Healthcare professionals' perspectives on oral health care in acute stroke patients: a qualitative study

BACKGROUND

Stroke is a major public health problem, with the disabilities of the patients increasing their risk of poor oral health. Currently, in Ghana and Nigeria, no guideline exists for oral health care in stroke patients, while most of our acute stroke care settings have no documented protocol.

AIM

This study sought to understand the perspectives of healthcare professionals in Ghana and Nigeria about oral healthcare in acute stroke patients.

METHODS

A qualitative inductive approach was employed to explore healthcare professionals' perspectives. After obtaining informed consent, in-depth interviews were conducted among doctors, nurses, and physiotherapists using semi-structured question guides. Participants' responses were audiotaped for transcription and analysis. Interviews were conducted until data saturation was reached. Data were analyzed thematically to generate themes and sub-themes using an inductive approach.

THE RESULTS

Twenty-five (25) health care professionals (HCP) aged 25-60 years with a mean age of 36.2 ± 4.2 years were interviewed. There were 15 (60.0%) males and 10 (40.0%) females. HCP included nurse practitioners 14 (56.0%), medical doctors 7 (28.0%), and physiotherapists 4 (16.0%). The HCP demonstrated adequate knowledge of stroke and considered oral health important for esthetic and clinical reasons. They, however, reported being unable to give it the required attention due to inadequate collaboration between the various professional cadres, insufficient equipment, and a skewed focus on other clinical needs of the acute stroke patients.

CONCLUSIONS

The findings indicate that HCPs perceived oral health care as very important among patients with acute stroke. However, they reported a lack of collaboration and integration of oral health care in routine stroke care as a major impediment.

Perceptions of patients towards oral health care in a spinal cord injury rehabilitation unit: A qualitative study

BACKGROUND

Individuals with spinal cord injuries (SCIs) are at an increased risk of poor oral health compared to the general population. However, little is known about the related barriers and facilitators experienced by these individuals within the hospital setting.

OBJECTIVES

Understand the oral health knowledge, attitudes and practices of people with SCIs, barriers and facilitators to managing their oral health, and recommendations to improve oral care at acute/rehabilitation hospital settings.

METHODS

Semi-structured interviews were conducted with 11 participants, from a major metropolitan hospital in Sydney, Australia. The interviews were thematically analysed.

RESULTS

Three themes were constructed. Participants believed that the onus was on them to manage their oral health. Individuals also had limited knowledge of its importance to general health, and placed a lower priority on oral health compared to other aspects of health. All participants identified a combination of factors, such as cost, time, resources and prior negative experiences, that contributed to the neglect of their oral care. Participants also discussed the need of support from the multidisciplinary team and family/carers to facilitate oral care and identified various appropriate oral health education formats.

CONCLUSION

This study highlighted some areas where oral health knowledge among people with SCIs could be improved. It also identified the need for oral health training for the multidisciplinary team, as well as carers, to better integrate oral care during rehabilitation in the hospital. The development of oral health interventions would need to utilise a co-design approach to best support clients and their carers to facilitate oral care self-management.

Similarities and differences in factors associated with high and low sedentary behavior after stroke: a mixed methods study

PURPOSE

To identify similarities and differences in factors affecting activity engagement between adults with stroke who are more and less sedentary.

MATERIALS AND METHODS

Data were pooled from two studies of adults with stroke (N = 36). Sedentary time was measured activPAL micro3. Participants completed activPAL interviews, which were analyzed using framework analysis. Participants were stratified into more and less sedentary groups based on activPAL data. Between-group similarities and differences were identified.

RESULTS

Adults with stroke (mean [SD] age = 65.8 [13.6] years, stroke chronicity = 40.5 [SD = 38.3] months, 36.1% female) were more sedentary (785.5 [64.7] sedentary minutes/day) and less sedentary (583.6 [87.4] sedentary minutes/day). Those who were more sedentary: engaged in basic activities of daily living, avoided activities, received assistance from other people, and did not use strategies to overcome barriers. Those who were less sedentary: engaged in instrumental and community activities, embraced new strategies, did activities with other people, and used strategies to overcome environmental barriers.

CONCLUSIONS

Factors affecting activity engagement differed between people who are more and less sedentary. Interventions that aim to reduce post-stroke sedentary behavior should consider the: (1) types of activities, (2) role of other people, and (2) application of strategies to overcome activity and environment-related barriers.

Occupational Therapy Practice Guidelines for Adults With Stroke

IMPORTANCE

Stroke is a leading cause of disability. Occupational therapy practitioners ensure maximum participation and performance in valued occupations for stroke survivors and their caregivers.

