This study demonstrated that the oral health educational programme improved the attitude and overall KAP of the healthcare workers in the intervention group, consistent with previous research [15, 21 However, there was no improvement observed in the knowledge and practice of the intervention group after the OHE programme, possibly due to the limitations of the COVID-19 pandemic that was indeed not supportive for effective knowledge acquisition as well as the practice of oral health delivery. The OHE programme should be simplified and improved to increase the awareness and interest of healthcare workers in oral health. Innovative modes of learning, such as virtual reality or simulation, could increase healthcare workers' situation awareness and clinical skill translation in daily care. This learning mode provides more flexibility and applicability of the learning content in real practice [27]. Furthermore, healthcare workers implementing oral care in LTCI residents should receive training in appropriate oral care assessment and regular evaluation.
Interestingly, the control LTCI healthcare workers showed better knowledge and practice at baseline, and their practice remained significantly higher even after the intervention group received training (Table 3). However, their knowledge significantly deteriorated after the intervention, indicating that healthcare workers may lack confidence in their oral care knowledge without proper training. Personal beliefs and external barriers, such as fear of handling uncooperative older residents, can also affect the delivery of oral care practice [28, 29]. Personal beliefs and external barriers, such as fear of handling uncooperative older residents, can also impact the delivery of oral care practice [28, 29]. In addition to personal beliefs, training and support of healthcare workers play a crucial role in the delivery of oral care practice to LTCI residents. Most healthcare workers are aged 40 years or older and typically receive oral care training in a brief period to quickly prepare them to work at LTCIs under the supervision of licensed nurses. Healthcare workers in LTCIs may have limited awareness or authority to improve the oral conditions of older residents and promote good oral health [8, 17]. Their duties are based on tasks assigned by the nurse in charge, their daily routines, and the available manpower. The shortage of frontline healthcare workers has garnered significant attention from both professionals and the public since the COVID-19 pandemic. As such, ensuring good oral hygiene and care for older residents has become a new challenge. Caution must be exercised when interpreting the results of this study due to a small, convenient sample size.
The actual oral care practice performed by healthcare workers who received the OHE programme revealed some notable shortfalls. Firstly, during the procedure, older residents were seated without any support behind their heads, leading to increased fatigue, discomfort, and choking risk. This posture also made it difficult for healthcare workers to thoroughly assess the oral condition and clean the posterior part of the oral cavity. Additionally, our observations showed that healthcare workers were hesitant to perform oral care in front of unfamiliar colleagues or afraid of accidentally hurting the older residents. For example, despite being educated to use dental floss or interdental brushes for better oral care, the healthcare workers only used toothbrushes and toothpaste, resulting in inadequate cleaning of the older residents' oral cavity. Therefore, improvements in healthcare workers' confidence and training are crucial for better oral care practice.
The study highlights the poor oral conditions of partly self-care independent older residents, who presented with multiple oral problems. This finding underscores the need for assistance in self-care, regular dental consultation, and potential nutritional concerns. The lack of regular assessment may be associated with the underdetermination of self-care dependence (such as BIAL) and cognitive status (such as MMSE) of the older residents, leading to inadequate self-care dependence for oral care. However, their inadequate self-care dependence for oral care may need to be neglected [5,7.8]. Additionally, the instruction to open their mouths wide was not adhered to, limiting the effectiveness of brushing, particularly for the posterior teeth. Furthermore, routine oral health assessment was lacking, and various severities of periodontal and dental diseases were identified through photograph-based oral examination. (Tables 4 and 5). Their oral conditions may impact on balanced diet/proper nutrition acquisition requires follow-up accordingly [30]. F These findings highlight the need for follow-up to ensure balanced diet and proper nutrition acquisition, using validated, objective tools for evaluating nutritional status and diet quality [31, 32] and diet quality [33, 34]. Lacking regular dental check-ups is an important reason for the poor oral health conditions of the three LTCI residents. Outreach Dental Care should be advocated to provide onsite dental health services with adequate support from the older residents and their families. [35, 36].