Haenszel chi-square test were used for categorical variables. A two-sample t-test or Wilcoxon rank-sum test was used, when appropriate, to compare the groups with respect to quantitative measures. A multiple logistic regression model was used to identify factors associated with caregivers’ comfort level while providing oral hygiene measures to consumers with SHCN who physically resisted the care. The variables, which showed significant association with the primary outcome (p ≤ 0.10), were considered as candidates for the final logistic regression model. Forward and backward procedures were performed in the stepwise logistic regression analysis. A p value of less than 0.05 was used as a criterion for statistical significance, and 0.05 ≤ p < 0.10 was used as a criterion for marginal significance. SAS for Windows (v9.3, SAS Institute Inc., Cary, NC) was used for all analyses.
Re s ult s
A total of 884 surveys were distributed to caregivers in six group homes. Four hundred and fifty-nine surveys were returned for a response rate of 52%. The final number of usable surveys was 457. One
survey was returned blank, and one caregiver declined to participate. Table 1 provides relevant characteristics for the 457 caregivers in this study. The mean age of caregivers was 32.1 years (SD = 12; range = 15–69 years) and 75% were female. Respondents reported a mean of 5.8 years working as a caregiver and an average of 3.6 years in their current group home. Caregivers provided daily care for an average of 10 consumers with a total of 32.4 hours a week of direct consumer care. Approximately one-third of consumers were reported to be incapable of brushing independently (32.2%) and another one-third required assistance when brushing their own teeth (37.4%). The vast majority of caregivers (81%) reported receiving some type of training on providing direct oral hygiene care to consumers with SHCN, while 65% reported receiving training from their current facility. However, about 46% expressed an interest in participating in further educational programs that provide training in either handling the uncooperative consumer or performing oral hygiene care. Nearly 56% of the caregivers rated their own oral health as “excellent” or “very good” and about 30% of the respondents needed dental care within the last 6 months. Among those who needed dental care, 59% needed a check-up and cleaning, 17% needed restorative treatment (fillings, extractions, etc.), and 5% needed emergency dental care. Table 2 depicts the perceived comfort levels, problems encountered, and barriers regarding oral hygiene care. Most caregivers felt “somewhat comfortable” to “very comfortable” providing oral hygiene care for cooperative consumers (89%). However, for consumers who physically resisted the oral care, only 61% of caregivers felt comfortable providing the hygiene measures. Regardless of how a consumer's cooperation level was perceived by the caregiver, the majority of caregivers never flossed the consumers’ teeth. Sixty-four percent never flossed the teeth of cooperative consumers and 68% never flossed those of uncooperative
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Table 1. Summary of relevant characteristics of caregivers providing oral hygiene care to individuals with special health care needs (SHCN).a Variable
Mean
Standard deviation
Age of caregiver in years
32.1
12.0
Number of years working as a caregiver
5.8
6.3
Number of years caregiver has worked at current location
3.6
4.8
Number of consumers caregiver provides direct care for on a weekly basis
10.0
12.1
Hours per week providing direct care
32.4
10.7
Percentage of consumers who are incapable of brushing their own teeth
32.2
31.7
Percentage of consumers who require assistance when brushing their teeth
37.4
31.6
Percentage of consumers who are independent and brush their own teeth
32.5
34.3
Frequency
Valid Percent
Reach For Your Potential
61
13
Systems Unlimited, Inc.
202
44
REM Iowa
36
8
Community Care, Inc.
