Background

Globally, including in Norway, the population of care-dependent older adults with complex health needs is increasing [1], and healthcare services are enduring change as a result of demographic changes and changing health needs [2]. In the coming decades, the demand for health services, such as home care services (HCS), is expected to increase, necessitating an expansion of home care employees’ responsibilities [3]. Norway like many other countries faces challenges with access to qualified healthcare personnel [4]. A larger need for qualified personnel in home care services and difficulties in recruiting qualified personnel, HCS has had to use unskilled personnel [4,5,6]. In 2020 a proportion of unskilled personnel working in HCS in Norway was almost 19% [6]. In Norway, the responsibility for providing HCS is delegated to the municipalities [7, 8] and is mainly publicly funded. The users of HCS differ in terms of age, diseases, and conditions. All individuals with special assistance need arising from illnesses or disabilities can apply for HCS in the municipality in which they are living or have temporary residency [8, 9]. In 2020, nearly 200,000 people were receiving help from HCS in Norway, 59% of whom were adults above the age of 67 years [10]. Care of older people in Norway is regulated by general legislation [9, 11], and many care-dependent older adults are not institutionalized, but rather, they live with supervision at home with assistance from HCS. Home care services personnel (HCS personnel) in Norway offer a range of services, such as somatic and psychiatric care, assistance in daily living, and user-controlled personal assistance, to mention some [9, 12]. HCS personnel are also responsible for different tasks such as wound care, administering medication, and daily personal hygiene, including oral healthcare [9, 12]. There are several professions with different levels of education working in Norwegian HCS such as registered nurses, social workers, assistant nurses, and those without any formal education [6]. Among the elderly people still living at home, there are many who are dependent on help for the basic necessities of life.

Today, there is a high proportion of older adult who keep their teeth for life [13, 14]. Many of these adults are care-dependent and need help from HCS to manage personal hygiene, including taking care of the oral hygiene [9, 11]. Due to impairments in general health such as reduced muscle strength, coordination, or cognitive impairment, these individuals will possibly present some challenges in maintaining daily oral hygiene [15]. According to the World Health Organization, oral health is a key indicator of overall health, well-being, and quality of life, and most oral diseases share modifiable risk factors with the leading noncommunicable diseases such as: cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes. Adequate oral function and absence of oral diseases are necessary to maintain good oral health [16].

In a study among care-dependent older people in Sweden, Holmen et al. [17] found that there was a higher proportion of care-dependent elderly that had dental treatment needs compared with healthy older adults. An increasing number of dentate care-dependent elderly with complex needs required HCS personnel with a broader knowledge of oral healthcare [18]. The public dental health service (PDS) in Norway has an outreach responsibility towards home dwelling elderly receiving service from home care service. According to Norwegian law the DPS are obliged to provide the nursing staff with information which enables them to perform oral healthcare on the elderly [19]. An interdisciplinary approach and collaboration between these two health services is necessary in order to ensure that employees have sufficient oral health knowledge and that the elderly receive the assistance to which they are entitled [20]. HCS personnel who are younger and have less work experience have been demonstrated to require more training in oral health to properly assist the dependent elderly with oral health [21]. Despite positive attitudes toward oral health, earlier studies have revealed a lack of knowledge among HCS personnel working with the elderly [22, 23]. Knowledge about oral health of the care-dependent older person, and more focus on oral healthcare education has been noted to be necessary to practice better oral healthcare [24]. Moreover, in a systematic review, the barriers and facilitators for providing oral healthcare for care-dependent older adults were assessed from different stakeholders’ perspectives, and a lack of knowledge was identified as one of the main barriers to the provision of good oral healthcare [25].

There is little knowledge about home care services personnels’ oral healthcare beliefs in Norway. Therefore, this study aimed to map the oral healthcare beliefs among home care services personnel in Norway, and has the following question: How does the education level, years of work experience and training in oral health have impact on home care services personnel oral healthcare beliefs?.

Methods

Study population

The present study was a cross-sectional study among HCS personnel working with elderly in four municipalities in south-eastern Norway. A total of 893 HCS personnel representing different geographical areas were invited to participate. Both permanent and temporary employees, as well as part-time and full-time employees, were invited to participate.