OBJECTIVE

These Practice Guidelines are meant to support occupational therapy practitioners' clinical decision making when working with people after stroke and their caregivers.

METHOD

Clinical recommendations were reviewed from three systematic review questions on interventions to improve performance and participation in daily activities and occupations and from one question on maintaining the caregiving role for caregivers of people after stroke.

RESULTS

The systematic reviews included 168 studies, 24 Level 1a, 90 Level 1b, and 54 Level 2b. These studies were used as the basis for the clinical recommendations in these Practice Guidelines and have strong or moderate supporting evidence.

CONCLUSIONS AND RECOMMENDATIONS

Interventions with strong strength of evidence for improving performance in activities of daily living and functional mobility include mirror therapy, task-oriented training, mental imagery, balance training, self-management strategies, and a multidisciplinary three-stages-of-care rehabilitation program. Constraint-induced therapy has strong strength of evidence for improving performance of instrumental activities of daily living. Moderate strength of evidence supported cognitive-behavioral therapy (CBT) to address balance self-efficacy, long-term group intervention to improve mobility in the community, and a wearable upper extremity sensory device paired with training games in inpatient rehabilitation to improve social participation. Practitioners should incorporate problem-solving therapy in combination with CBT or with education and a family support organizer program. What This Article Adds: These Practice Guidelines provide a summary of strong and moderate evidence for effective interventions for people with stroke and for their caregivers.

The Influence of 6-Month Interdisciplinary Accompaniment on Family Caregivers’ Knowledge and Self-Efficacy Regarding Diabetic Wound Care

Introduction

Diabetes mellitus (DM) is a global health issue. Diabetic wounds have become a severe health complication. Interdisciplinary education and the use of homecare have led to improvements in the health of patients with chronic disease. The family caregiver's knowledge and self-efficacy positively impact the DM patient's self-care in the physical and psychological dimensions. There is still a need for interdisciplinary education to enhance family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Objective

To determine the effect of 6 months of interdisciplinary education on family caregivers’ knowledge and self-efficacy regarding diabetic wound care.

Methods

A quantitative longitudinal study with a quasi-experimental, one-group, pretest–posttest design was conducted. Family caregivers received 6 months of interdisciplinary education regarding diabetic wound care. The Foot Care Confidence Scale (FCCS) was used to measure the family caregivers’ knowledge and self-efficacy regarding diabetic wound care. The dependent samples t test and the Wilcoxon signed-rank test were used for statistical analysis.

Results

Sixteen caregivers of patients with diabetic ulcer wounds in the homecare unit participated in this intervention with a 6-month follow-up. Six months of interdisciplinary education significantly increased the family caregivers’ knowledge ( p = 0.001) and self-efficacy ( p = 0.001). However, there was no significant correlation between self-efficacy and gender, age, education level, or duration of wound care ( p = 0.91; 0.93; 0.38; 0.40, respectively). Long-term interdisciplinary education improved caregiver performance across genders, ages, education levels, and wound care experience durations.

Conclusion

Long-term interdisciplinary education of family caregivers is recommended as one method to enhance the family support system with respect to diabetic ulcer care management. In addition, interprofessional collaboration could be performed to enhance the understanding of healthcare, especially diabetic ulcer care.

Education and Training Interventions for Caregivers of People With Stroke (January 1, 1999-December 31, 2019)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from a systematic review on interventions providing only education and training for caregivers of people with stroke.

Couple and family interventions for high mortality health conditions: A strategic review (2010-2019)

The earliest publications in the field of marriage and family therapy introduced interventions conducted with families experiencing complex health conditions. This strategic review captures an evaluation of efficacy for 87 couple and family interventions published between 2010 and 2019 with a focus on the leading causes of mortality in the United States. These health conditions include chromosomal anomalies and accidents with infants aged 0-4 years; accidents and cancer among children aged 5-14; accidents among adolescents aged 15-24; and heart disease, cancer, accidents, chronic lower respiratory diseases, stroke, Alzheimer's disease, diabetes, influenza/pneumonia, and nephritis/nephrosis among adults 25 and older. Results support the need for greater inclusion of couples and families in assessments and interventions. The greatest chasm in efficacy research was with minoritized couples and families. Implications include ways to initiate couple and family interventions in the context of health conditions with attention given to accessibility, recruitment, retention, and evaluation.

Information provision for stroke survivors and their carers

BACKGROUND

A stroke is a sudden loss of brain function caused by lack of blood supply. Stroke can lead to death or physical and cognitive impairment and can have long lasting psychological and social implications. Research shows that stroke survivors and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

The primary objective is to assess the effects of active or passive information provision for stroke survivors (people with a clinical diagnosis of stroke or transient ischaemic attack (TIA)) or their identified carers. The primary outcomes are knowledge about stroke and stroke services, and anxiety.

