Oral Health Promotion to Improve the Quality of Life in

Older Adults Living Independently

Jorge Trapaga

UAGM

Scholarly Project

Oral health promotion to improve the quality of life in older adults living independently

Oral health diseases are the most neglected in healthcare organizations, affecting almost 3.5 billion people worldwide. They are not highly discussed for all age groups, but when it comes to older people, they need more care. Most of the problems are related to dentistry, but older adults, especially those who live independently, are highly prone to the disorders. Older adults do not have the strong immunity to face the different diseases. Oral diseases are common because of the decayed tooth and dental carriers. The project will discuss the problem in detail (Allin, 2020).

Older adults need the care of their families to face the different issues. The research and practice problem focuses on the oral health problems of older adults who lack family care and live independently. They have different experiences in self-care and dental issues. Sometimes, the older adults are neglected because they do not have enough money to go to a dentist or physician to treat their diseases or suffer from other diseases, so they ignore the oral health disorders. The topic of oral health will have huge scope in the future (Li, 2021).

The state of being physically, mentally, and socially well is referred to as health. Such definition has been widely accepted and is used as a guiding principle by healthcare practitioners. The process of empowering people to exert more control over and improve their health is known as health promotion. It shifts away from an emphasis on personal conduct and toward the various societal and environmental interventions. Broad research has been studied to determine the importance of oral health and increase awareness of its significance to the general population. Poor oral health can lead to pain, eating and speaking difficulties, and poor self-esteem (Li & Yao, 2021). It can also have a negative effect on general health, contributing to heart disease, stroke, pneumonia, and other health complications.

Oral health promotion involves the various activities, including education, policy development, and community-based initiatives. Current statistics demonstrates that over 78% of the elderly population experience issues with oral health (Janto et al., 2022). It shows that oral health is among the highly overlooked conditions in healthcare. It is not highly discussed for all age groups, but when it comes to older people, they need more care. Most of the issues are related to dentistry, but older adults, especially those who live independently, are highly prone to the disorders (Drachev et al., 2022). The elderly do not have the strong immunity to face the different diseases.

Oral diseases are common because of the decayed tooth and dental caries (Li & Yao, 2021). A number of factors contributes to the oral health problems experienced by older adults, and they include age-related changes in the mouth, such as a decrease in saliva production and increase in a number of teeth with fillings or crowns, gingivitis and periodontal disease, tooth decay and loss, abscessed tooth; chronic illnesses, such as diabetes; and medications, such as those used to treat high blood pressure and depression. Apart from that, older adults are more likely to have a poorer diet and be less physically active, which can affect oral health (Allin et al., 2020).

Older adults have experienced the health problems like caries, periodontal, and plaque. All of these will be focused on in the research project. After the identification of the problem, the intervention will be implemented. There are three components of the intervention. The first is to give awareness and educational sessions to the older people who will be the participants. They will be informed of the predicted issues of oral disorders. Moving on, the assessments will be conducted before and after the program, and in the end, the health belief model will be implemented throughout the research project.The project’s purpose is to explore the effect of a four-week oral health education project on elderly persons living independently at an adult community within Miami, Florida.

Significance of the Practice Problem

Today, a great majority of countries have faced the issue of the aging population. At the same time, an increase in the proportion of the elderly implies the increase in the prevalence of poor health outcomes (Thomson et al., 2021). Typically, older people are associated with high medicine use, various chronic and acute illnesses, and multiple physiological alterations in aging body systems (Schensul et al., 2020). Oral health at an advanced age is considered a highly significant determinant of life satisfaction and quality of life (Reisine et al., 2020). Usually, the elderly is at higher risk of numerous health problems and social isolation because of life crises, hence implying greater alteration in their informal relationships (Karkada et al., 2021(b)). Apart from the fact that older people endure discomfort and pain related to poor health, they exhibit poor psychosocial and physical functioning, thus affecting the ability to perform daily activities and maintain social connections (Karkada et al., 2021(a)). In addition, they suffer from poor oral health, which becomes a substantial problem at an advanced age.