The questionnaire and description of background variables

The questionnaire consisted of two parts, background information about the HCS personnel and the nursing Dental Coping Beliefs scale (nDCBS) [26]. Background information about the HCS personnel included gender, education level, years of work experience, and employment status. Employment status was defined as 100% position when working full time per year, whereas 0–50% and 51-99.9% as working part time per year. Education level was recorded in the following categories: no higher education (without any formal nursing education), student (nurse student or assistant nurse student), assistant nurse, social worker, or registered nurse (three years’ tertiary education), and master’s degree or higher. Work experience was categorized as < 5 years, 5–10 years, 11 − 2 0 years, 21–30 years, and > 30 years. Training in oral healthcare was assessed by the question “I received training in how I can help users with their oral healthcare,” with response alternatives (yes/no). The term users in this question refers to all users of HCS. If respondents answered “yes” to receiving training, an additional question about “where did you receive the training in oral healthcare?” was asked.

Nursing Dental Coping Beliefs scale (nDCBS)

The nDCBS was used to assess oral healthcare beliefs among HCS personnel working with older people in HCS. The DCBS was developed in the United States [27, 28] and was built on three behavioral psychology models: the Cognitive Behavioral model, Locus of Control, and Self-efficacy. A modified scale was later developed in 2005, which reduced the number of items to 28, and it is called the nursing DCBS [26].

The nDCBS we used consists of four dimensions: oral healthcare beliefs (OHCB), external locus of control (EL), internal locus of control (IL), and self-efficacy (SE). Seven items comprised each dimension. The responses were recorded with a five-point Likert scale, from 1 (“strongly agree”) to 5 (“strongly disagree”). For each dimension, it was possible to have a minimum sum score of 7 points and a maximum sum score of 35 points.

The Norwegian version of the nDCBS used in this study was first tested in 2020 in a pilot study conducted in Eastern Norway [29]. We followed the guidelines for translation of the questionnaire from Swedish to Norwegian using two independent translators with Norwegian as their first language [30]. The two translations were then compared and retranslated back to Swedish by two other translators with Swedish as their first language. After a minor linguistic adjustment, that questionnaire was used in this study.

Nettskjema, a software developed and operated by the University of Oslo, was used for designing the electronic questionnaire for data collection. The questionnaire was distributed by leaders of HCS in the four municipalities, who forwarded an Internet link to all employees. One reminder was sent to all leaders of HCS in the respective municipalities after two weeks. Because of a low response rate to the electronic questionnaire, additional data collection was conducted using paper questionnaires distributed at HCS staff meetings. The purpose of the survey was explained to the participants verbally and in writing, but they didn’t get explanation of each question. Participation was voluntary, and written consent was obtained before the questionnaire was completed. The responses were anonymous.

Statistical methods

Descriptive statistics in the form of frequency and percentage distributions were used to describe categorical variables. Education level was trichotomized into “no higher education” (unskilled / without any formal education), “< 3 years of higher education” (assistant nurse and students), and “≥ 3 years of higher education” (social worker, registered nurse, master’s degree or higher). The employment state was trichotomized into 0–50%, 51–99.9% and 100%. Years of work experience were trichotomized into < 5 years, 5–10 years, and ≥ 11 years of work experience.

The items in the nDCBS were grouped into four dimensions: Oral health care beliefs, External locus of control, Internal locus of control, and Self-efficacy, each with seven items. Sums of scores were obtained for each dimension, where high sum scores for the Oral health care beliefs and External locus of control dimensions indicated positive oral healthcare beliefs; for dimensions Internal locus of control and Self-efficacy, positive oral healthcare beliefs were indicated by low sum scores. The sums of scores were then divided into quartiles, with Q3 and Q4 representing high sum scores (positive beliefs for external locus of control and Oral healthcare beliefs), and Q1and Q2 representing low sum scores (positive beliefs for internal locus of control and Self-efficacy dimensions).

Proportions (%) with 95% confidence intervals (CI) were used to describe the distribution of participants’ background variables in each quartile. Differences across the quartiles were established from tests for trends of proportions in statistics software R.

The quartiles have a natural ordering, hence we tried to fit an ordered logistic regression to identify factors associated with being in different quartiles of each construct. However, the assumption of proportionality between the quartiles was violated for some independent variables. Therefore, we fitted generalized partial ordered logistic regression models using the Stata user command gologit2 (Stata Corp LLC version 17, College Station, Texas, USA). We obtained three equal proportional odds ratio (OR) estimates for variables that satisfied the proportionality assumption, whereas different OR estimates were obtained for variables that violated the proportionality assumption.