SEARCH METHODS

We updated our searches of the Cochrane Stroke Group Specialised Register on 28 September 2020 and for the following databases to May/June 2019: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) and the Cochrane Database of Systematic Reviews (CDSR; 2019, Issue 5) in the Cochrane Library (searched 31 May 2019), MEDLINE Ovid (searched 2005 to May week 4, 2019), Embase Ovid (searched 2005 to 29 May 2019), CINAHL EBSCO (searched 2005 to 6 June 2019), and five others. We searched seven study registers and checked reference lists of reviews.

SELECTION CRITERIA

Randomised trials involving stroke survivors, their identified carers or both, where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone, or where the comparison was between active and passive information provision without other differences in treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We categorised interventions as either active information provision or passive information provision: active information provision included active participation with subsequent opportunities for clarification and reinforcement; passive information provision provided no systematic follow-up or reinforcement procedure. We stratified analyses by this categorisation. We used GRADE methods to assess the overall certainty of the evidence.

MAIN RESULTS

We have added 12 new studies in this update. This review now includes 33 studies involving 5255 stroke-survivor and 3134 carer participants. Twenty-two trials evaluated active information provision interventions and 11 trials evaluated passive information provision interventions. Most trials were at high risk of bias due to lack of blinding of participants, personnel, and outcome assessors where outcomes were self-reported. Fewer than half of studies were at low risk of bias regarding random sequence generation, concealment of allocation, incomplete outcome data or selective reporting. The following estimates have low certainty, based on the quality of evidence, unless stated otherwise. Accounting for certainty and size of effect, analyses suggested that for stroke survivors, active information provision may improve stroke-related knowledge (standardised mean difference (SMD) 0.41, 95% confidence interval (CI) 0.17 to 0.65; 3 studies, 275 participants), may reduce cases of anxiety and depression slightly (anxiety risk ratio (RR) 0.85, 95% CI 0.68 to 1.06; 5 studies, 1132 participants; depression RR 0.83, 95% CI 0.68 to 1.01; 6 studies, 1315 participants), may reduce Hospital Anxiety and Depression Scale (HADS) anxiety score slightly, (mean difference (MD) -0.73, 95% CI -1.10 to -0.36; 6 studies, 1171 participants), probably reduces HADS depression score slightly (MD (rescaled from SMD) -0.8, 95% CI -1.27 to -0.34; 8 studies, 1405 participants; moderate-certainty evidence), and may improve each domain of the World Health Organization Quality of Life assessment short-form (WHOQOL-BREF) (physical, MD 11.5, 95% CI 7.81 to 15.27; psychological, MD 11.8, 95% CI 7.29 to 16.29; social, MD 5.8, 95% CI 0.84 to 10.84; environment, MD 7.0, 95% CI 3.00 to 10.94; 1 study, 60 participants). No studies evaluated positive mental well-being. For carers, active information provision may reduce HADS anxiety and depression scores slightly (MD for anxiety -0.40, 95% CI -1.51 to 0.70; 3 studies, 921 participants; MD for depression -0.30, 95% CI -1.53 to 0.92; 3 studies, 924 participants), may result in little to no difference in positive mental well-being assessed with Bradley's well-being questionnaire (MD -0.18, 95% CI -1.34 to 0.98; 1 study, 91 participants) and may result in little to no difference in quality of life assessed with a 0 to 100 visual analogue scale (MD 1.22, 95% CI -7.65 to 10.09; 1 study, 91 participants). The evidence is very uncertain (very low certainty) for the effects of active information provision on carers' stroke-related knowledge, and cases of anxiety and depression. For stroke survivors, passive information provision may slightly increase HADS anxiety and depression scores (MD for anxiety 0.67, 95% CI -0.37 to 1.71; MD for depression 0.39, 95% CI -0.61 to 1.38; 3 studies, 227 participants) and the evidence is very uncertain for the effects on stroke-related knowledge, quality of life, and cases of anxiety and depression. For carers, the evidence is very uncertain for the effects of passive information provision on stroke-related knowledge, and HADS anxiety and depression scores. No studies of passive information provision measured carer quality of life, or stroke-survivor or carer positive mental well-being.