23
5
Prairie House
16
4
Handicapped Development Center
119
26
Male
114
25
Female
337
75
5
1
Location staff
312
70
Onsite supervisor
58
13
Other
70
16
7
2
High school diploma
216
48
Two year college degree
87
20
Four year college degree
122
27
Graduate degree
15
3
Variable Employment facility
Gender
Job description Office supervisor
Education Some high school
Ever received training on how to provide direct oral health care (i.e., brushing and flossing) for consumers with SHCN Yes, only by verbal training
85
19
Yes, only by hands-on training/demonstration
49
11
Yes, by verbal and hands-on training/demonstration
30
51
No, I have not received any training
89
19
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consumers. The following were problems encountered during delivery of oral hygiene care: 40% of consumers did not open their mouths; 34% pushed the caregiver away; 30% moved their heads uncontrollably; 26% hit and/or kicked the caregiver; and 40% completely refused oral care in at least one in four encounters. In cases when a consumer physically refused oral care, 49% of caregivers reported never continuing delivery of the oral hygiene measures, and 83% of caregivers stopped the oral care and attempted again at a later time. In general, the greatest percentage of caregivers “strongly disagreed” to “disagreed” that the following were barriers to providing oral care to consumers: not being able to devote enough time to oral care (62%); and lack of additional staff to help (63%), knowledge (63%), training (57%), or confidence in providing oral hygiene care (61%). When asked if the consumer who physically resisted oral hygiene care was a barrier, 40% of caregivers “disagreed” to “strongly disagreed,” and 32% of caregivers “agreed” to “strongly agreed.” Table 3 presents the bivariate (unadjusted) results for those variables which showed significance in the bivariate analyses and then were entertained as candidates to develop the final logistic regression model. When compared to their analog counterparts, caregivers who felt comfortable about providing oral hygiene care for physically resistant consumers were significantly more likely to provide direct care for a greater number of consumers per week (11 vs. 9 persons, p = 0.0044) they also had received both verbal and hands-on training (70.4% vs. 50.7%, p < 0.0001) had training at their current facility (66.7% vs. 49.0%, p = 0.0005), flossed the teeth of cooperative consumers 25–100% of the time (67.8% vs. 57.3%, p = 0.0362), and brushed the teeth of consumers, both cooperative and uncooperative, 75–100% of the time (67.1% vs. 52.0% p = 0.0018; 75.0% vs. 45.6%, p < 0.0001) respectively. Higher comfort levels in brushing and flossing the teeth of consumers with SHCN were associated with a greater likelihood of feeling comfortable with providing oral
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hygiene measures for consumers who physically resisted the care (p < 0.0001 in each instance; Table 3). Caregivers who experienced a higher frequency of consumers’ behavior problems, such as not opening their mouth, pushing the caregiver away, moving their head, spitting and hitting the caregiver, were more likely to feel comfortable with providing oral hygiene measures to the consumers who physically resisted the care. Moreover, caregivers who felt comfortable about providing oral hygiene measures for the consumers who were physically resistant were more likely to continue the oral care or attempt again at a later time (p < 0.05 in both instances; Table 3). Bivariate analysis of the data found that gender, age, education, and job position of the caregiver were not significantly associated with the comfort levels of the caregivers who provided oral hygiene care to physically resistant consumers. Caregivers’ opinions regarding barriers while providing oral hygiene measures were also not significant. However, it is worth noting that the number of hours caregivers reported providing direct care for consumers with SHCN on a weekly basis approached a marginally significant value (p = 0.0545; Table 3).
Table 1. Continued. Variable
Mean
Standard deviation
Received training from current employment facility on how to provide oral health care (i.e., brushing and flossing) for consumers with SHCN Yes
289
65
No
152
35
Interested in participating in an oral health program (both oral and hands-on training) on how to handle uncooperative consumers who resist oral care Yes
206
46
Interested in participating in an oral health program (both oral and hands-on training) on oral hygiene tips Yes
207
46
Interested in participating in an oral health program (both oral and hands-on training) on oral health education Yes
201
45
186
42
Excellent
94
21
Very good
163
37
Good
137
31
Fair
43
10
Poor
6
1
Yes
138
32
No
294
68
Not interested in oral health related courses at this time Yes How would you rate own oral health?
Needed dental care for yourself in the past 6 months
a
Due to missing data, not all variables add up to the total sample size population of 457.