The adjusted generalized ordered logistic regression analyses were purposefully fitted to the data based on independent variables with P ≤ 0.20 in the unadjusted models. We also fitted models based on independent variables with P < 0.05 from the univariate analyses and used the Bayesian information criterion (BIC) to select the best model. The BIC states that the model with the smallest BIC among nested models is considered a better fit. The analyses were performed using Stata SE version 17, and statistical software R-4.2.1. The statistical significance level was set at a = 0.05.

Results

Characteristics of the study participants

Two hundred and sixty-two HCS personnel responded to the questionnaire (response rate, 29.3%). The majority were female (83.5%), and 9.2% were with no higher education, 44.8% were HCS personnel with ≥ 3 years of higher education. More than half (59.5%) stated that they did not receive any training in oral healthcare. Not all participants answered the questions about where they got training in oral healthcare, but most of them (42) who received training in oral healthcare stated that training was given under education; 30 HCS personnel stated that they received training from the HCS, and 26 from the Public Dental Services (PDS). There were 171 (65.2%) who had 10 years or less of work experience, and more than half of the participants were employed in 100% positions. All background characteristics are shown in Table 1.

Table 1 Background characteristics of the respondents (N = 262)
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Nursing dental coping beliefs scale

Table 2 shows the frequency distribution of responses in different dimensions of the nDCBS, and the results from Cronbach’s alpha (0.6038–6438) for each dimension. The frequency distribution of participants in each quartile are represented in the appendix (Table S1). The results from adjusted ordered logistic regression, and the background variables that were significantly associated with being in higher quartiles, are presented in Table 3.

Table 2 Distribution of nDCBS responses in different dimensions with Cronbach’s alpha estimates
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Table 3 Factors associated with being in higher quartiles of OHCB, SE, EL, and IL
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Oral healthcare beliefs

The Oral health care beliefs dimension says something about the person’s perceptions of preventive oral health behavior [31]. As shown in Table 2, more than half of the HCS personnel were uncertain about the possibility of stopping gum disease when the disease had already started. Over 60% of respondents disagreed that patients would ask when oral healthcare assistance was needed, and a clear majority of HCS personnel disagreed that one should stop flossing and brushing if gums were bleeding. Most of the HCS personnel (93%) disagreed that visiting the dentist was only necessary when experiencing pain, and 61.5% disagreed that dentures were less troublesome than taking care of natural teeth. A larger proportion of HCS personnel did not agree that fluoride products were most suitable for children. As shown in Table 3 and Fig. 1, having ≥ 3years of higher education, was associated with higher Oral health care beliefs scores and the odds of being in the higher quartile were 2.12 times higher among those group. Analysis from Table 3 showed also that when compared with males, females were 3.37 times more likely to score higher and be in the higher quartile of Oral healthcare beliefs.

External locus of control

The External locus of control dimension represents respondents’ beliefs in external factors as ones that affect prevention of oral health diseases (factors beyond one’s control) [32]. The majority of the HCS personnel did not agree that if both parents had bad teeth, brushing and flossing would not help. Furthermore, they did not agree that a dentist was the only one who could prevent cavities and gum diseases. More than half of the HCS personnel (59.4%) disagreed on the question “It is not possible to prevent sickness and medicines from destroying teeth”. As many as 72% of those who responded did not agree that one method of brushing was just as effective as any other, and the majority did not agree that teeth fell out as one got older. Sixty-seven (26%) HCS personnel were uncertain about the claim that tooth loss was a normal part of growing old. Results obtained from the generalized ordered logistic regression model showed that having higher education was associated with being in the higher quartiles of EL (result did not reach statistical significance) (Table 3). The model predicted a 21.1% chance of being in Q4 for those with higher education compared with 13% for those without any formal education (Fig. 1).

Internal locus of control

The Internal locus of control dimension represents respondents’ beliefs in the possibility of preventing oral health diseases by one’s own actions (controlling one’s own life) [32]. As shown in Table 2, the majority of HCS personnel agreed that cavities and gum disease could be prevented. They also agreed that dental flossing and tooth brushing could help prevent cavities. The respondents agreed that the patients wanted help with oral care (69.5%). On the question of whether their patients ate better if they had a healthy and clean mouth, 88.8% agreed. 72% agreed that teeth could be preserved for a lifetime.