AUTHORS' CONCLUSIONS

Active information provision may improve stroke-survivor knowledge and quality of life, and may reduce anxiety and depression. However, the reductions in anxiety and depression scores were small and may not be important. In contrast, providing information passively may slightly worsen stroke-survivor anxiety and depression scores, although again the importance of this is unclear. Evidence relating to carers and to other outcomes of passive information provision is generally very uncertain. Although the best way to provide information is still unclear, the evidence is better for strategies that actively involve stroke survivors and carers and include planned follow-up for clarification and reinforcement.

"They Know Me and My Situation-Patients' and Spouses' Perceptions of Person-Centered Care in Hospital-at-Home Care"

Realization of person-centered care (PCC) is contextual. How is it perceived at hospital-at-home? Pairwise telephone interviews of patients (n = 27) and their spouses (n = 18) emerged in 4 themes. Care was found to be person-centered when both the principles and activities that underpin the concept PCC were realized.

Oral care practices in stroke: findings from the UK and Australia

Aims

To examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia.

Background

Poor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries.

Design

A cross-sectional survey.

Methods

Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times.

Results

Completed questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents.

Conclusion

Unacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00642-y.

Interventions for improving oral health in people after stroke

BACKGROUND

For people with physical, sensory and cognitive limitations due to stroke, the routine practice of oral health care (OHC) may become a challenge. Evidence-based supported oral care intervention is essential for this patient group.

OBJECTIVES

To compare the effectiveness of OHC interventions with usual care or other treatment options for ensuring oral health in people after a stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group and Cochrane Oral Health Group trials registers, CENTRAL, MEDLINE, Embase, and six other databases in February 2019. We scanned reference lists from relevant papers and contacted authors and researchers in the field. We handsearched the reference lists of relevant articles and contacted other researchers. There were no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated one or more interventions designed to improve the cleanliness and health of the mouth, tongue and teeth in people with a stroke who received assisted OHC led by healthcare staff. We included trials with a mixed population provided we could extract the stroke-specific data. The primary outcomes were dental plaque or denture plaque. Secondary outcomes included presence of oral disease, presence of related infection and oral opportunistic pathogens related to OHC and pneumonia, stroke survivor and providers' knowledge and attitudes to OHC, and patient satisfaction and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and full-text articles according to prespecified selection criteria, extracted data and assessed the methodological quality using the Cochrane 'Risk of bias' tool. We sought clarification from investigators when required. Where suitable statistical data were available, we combined the selected outcome data in pooled meta-analyses. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

Fifteen RCTs (22 randomised comparisons) involving 3631 participants with data for 1546 people with stroke met the selection criteria. OHC interventions compared with usual care Seven trials (2865 participants, with data for 903 participants with stroke, 1028 healthcare providers, 94 informal carers) investigated OHC interventions compared with usual care. Multi-component OHC interventions showed no evidence of a difference in the mean score (DMS) of dental plaque one month after the intervention was delivered (DMS -0.66, 95% CI -1.40 to 0.09; 2 trials, 83 participants; I² = 83%; P = 0.08; very low-quality evidence). Stroke survivors had less plaque on their dentures when staff had access to the multi-component OHC intervention (DMS -1.31, 95% CI -1.96 to -0.66; 1 trial, 38 participants; P < 0.0001; low-quality evidence). There was no evidence of a difference in gingivitis (DMS -0.60, 95% CI -1.66 to 0.45; 2 trials, 83 participants; I² = 93%; P = 0.26: very low-quality evidence) or denture-induced stomatitis (DMS -0.33, 95% CI -0.92 to 0.26; 1 trial, 38 participants; P = 0.69; low-quality evidence) among participants receiving the multi-component OHC protocol compared with usual care one month after the intervention. There was no difference in the incidence of pneumonia in participants receiving a multi-component OHC intervention (99 participants; 5 incidents of pneumonia) compared with those receiving usual care (105 participants; 1 incident of pneumonia) (OR 4.17, CI 95% 0.82 to 21.11; 1 trial, 204 participants; P = 0.08; low-quality evidence). OHC training for stroke survivors and healthcare providers significantly improved their OHC knowledge at one month after training (SMD 0.70, 95% CI 0.06 to 1.35; 3 trials, 728 participants; I² = 94%; P = 0.03; very low-quality evidence). Pooled data one month after training also showed evidence of a difference between stroke survivor and providers' oral health attitudes (SMD 0.28, 95% CI 0.01 to 0.54; 3 trials, 728 participants; I² = 65%; P = 0.06; very low-quality evidence). OHC interventions compared with placebo Three trials (394 participants, with data for 271 participants with stroke) compared an OHC intervention with placebo. There were no data for primary outcomes. There was no evidence of a difference in the incidence of pneumonia in participants receiving an OHC intervention compared with placebo (OR 0.39, CI 95% 0.14 to 1.09; 2 trials, 242 participants; I² = 42%; P = 0.07; low-quality evidence). However, decontamination gel reduced the incidence of pneumonia among the intervention group compared with placebo gel group (OR 0.20, 95% CI 0.05 to 0.84; 1 trial, 203 participants; P = 0.028). There was no difference in the incidence of pneumonia in participants treated with povidone-iodine compared with a placebo (OR 0.81, 95% CI 0.18 to 3.51; 1 trial, 39 participants; P = 0.77). One OHC intervention compared with another OHC intervention Twelve trials (372 participants with stroke) compared one OHC intervention with another OHC intervention. There was no difference in dental plaque scores between those participants that received an enhanced multi-component OHC intervention compared with conventional OHC interventions at three months (MD -0.04, 95% CI -0.33 to 0.25; 1 trial, 61 participants; P = 0.78; low-quality evidence). There were no data for denture plaque.