Table 2. Responses of caregivers’ comfort level, behaviors, problems and barriers encountered.a Comfort
Very uncomfortable n (%)
Somewhat uncomfortable n (%)
Somewhat comfortable n (%)
Very comfortable n (%)
How comfortable do you feel providing the following oral health care for consumers? Brush the consumers’ teeth
42 (9)
17 (4)
81 (18)
307 (69)
Floss the consumers’ teeth
94 (22)
89 (21)
100 (23)
145 (34)
How comfortable do you feel providing oral health care for: Consumers who are cooperative with oral care
41 (9)
10 (2)
64 (15)
324 (74)
Consumers who verbally resist oral care
40 (9)
66 (16)
134 (31)
190 (44)
Consumers who physically resist oral care
68 (16)
Behaviors
Never 0% n (%)
99 (23) Sometimes at least 5% n (%)
Usually at least 50% n (%)
125 (30)
131 (31)
Almost always at least 75% n (%)
Always 100% n (%)
For your cooperative consumers, what percent of the time do you directly perform the following? Brush the consumers’ teeth
84 (19)
62 (14)
48 (11)
99 (22)
148 (34)
Floss the consumers’ teeth
277 (64)
61 (14)
36 (8)
26 (6)
32 (8)
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Table 2. Continued. For your uncooperative consumers, what percent of the time do you directly perform the following? Brush the consumers’ teeth
87 (22)
44 (11)
49 (12)
88 (22)
133 (33)
Floss the consumers’ teeth
259 (68)
42 (11)
23 (6)
21 (5)
39 (10)
Never 0% n (%)
Sometimes at least 25% n (%)
Usually at least 50% n (%)
Almost always at least 75% n (%)
Always 100% n (%)
Problems encountered
When you provide oral hygiene care, how often consumers: Do not open their mouths
126 (30)
168 (40)
78 (18)
37 (9)
12 (3)
Place hands over their mouths
269 (64)
102 (24)
34 (8)
9 (2)
8 (2)
Push caregiver away
194 (46)
144 (34)
56 (13)
16 (4)
12 (3)
Move their heads uncontrollably
183 (43)
125 (30)
64 (15)
34 (8)
15 (4)
Bite the caregiver
321 (76)
73 (18)
14 (3)
5 (1)
7 (2)
Spit at the caregiver
322 (76)
72 (17)
18 (4)
2 (1)
7 (2)
Hit and/or kick caregiver
290 (69)
105 (26)
13 (3)
6 (1)
6 (1)
Completely refuse oral care
209 (50)
169 (40)
28 (7)
9 (2)
6 (1)
104 (27)
105 (27)
47 (12)
25 (6)
107 (28)
Stop the oral hygiene care, attempt again later
67 (17)
74 (18)
74 (18)
77 (19)
112 (28)
Stop the oral hygiene care, seek assistance of another caregiver
102 (27)
92 (24)
78 (20)
48 (13)
62 (16)
What do you do when a consumer physically refuses oral hygiene care? Stop the oral hygiene care
Continue the oral hygiene care
187 (49)
69 (18)
65 (17)
31 (8)
32 (8)
Strongly disagree n (%)
Disagree n (%)
Neutral n (%)
Agree n (%)
Strongly agree n (%)
149 (36)
106 (26)
103 (25)
34 (8)
18 (5)
Lack of additional staff to help
132 (33)
122 (30)
101 (25)
42 (10)
9 (2)
Lack of knowledge on how to provide oral hygiene care
145 (36)
112 (27)
95 (23)
45 (11)
12 (3)
Lack of training on how to provide oral hygiene care
141 (35)
91 (22)
111 (27)
50 (12)
17 (4)
Lack of confidence in skills in providing oral hygiene care
142 (35)
106 (26)
105 (26)
42 (10)
13 (3)
Consumer physically resists oral care
88 (22)
75 (18)
115 (28)
86 (21)
44 (11)
Barriers encountered How much do you consider the following to be a barrier while providing oral care to consumers? Not able to devote enough time to oral care:
aDue
to missing data, not all variables add up to the total sample size population of 457.
Table 4 displays results from the final multiple logistic regression model, which explored significant factors associated with caregivers’ perceived comfort while providing oral hygiene measures to consumers who physically resisted the care. The significant predictors in the final models included training from the current facility on providing oral health care
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for consumers with SHCN (p = 0.0424), percentage of time spent brushing the teeth of uncooperative consumers (p < 0.0001), comfort level for flossing the consumers’ teeth (p < 0.0001), comfort level for providing oral hygiene care for the cooperative consumers (p < 0.0001), and frequency of the consumer pushing the caregiver away (p = 0.0076).
Caregivers who reported feeling comfortable providing oral hygiene measures to consumers who physically resisted the care were: (1) 1.76 times as likely to report receiving training from their current facility on how to provide oral health care for consumers with SHCN compared to those who did not receive training; (2) 3.71 times as likely to brush
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Table 3. Results of bivariate analyses for the factors associated with caregivers’ reported comfort in providing oral hygiene measures for consumers who physically resist the care.a,b Variables
Caregivers’ comfort levelc Comfortable N = 256
Uncomfortable N = 167
p Value
Practice characteristics of the caregiver Number of hours per week providing direct care for consumers with SHCN Mean (hours)
32.6
31.7
0.0545
9
0.0044
Number of consumers providing direct care for on a weekly basis Mean (person)
11
Ever received training on providing oral health care (i.e., brushing and flossing) for consumers with SHCN Yes, verbal and hands-on training/demonstration
152 (70.4%)
64 (29.6%)
Yes, verbal training or hands-on training only/ or no training
103 (50.7%)
100 (49.3%)