Not having training in oral healthcare significantly increased the likelihood of getting a higher score and being in a higher quartile of Internal locus of control by 1.89 times (Table 3). HCS personnel who were trained in oral health had 38.2% chance of being in Q1 of Internal locus of control compared with 24.7% who were not trained in oral health (Fig. 2).

Self-efficacy

Self-efficacy refers to a person’s belief in their own ability to cope with challenges and achieve success, or the respondents’ belief in their “ability to achieve goals” [33]. Most of the HCS personnel agreed that they expected fewer dental problems if respondents brushed and flossed correctly. They also agreed that they knew how to prevent oral candidiasis (77.2%). Less than half of respondents were uncertain about how different oral mucosal disorders could be treated, and almost two-thirds believed that they could successfully remove plaque to prevent cavities and gum diseases. The majority (79.2%) believed that more facts about dental disease could make them practice better oral health.

Not having higher education and not having training in oral healthcare significantly increased the likelihood of being in higher quartiles of Self-efficacy, which is not positive of this dimension (Table 3). Furthermore, 34.7% of those who were trained in oral health were more likely to be in Q1 compared with 24.3% in the untrained group (Fig. 2).

Fig. 1
figure 1

Predicted probabilities for each OHBC and EL quartile by level of education

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Fig. 2
figure 2

Predicted IL and SE quartile probabilities by training in oral health

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Discussion

The present study mapped the oral healthcare beliefs among HCS personnel and identified several factors associated with their beliefs in oral health. To our knowledge, this is the first study on that topic to be published in Norway.

The current study found that most HCS personnel have positive beliefs about oralhealth and, how to prevent gum diseases, dental caries, and oral yeast infections. There were more uncertainties on whether sickness and medicine can destroy teeth, and how to treat oral mucosal disorders. Receiving oral healthcare training and a higher level of education seem to have a significant effect on HCS personnel being in the higher quartiles of External locus of control and Oral health care beliefs, and the lower quartiles of Self-efficacy, which means positive beliefs.

In our study, while HCS personnel, knew what was important to prevent oral diseases, there were still little knowledge about impact of age, diseases, and medication on oralhealth (External locus of control). The majority of HCS personnel seemed to have positive beliefs about gum disease and tooth cavities being preventable; similar results have been shown in an earlier study in Finland [24]. HCS personnel agreed that patients eat better if they have a healthy, clean mouth. Previous studies have shown that oral healthcare is an important aspect of patients’ comfort and maintenance of dietary intake [34]. HCS personnel in our study were aware that to prevent dental problems, good oral hygiene is important. HCS personnel with oral health training were more confident that what they did could prevent oral diseases. Despite knowing that certain actions, such as brushing your teeth, prevent cavities and gum diseases (Internal locus of control), they were unsure if they could remove plaque correctly (Self-efficacy). They felt that they could overestimate the effect of external factors on oral health ( External locus of control) and were unsure whether tooth loss is a normal part of aging, and that if both parents had bad teeth, brushing and flossing would not help which may be due to lack of knowledge or personal experience with dental disease [21] Our findings are in agreement with findings from other healthcare personnel studies [21, 23, 35, 36].

Almost 41% of HCS personnel answered “agree” or “I don’t know” to the statement that “it is not possible to prevent sickness and medication from destroying teeth.” Edman & Wårdh [21] have argued in their study that this may be due to a lack of knowledge and wrong perceptions of oral diseases. Lack of knowledge about the treatment of different oral mucosal disorders and how to correctly remove plaque may prevent HCS personnel from helping the users with for instance teeth brushing. One possible explanation may be that the HCS personnel has not received sufficient instructions, practice, and support in tooth brushing for care-dependent older adults [37]. An increasing number of dentate care-dependent elderly with complex needs requires HCS personnel with a broader knowledge of oral healthcare [18]. At the same time, shortage of qualified HCS personnel has resulted in more unqualified personnel working in HCS with users who require a lot of expertise [38]. HCS personnel need knowledge about oral health to manage older people’s oral healthcare. The performance of oral healthcare is affected by oral health beliefs, which in turn, are affected by how much education the individual has about oral health [26, 39]. HCS personnel believe that they need more training on oral diseases to give better help with oral healthcare to the elderly. In our study, having training in oral healthcare was associated with being in the lower quartiles of Internal locus of control and Self- efficacy, and those with oralhealth training had more confidence on their action will be important to prevent oral health diseases, these results are in line with results from other studies showing that HCS personnel need oral healthcare training [23, 40, 41] and more knowledge about oral diseases, as well as practice, to gain more confidence in how to prevent oral diseases [21, 24, 35, 36]. Our study showed that having more education improved oral health beliefs and was associated with being in higher quartiles in the dimensions OHCB and External locus of control, and in the lower quartile of Internal locus of control. Some earlier studies show that more education does not necessarily lead to better oral healthcare behavior among HCS personnel [23]. Even so, knowledge can influence their beliefs about consequences and their abilities, which can influence their behavior [24, 25]. However, previous studies have indicated that there is a gap between knowledge and practice in HCS personnel beliefs about the oral healthcare of the dependent elderly [42]. In the Oral health care beliefs dimension, being male was associated with being in the lower quartile; a study from Sweden supports our findings [21].