Oral health is an integral part of people’s lives and has an impact on physical, social, and emotional health. Firstly, poor oral health has several clinical outcomes (Montanha-Andrade et al., 2019). Frequently, it is associated with plaque buildup, edentulism, tooth loss, as well as root and coronal caries (Bianco et al., 2021). Apart from this, Ortíz-Barrios et al. (2019) mention that older adults often experience oral mucosal lesions, chewing problems, and the use of non-functional dentures (complete or partial), among other conditions. Apparently, preventing deterioration in swallowing and chewing function can assist in prolonging a healthy lifespan (Saito et al., 2020). Although the elderly generally retains their teeth longer, they experience poor oral health due to accumulated oral deficiency (Roma et al., 2021).Apart from various clinical outcomes, the effect of poor oral health on quality-of-life parameters is highly pronounced among the elderly (Rosli et al., 2019). For instance, often, damaged dentition results in functional limitations, such as problems with biting and chewing, psychological effects including reluctance to eat in front of other people, behavioral effects, such as restriction on the amounts or types of foods, and discomfort or pain while eating (Rosli et al., 2019). However, age is not the main reason why older people have oral problems. Thus, poor oral hygiene and ignored chronic diseases are the major reasons for poor oral health (Teufer et al., 2019). The situation is exacerbated by the fact that the elderly seeks dental care less often compared to other age groups. In turn, poor oral health can threaten normal speech and food intake, which can result in adverse psychological and social outcomes (Roma et al., 2021). Moreover, treatment of oral diseases can be difficult in this age group due to low motivation and chronic diseases (Roma et al., 2021). In such a way, oral health is highly important to the elderly, which is why oral health promotion is necessary to improve their quality of life.

When examining oral health in the elderly, oral health-related quality of life (OHRQoL) should be considered. Often, older people living independently, who have different oral problems, exhibit poor psychosocial and physical function, as well as discomfort and pain. In turn, these conditions have significant implications on their ability to carry out daily activities and imply problems in their social communication and oral functioning (Ortíz-Barrios et al., 2019).Czwikla et al. (2021) indicate that, generally, older adults who live independently are less able to visit the dental office, brush teeth, and take care of dentures. This can result in toothache, systemic disease, poor oral health, poor nutritional status, and an increased risk of tooth loss (Czwikla et al., 2021). Apart from this, the outcomes of insufficient oral health can contribute to reduced quality of life and increased healthcare costs (Czwikla et al., 2021). Tooth loss is considered one of the major elements that have an impact on the biopsychosocial state of the elderly (Ortíz-Barrios et al., 2019). Tooth loss is not only a result of untreated periodontal disease or caries since it can indicate extraction of teeth during the orthodontic intervention, trauma, and a complex of other factors not associated with dental illnesses, for example, inability or unwillingness to pay, the lack of access to dental services, and adverse attitudes towards healthcare (Ortíz-Barrios et al., 2019). In the elderly, there are signs of healthy habits obtained early in life, hence meaning that the aging process produces a series of alterations in sensory perception, social status, as well as motor and cognitive functions. On a large scale, social origin has a close association with the risk of illnesses, including periodontitis and caries (Ortíz-Barrios et al., 2019). Social context has a strong effect on individual behavior, with oral hygiene becoming the most significant behavioral factor. Therefore, many older adults face problems with social communication and oral functioning when it comes to oral health, and, therefore, it is necessary to implement effective oral health promotion programs. Older people should follow an oral hygiene regimen that can be performed with the help of various devices, for instance, mobile phones that provide an opportunity to introduce behavioral programs into real-life contexts.

Research Problems, PICOT Question, and Hypotheses

Older adults need the support from their families to face the different issues. The research and practice problem focuses on the oral health issues of older adults that lack family care and live independently. Oral health is disregarded mainly by many people, especially older adults, which is why this topic was chosen. Caries, periodontal disease, and plaque are among the oral health issues that are more prevalent among the elderly. They have different experiences in self-care and dental problems. Sometimes, the older adults are neglected since they do not have enough money to go to a dentist or physician to treat their diseases or suffer from other conditions, so they ignore the oral health disorders. The topic of health would have immense scope in the future.

The research question is: “What is the effect on oral health(O), before and after, (C) of a four-week (T) oral health education program (I) among older adults living independently in an adult living facility in Miami, Florida (P)?”The elderly persons at an independent adult living in Florida are the demographic being studied. The study’s intervention is an oral health education program, as contrasted to the failure to perform the education. The desired outcome is an improvement of oral health to be achieved in four weeks. Older adults have experienced the health problems of caries, periodontal, and plaque. The research would concentrate on each of these. Oral health is the dependent variable in this inquiry. A four-week oral health education program for elderly individuals living independently in a Miami, Florida, adult living facility, is the independent variable. The study hypothesizes that the four-week oral well-being education scheme would encourage the oral health amongst the elderly population.

There are three components of the intervention. The first is to give awareness and educational sessions to the older people, the participants. They would be informed of the predicted issues of oral disorders. Moving on, the assessments would be conducted before and after the program, and in the end, the health belief model would be implemented throughout the research project.

Theoretical Framework: The Health Belief Model (HBM)

It is logic that older adults face many health issues, however, this project is devoted to one of the aspects of their health that is often neglected, namely oral health. The purpose is to check how proper education in this area will help this group to be more attentive to oral health. The health belief model (HBM) is a handy tool to reach this purpose. Using the HBM, older adults will have some properly shaped perceived constructs, like susceptibility, severity and benefits, will not see any barriers to applying to health providers and will correctly accept the offered action clues in the form of the educational materials. The results of a four-week educational session in the HBM framework will be favorable for the considered age group.