AUTHORS' CONCLUSIONS

We found low- to very low-quality evidence suggesting that OHC interventions can improve the cleanliness of patient's dentures and stroke survivor and providers' knowledge and attitudes. There is limited low-quality evidence that selective decontamination gel may be more beneficial than placebo at reducing the incidence of pneumonia. Improvements in the cleanliness of a patient's own teeth was limited. We judged the quality of the evidence included within meta-analyses to be low or very low quality, and this limits our confidence in the results. We still lack high-quality evidence of the optimal approach to providing OHC to people after stroke.

Technology for maintaining oral care after stroke: considerations for patient-centered practice

PURPOSE

Activities of daily living including oral care may be challenging after stroke. Some stroke survivors are not able to complete oral care independently and need assistance from healthcare professionals and care partners. Poor oral hygiene may impact stroke recovery and rehabilitation possibly incurring issues such as aspiration pneumonia, malnutrition, and social isolation. The objective of this paper is to outline practical ways to apply oral care technology in daily use for stroke survivors.

MATERIALS AND METHODS

We reviewed the literature on i) stroke-related impairments impacting oral care, ii) oral hygiene dental devices, and iii) technology for oral care education.

RESULTS

Oral care activities involve integrated skills in the areas of motivation, energy, planning, body movement and sensation, and mental acuity and health. Post-stroke impairments such as fatigue, hemiparesis, and mental impairments may impact oral care activities. Technology may help survivors and caregivers overcome some barriers. Three types of technologies are available for facilitating post-stroke oral care: i) non-powered tools and adaptations; ii) powered oral care tools, and; iii) electronic aids to guide oral care activities. Particular choices should maximise patient safety and autonomy while ensuring accessibility and comfort during oral care tasks.

CONCLUSION

The available device and technologies may help substantially with the accommodations needed for post-stroke oral care, improving the oral health of stroke survivors. Good oral health confers benefit to overall health and well-being and could enhance recovery and rehabilitation outcomes. Nonetheless, more research is necessary to demonstrate the feasibility and effectiveness of technology in stroke contexts.IMPLICATIONS FOR REHABILITATIONOral care may be challenging after stroke due to patient fatigue, hemiparesis, cognitive impairments, and other impaired body functions.Poor oral hygiene may impact stroke recovery and rehabilitation due to risk of aspiration pneumonia, malnutrition, and social isolation.Powered oral care tools, non-powered tools, and adaptations to non-powered tools are some of the technology available to help overcome post-stroke barriers for oral care.Computer programs and online resources for education and guidance for oral care activities may help improve recommendation uptake and compliance.

Interventions to improve oral health of older people: A scoping review

OBJECTIVES

A range of interventions have been tested to improve oral health of older people. We performed a scoping review to map interventions' aims, outcome measures and findings, and to locate them on different levels of care.

DATA

We systematically screened for (1) controlled studies on (2) people over 65 years of age, (3) comparing at least two interventions to improve oral health. Interventions were summarized according to their aims and the employed intervention type, mapped on their level of action, and classified as primary/secondary/tertiary prevention.

SOURCES

Studies retrieved via MEDLINE, EMBASE, CINAHL.

STUDY SELECTION

Eighty-one studies (published 1997-2019, conducted mainly in high-income countries) were included. Sample sizes varied (n = 24-1987). Follow-up was 0.25-60 months. Most studies (64/81) found a statistically significant benefit of the intervention. A total of 13 different aims were identified, and a range of intervention types employed (e.g. educational interventions, professional oral healthcare, restorative treatment, fluoride application and, generally, dentifrices, mouthwashes, chewing gums/food supplements). Most studies were located on the carer/patient level (56/81 studies) or the system/policy-maker level (44/81). The majority of studies aimed for primary prevention (64/81).