More than half of HCS personnel lack training in oral healthcare. This is not unique to Norway as studies from other countries have shown similar results [39, 43, 44]. This is despite oral health training being included in the curriculum of the education system, and the PDS having responsibility for collaborating with the municipality to provide training sessions or courses for employees of HCS once per year [9, 45]. Among those who had training in oralhealth only 26 participants answered they have received training from PDS. Notably, HCS personnel do not always attend the training sessions. This could be because of a high workload or low priorities for oral health [40]. There are HCS personnel with different levels of education working in the HCS, our results showed that education level had a positive association with having positive oral health beliefs and the fact that one in five of HCS personnel in Norway are unskilled, the HCS and PDS must ensure that knowledge about oral health is implemented and the competence of HCS personnel is good enough to cope with the tasks they encounter in the working day. A study conducted by Mehl et al. [37] exploring the quality and quantity of oral healthcare in educational programs for auxiliary nurses in Norway concluded that the education program for oral health training was insufficient, and students did not have enough knowledge of oral healthcare to qualify them for future work in healthcare.

Years of work experience did not have an impact on oral healthcare-related beliefs, as no significant difference in any dimension was detected in our study. Previous studies have shown that working conditions, HCS personnel’ health perspectives, cultural differences [36], and personal experiences with oral diseases [21] all influence how HCS personnel approach the oral healthcare of older people.

It is important, regardless of educational level, that HCS personnel have the knowledge and confidence needed to help care-dependent elderly users of HCS. Educational institutions, municipalities, and the PDS are all responsible for ensuring and facilitating HCS personnel’ acquisition of the knowledge required to meet the challenges of an increasingly older population dependent on assistance to keep their teeth. Oral healthcare education is important, and it influences how HCS personnel practice oral healthcare for older people. More education and oral health training are required for HCS personnel so that they are able to provide the necessary oral healthcare for older HCS users.

Study limitations

Of the 893 HCS personnel working across four different municipalities that were included in the study, only about one-third responded to the survey. The low response rate might lead to bias because the beliefs of nonrespondents of the target population might differ from those of respondents. Therefore, the findings should be taken with care considering the implications for health services research. This is not unique to our study, as prior research has revealed response rates of 20–75% [21, 22, 34]. The low rate of participation can be explained by the fact that oral healthcare is not a high priority among HCS personnel [26, 46]. This might be due to a lack of time allotted for this topic and busy schedules. Another explanation could be that the COVID-19 pandemic caused extraordinary conditions in the healthcare system, requiring more health personnel. As a result, participating in research projects was not a priority. In addition, two of the four municipalities that participated in the survey were in the process of reorganizing HCS during the data collection. In our study, we had low Cronbach’s alpha values (0.6038–0.6438). One of the possible explanations for low consistency could be the heterogeneous group of respondents, who had different levels of education. Edman & Wårdh [21] have also questioned whether low consistency could be because there are several different levels of education among the participants. Another limitation of this study is that a questionnaire was used, and the possibility of a socially complacent answer and the social desirability phenomenon must be taken into account. Theres also a possibility that the respondent didn’t know if the subject of the questions was for them or for an older adult. The strength of this study is, to the best of our knowledge, the first to investigate oral healthcare beliefs among HCS personnel in Norway, and we have used nursing dental Coping Belief Scale, and the result can be compared with previous studies.

Conclusions

The home care services personnel beliefs about oral healthcare improved with an increasing level of education and having had training in oral healthcare. This suggests that HCS personnel need more education and training in oral healthcare. Additional studies are needed to investigate more about the routines for providing good oral healthcare for elderly users of HCS in Norway.