A Brief History of the HBM

It is worth noting that the HBM is not a product of nurses. It is a non-nursing approach, developed by y social scientists of the U.S. Public Health Service in the early 1950s (The health, 2019). The material, named Main Constructs (n.d.), gives a more detailed information and reveals that the theory was developed by social psychologists Hochbaum, Rosenstock and others. So, the HBM is a group work. The initial aim of the HBM was “to understand the failure of people to adopt disease prevention strategies or screening tests for the early detection of disease.” (The health, 2019, para.1). Though the HBM was not developed by nursing providers, some scientific scholarly base for its development is present: “chest x-rays for tuberculosis (TB) screening that were underused because many people with TB did not recognize their symptoms and did not seek medical care for what they deemed a mere cough (Green et al., 2020). Thus, the HBM development is properly grounded.

Social psychologists saw that they could help healthcare providers to solve the problem of people’s disbelief that they may have something wrong with their health and that conventional medical approaches can significantly help them to improve their quality of life. At the initial stages of its development the HBM was rooted in the process of information giving about different preventive healthcare services and immunization. Later some educational sessions were added. The HBM had to address some people’s concerns about whether some physical and moral efforts, implemented into the healthcare process are truly worth the received results (Green et al., 2019). Thus, the main goal of the HBM is to convince people in the necessity to be treated.

It is possible to state that both psychologists and the obtained test results of the patients played a crucial role in the HBM development. The information helped to prepare a scientific base for the approach. Psychologists shared their experience in this aspect and stated that people were truly afraid of developing some serious illness and this perceived fear could be managed. Different messages on TV and social media could encourage people to apply to preventive services or to pass some additional tests (Green et al., 2019). Thus, the HBM does both: explains why people lose belief in medical services and determines how it is possible to help such possible patients from a psychological point of view.

Constructs of the HBM

As it is clear from the previous paragraphs, the HBM proved to be very useful, as it answers many questions about people’s behavior in terms of healthcare. The model has a number of properly developed constructs. They are perceived benefits, severity, susceptibility and barriers and acute cues and self-efficacy (Main construct, n.d.). Perceived susceptibility is often named as the first construct. The scholars define it as: “belief about getting a disease or condition” (Main constructs, n.d.). It is a starting term, because, if a psychologist learns that a person fears to develop some illness, it can be a starting point for applying the HBM.

It is interesting to note that the HBM can be applied to any perceived parameter and that if a person has one, this fact does not mean that he/she has others or all the others. A person may have a strong belief in the severity of his/her state and the benefits of applying to some medical services. However, he/she may have such a strong belief into the existing barriers to a healthcare process that he/she will not do anything. It is the time to give a person some cues to action in the form of the educational materials. In such a way he/she may have a feeling of self-efficacy, the construct, which was added later to the list (Green et al., 2019). Thus, the HBM logically distributes the activities.

Besides the enumerated constructs, the developers of the HBM theory state that there are some individual factors that influence people’s desire to apply to healthcare providers. They are age, gender, ethnicity and other (Main constructs, n.d.). It is easy to understand these personal characteristics. For example, if a person is too young, he/she may treat his/her health carelessly, simply because he/she mostly feels good. People of male gender do not tend to apply to providers, because they are mostly overloaded with work or think that their wives will assume a responsibility for everything. In order for the HBM to properly influence an individual, he/she should be ready to change his/her health behaviors. The approach is effective for people, who continuously repeat the same harmful actions like do not fasten their seat belt or consume fast food. The HBM works for people, who do not believe that they can quit their unhealthy habit like smoking or regular alcohol consumption (Green et al., 2019). Thus, there are numerous circumstances, when the HBM is effective.

Components of the HBM and the Practice Change Model

The project of the practice change model is devoted to evaluating the results of a 4-week educational session about the importance of oral health for older adults, living in Miami, Fl. Different reasons for such a careless attitude of older adults to their oral health are possible. One factor is that they live independently. Other factors are the enumerated perceived constructs. The discussed HBM is the most suitable to encourage the older adults to care for their oral health.

It is a well-known fact that oral health is very important for the overall state of health of an individual. Caries and periodontitis are the most common dental health problems in the world (Ashoori, et al., 2020). Older adults can suffer from plaque too. Ashoori et al. (2020) write that their research of students’ oral health issues showed “the necessity to emphasize the perceived benefits, self-efficacy and cues to action.” (p.26). With the purpose to solve the existing dental health issues of the students. Older adults, as another age-group, may perceive these actions well too. It is possible to additionally add the concept of perceived severity, as older adults definitely want to prevent the development of any complications. Thus, it is obvious that my research proposal should be devoted to the HBM.