CONCLUSIONS

Oral health improvement interventions are widely studied. However, study aims, methods and outcome measures are highly heterogeneous, which limits the ability for robust conclusions. Current research focusses on primary prevention on the level of patients/carers or system/policy-maker level. Future studies may want to consider interventions on dentists' level focussing on secondary prevention. These studies should rely on a core set of comprehensive, standardized set of outcome measures.

CLINICAL SIGNIFICANCE

While specific interventions seem efficacious to improve older people's oral health, the current body of evidence is neither comprehensive (significant gaps exists in relevant levels of the care process) nor comparable enough to draw robust conclusions.

The effectiveness of an oral hygiene program combined with health-promoting counseling for rural adults with cardiometabolic risks: A quasi-experimental design

AIM

The aim of this study was to explore the effectiveness of an oral hygiene program combined with home-phone health promoting counseling for rural adults with metabolic syndrome.

BACKGROUND

Metabolic syndrome is an important risk factor for cardiometabolic diseases. Evidence indicates that the poor oral hygiene and unhealthy lifestyles are closely related to metabolic syndrome.

METHODS

A prospective quasi-experimental design involved a total of 136 community adults, with metabolic syndrome living in two rural townships, were clustered and conveniently assigned to intervention and control group between June 2017 and December 2018. The primary outcome was the change in cardiometabolic biomarkers. The secondary outcome comprised changes in the health-promoting behaviors. The intervention effect was assessed using a generalized estimating equation model.

RESULTS

There were 80 and 56 participants in the intervention and control group, respectively. The mean age was 56 years and ranged from 33 to 70 years. The intervention group exhibited a greater improvement in body mass index (P < 0.01), waist circumference (P < 0.05), body fat percentage (P < 0.05), triglyceride level (P < 0.05), use of dental floss (P < 0.05), regular tooth scaling (P < 0.05), physical activity (P < 0.001), and total score of health-promoting behaviors (P < 0.001) than the control group.

CONCLUSION

This study supports the use of an oral hygiene program combined with home-phone counseling, which offers more advantages than its counterpart. Considering the global epidemic of cardiometabolic diseases, this is a community health nursing model worth to replicate and evaluate. Further study should consider innovative strategies to improve the awareness and adoption of a healthy lifestyle in residents with cardiometabolic risks.

Using metagenomic analysis to assess the effectiveness of oral health promotion interventions in reducing risk for pneumonia among patients with stroke in acute phase: study protocol for a randomized controlled trial

BACKGROUND

The prevalence of pneumonia complicating stroke in acute phase has a poor prognosis and higher risk for death. Oral opportunistic pathogens have been reported to be associated with pneumonia among people with compromised health. Oral health promotion is effective in reducing dental plaque among patients with stroke, which is considered as reservoirs for oral opportunistic pathogens. This study evaluates the effectiveness of oral health promotions in reducing the prevalence of pneumonia via its effects on composition and relative abundance of oral opportunistic pathogens.

METHODS/DESIGN

This study is a randomized, single-blind, parallel trial of 6 months duration. The study is being conducted at one of the largest medical teaching hospitals in Hefei, China. A total of 166 patients with stroke and free from any post-stroke complication will be recruited. After enrollment, patients will be randomized to one of the following groups: (1) oral hygiene instruction (OHI) or (2) OHI, 6-month use of powered tooth brushing, and 0.2% chlorhexidine gluconate mouth rinse (10 ml twice daily). The primary outcome is the prevalence of pneumonia complicating stroke. Patients will be monitored closely for any occurrence of pneumonia over the entire period of this trial. Oral rinse samples will be collected at baseline and multiple follow-up reviews (3, 5, 7 days, and 1, 3, 6 months after baseline). Next-generation sequencing will be employed to detect composition and relative abundances of the microorganism in the oral rinse samples. Questionnaire interviews and clinical oral examinations will be conducted at baseline and 1, 3, and 6 months after baseline.

DISCUSSION

The findings of this trial will provide evidence whether oral health promotion intervention is effective in reducing the prevalence of pneumonia complicating stroke via its effect on the oral microbiome. The analysis of the outcomes of this trial is empowered by metagenomic analysis at 16S rRNA level, which is more sensitive and comprehensive to help us detect how oral health promotion inventions affect the oral microbiome in terms of its composition, relative abundance, and interactions between species, which all may contribute to the occurrence of pneumonia complicating stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04095780 . Registered on 19 September 2019.

Exploring nursing and allied health perspectives of quality oral care after stroke: A qualitative study

BACKGROUND

Maintaining good oral health remains a challenge among those hospitalised after stroke. Stroke nurses and allied health clinicians have a potential role in providing oral care, but no studies in Australia to date have explored their perceptions and needs.

AIMS

To explore the perspectives of nursing and allied health stroke clinicians regarding oral care for stroke patients across acute care and stroke rehabilitation settings.

METHODS

This study followed an exploratory qualitative design, using a constructivist approach. Participants from two metropolitan public hospitals were purposively recruited to participate in focus groups. Data was thematically analysed.

RESULTS

Twenty-one clinicians participated. Clinicians' knowledge and practices relating to oral healthcare for stroke patients were inadequate. Most staff felt they did not have adequate knowledge, resources and training to administer oral care in this setting and proposed enhancing education of stroke clinicians, patients and informal caregivers, as well as improving quality point of care resources. There was overall support for the integrated dental care after stroke model of care.

DISCUSSION

This study revealed many gaps in current care and highlighted areas for improvement. Patients and their caregivers needed to be actively engaged as partners to improve oral healthcare within acute and rehabilitation stroke settings.

CONCLUSION

This study provided insight into nurses' and allied health stroke clinicians' current knowledge and practices of oral care in various stroke settings. The findings from this study will inform development of a model of care to train stroke nurses in providing oral care.

Professional care at home: Patient-centredness, interprofessionality and effectivity? A scoping review

The aim of this scoping review was to describe the state of knowledge on professional care at home with regard to different perspectives on patient-centredness, content of care, interprofessional collaboration, competence framework and effectivity. A scoping review, n = 35 papers, from four databases (EBSCO, CINAHL, Medline, Swemed) were reviewed between May and August 2018 using the terms: hospital-at-home, hospital-in-the-home, advanced home healthcare, hospital-based home care or patient-centered medical home. Criteria for inclusion in this review included full text papers, published between 2001 and 2018, in English, Swedish or Finnish. A descriptive content analysis was conducted. Patient-centredness appears to be one aim of professional care at home, but clarity is lacking regarding patient recruitment and the planning and evaluation of care. Content depends, to a certain degree, on the type of care at home and how it is organised: the more non-acute care needs, the more nurse-coordinated care and family involvement and the less interprofessionality. The competence framework presupposed for care at home was extensive yet not explicit, varying from maturity, clinical experience, collaboration skills, ongoing clinical assessment education to Master's studies or degree. The effectivity of care at home services was discussed in terms of experiential, clinical and economic aspects. Patients and their family caregivers were satisfied with care at home, but there was no consensus on clinical or economic outcomes compared with inpatient care. In the context of professional care at home, there is still a lot to do regarding patient-centredness, patient recruitment, patient and care staff education, the organisation of interprofessional collaboration and the analysis of effectivity.

[Interventions for stroke survivor caregivers: a systematic reviewIntervenciones para los cuidadores de los sobrevivientes de un accidente cerebrovascular: revisión sistemática]

OBJECTIVE

To synthesize and critically review the literature on interventions aimed at decreasing the burden of stroke survivor caregivers and other associated factors.

METHOD

The literature search for the present systematic review was performed in PubMed, SciELO, Coordination for the Improvement of Higher Education Personnel (CAPES) website, and the Virtual Health Library using the following search terms: Stroke AND Caregivers AND Intervention; and Stroke AND Caregivers AND clinical trial. Eight randomized controlled clinical trials (RCT) published between 2008 and 2017 were selected.

RESULTS

The selected studies were performed in Sweden, Taiwan, Germany, China, India, and the United States. Psychoeducational, support, and skill acquisition interventions produced positive results for caregivers - in the psychological, physical, and social domains, in the quality of the care provided, and in the acquisition of knowledge by caregivers - and for stroke survivors - for example, decreased use of health care services and improved capacity for self-care. The critical evaluation of the studies showed that none met all the methodological requirements for RCTs. The main limitations were missing data and the heterogeneity of interventions.

CONCLUSION

The interventions had positive results for caregivers and survivors. However, future studies should consider long term assessments of the outcomes, with detailed description of the baseline needs that guided the study and the sharing of the support materials used to allow the intervention to be reproduced.

Oral health-related quality of life in patients with stroke: a randomized clinical trial of oral hygiene care during outpatient rehabilitation

This study was to evaluate the effectiveness of oral hygiene care in improving oral health- and health-related quality of life (OHRQoL and HRQoL) among patients receiving outpatient stroke rehabilitation. Subjects were randomized to: (1) a conventional oral hygiene care programme (COHCP) comprising a manual toothbrush, and oral hygiene instruction, or (2) an advanced oral hygiene care programme (AOHCP) comprising a powered toothbrush, 0.2% chlorhexidine mouthrinse, and oral hygiene instruction. The interventional period lasted for 3 months, followed by a 3-month observational period. HRQoL was assessed by SF-12, and OHRQoL was assessed by Oral Health Impact Profile-14 (OHIP-14), General Oral Health Assessment Index (GOHAI), and Oral Health Transitional Scale (OHTS). Participants in AOHCP group had significantly better OHRQoL at the end of clinical trial as assessed by OHTS (p < 0.01), and at the end of observational study as assessed by GOHAI (p < 0.05) than those in the COHCP. Participants in the AOHCP group had significantly better HRQoL as assessed by physical component summary score (PCS) the end of both 3 and 6 months (both p < 0.05). This study provided the evidence that the AOHCP was more effective than the COHCP within stroke rehabilitation in improving subjective health.

A randomized clinical trial of oral hygiene care programmes during stroke rehabilitation

OBJECTIVES

The objectives of this study were to evaluate and compare the effectiveness of an advanced oral hygiene care programme (AOHCP) and a conventional oral hygiene care programme (COHCP) in improving oral hygiene, and reducing gingival bleeding among patients with stroke during outpatient rehabilitation.

METHODS

Subjects were randomized to receive (i) the COHCP comprising a manual toothbrush, toothpaste, and oral hygiene instruction, or (ii) the AOHCP comprising a powered toothbrush, 0.2% chlorhexidine mouthrinse, toothpaste, and oral hygiene instruction. Dental plaque, gingival bleeding, and other clinical oral health outcomes were assessed at baseline, the end of the clinical trial, and the end of observation period. Development of infectious complications was also monitored.

RESULTS

Participants of both programmes had a significant reduction in the percentages of sites with moderate to abundant dental plaque (p<0.001) and with gingival bleeding (p<0.05). Those in the AOHCP had significantly less plaque and gingival bleeding than those in the COHCP controlling for other factors at the end of the clinical trial period (both p<0.001) and the observational period (plaque: p<0.05, gingival bleeding: p<0.01).

CONCLUSIONS

Although both oral hygiene care programmes were effective in terms of plaque and gingival bleeding control, the AOHCP was more effective than the COHCP in reducing dental plaque and gingival bleeding.

CLINICAL SIGNIFICANCE

This study highlighted the value of oral hygiene programmes within stroke outpatient rehabilitation and provides evidence to advocate for the inclusion of oral hygiene care programmes within stroke outpatient rehabilitation for patients with normal cognitive abilities.

Effectiveness of a Web-Based Health Education Program to Promote Oral Hygiene Care Among Stroke Survivors: Randomized Controlled Trial

Background

Oral hygiene care is of key importance among stroke patients to prevent complications that may compromise rehabilitation or potentially give rise to life-threatening infections such as aspiration pneumonia.

Objective

The aim of this study was to evaluate the effectiveness of a Web-based continuing professional development (CPD) program on “general intention” of the health carers to perform daily mouth cleaning for stroke patients using the theory of planned behavior (TPB).

Methods

A double-blind cluster randomized controlled trial was conducted among 547 stroke care providers across 10 hospitals in Malaysia. The centers were block randomized to receive either (1) test intervention (a Web-based CPD program on providing oral hygiene care to stroke patients using TPB) or (2) control intervention (a Web-based CPD program not specific to oral hygiene). Domains of TPB: “attitude,” “subjective norm” (SN), “perceived behavior control” (PBC), “general intention” (GI), and “knowledge” related to providing oral hygiene care were assessed preintervention and at 1 month and 6 months postintervention.

Results

The overall response rate was 68.2% (373/547). At 1 month, between the test and control groups, there was a significant difference in changes in scores of attitude (P=.004) and subjective norm (P=.01), but not in other TPB domains (GI, P=.11; PBC, P=.51; or knowledge, P=.08). At 6 months, there were significant differences in changes in scores of GI (P=.003), attitude (P=.009), SN (P<.001) and knowledge (P=.001) between the test and control groups. Regression analyses identified that the key factors associated with a change in GI at 6 months were changes in SN (beta=.36, P<.001) and changes in PBC (beta=.23, P<.001).

Conclusions

The Web-based CPD program based on TPB increased general intention, attitudes, subjective norms, and knowledge to provide oral hygiene care among stroke carers for their patients. Changing subjective norms and perceived behavioral control are key factors associated with changes in general intention to provide oral hygiene care.

Trial Registration

National Medical Research Register, Malaysia NMRR-13-1540-18833 (IIR); https://www.nmrr.gov.my/ fwbLoginPage.jsp