The discussed findings can be complemented by some research results of other scholars. Sulat et al. (2018) indicate that researching more than 450 articles, devoted to the HBM “perceived benefits were the strongest predictor, while perceived severity was the weakest.” (p.500). However, for the investigated age group the construct of perceived severity will encourage the patients to apply to the oral health care. The planned educational sessions will have a preparatory part and a part that will show, which perceived constructs are revealed or shaped. First, it is required to learn, what facts older adults already know about dental health, including plaque reduction. Then possible patients will receive all educational materials and explanations. The last stage will be to learn how the views of older adults changed after the sessions, and if the materials or actions triggered this change and their oral health improved. Itis possible to change the views of the older patients on their oral health with the help of the HBM and give them such actions cues that they will include regular oral health examinations into their regular checks.

It is worth noting that the HBM is very practical and valuable for older adults with dental health problems. It is important to shape all perceived constructs for them. They should understand that their general state of health includes the condition of their oral health. The action cues in the form of educational sessions and written materials will demonstrate the older adults that there are not any barriers to applying to dental healthcare providers and they should be encouraged to do it with the help of the offered action cues. The HBM will definitely shape some constant oral health habits with the considered group of the older adults.

Synthesis of the Literature

Oral Health

A lot of literature is dedicated to the study of oral health problems and promotion to improve the quality of life in older adults who live independently. Such close attention to this topic is associated with the fact that the population is aging, which is a real problem in many countries. According to Bianco et al. (2021), aging is considered one of the most severe problems of the 21^st century for many countries. In 2000, the number of people aged 60 and older was around 605 million while, by 2050, it is estimated to increase to almost 2 billion (Mittal et al., 2019). Moreover, Shokouhi et al. (2019) state that the increase in the elderly population requires close attention to various needs of this age group affecting their quality of life, which is a measure of social development. Old age has a connection with certain physiological alterations, eating problems, and dental and oral issues, for instance, difficulty swallowing and chewing food and tooth loss, which is followed by various diseases (Shokouhi et al., 2019). The authors indicate that chronic diseases tend to increase with age (Shokouhi et al., 2019). The presence of chronic illnesses is exacerbated by the decline in the normal functioning of the aging body, isolation, dependency on others, disability, and the decline in the quality of life (Shokouhi et al., 2019). The aging population increases the burden of different chronic diseases including oral problems.

The elderly experiences a high prevalence of different dental diseases and conditions. They include tooth loss, periodontal disease, plaque buildup, caries, unmet oral care needs, and worsening quality of life (Schensul et al., 2019). Apart from this, Dhama et al. (2021) state that dry mouth, dental caries, and precancerous/cancerous lesions are the most common oral and dental conditions observed in the elderly. Oral health is related to chronic disease and systemic health problems in older age (Malekpour et al., 2022). For instance, cognitive decline, dementia related to serum Porphyromonas gingivalis, high levels of immunoglobulin G, and xerostomia from multiple medications, as well as diabetes and cancer treatments relate to high levels of decay, insufficient oral hygiene, edentulism, and loss of teeth (Schensul et al., 2019). Periodontal disease is related to stroke and heart attack while periodontal treatment can have a positive impact on diabetes control (Schensul et al., 2019). Furthermore, insufficient oral health has an adverse effect on the oral health quality of life (Schensul et al., 2019). Therefore, many older adults experience oral health problems, which is why oral health promotion is of paramount importance to improve the quality of life of this group of people.

Further, a lot of literature is dedicated to the study of various indexes and scales to measure oral health-related quality of life. Nowadays, the Geriatric/General Oral Health Assessment Index (GOHAI) is commonly applied in order to assess oral health-related quality of life. It is grounded onthree assumptions, namely, a) an individual can measure oral health through self-assessment; b) levels of oral health and hygiene vary from person to person, which can be demonstrated by applying measures grounded on an individual’s self-perception; c) self-perception has been determined as a predictor of oral health (Ortíz-Barrios et al., 2019). These indexes determine and measure problems associated with oral health in respondents with the 12-item questionnaire that assesses oral health problems in the last three months (Ortíz-Barrios et al., 2019). GOHAI is extremely useful since it assesses the severity of psychosocial consequences related to different oral diseases. GOHAI serves as a valuable tool for the evaluation of the outcomes of oral care services and programs (Ortíz-Barrios et al., 2019).The data provide the basis for efficient policies for an individual segment of the population, for instance, the elderly.

Moreover, Bianco et al. (2021) describe a positive side of using GOHAI. The authors mention that Atchison and Dolan elaborated the Geriatric/General Oral Health Assessment Index in 1990 (Bianco et al., 2021). The index explores the psychological, physical, and physiological needs of the elderly, therefore complementing clinical care. It evaluates three measures of quality of life-related to oral health, which include physical functions involving swallowing, speaking, and chewing; psychosocial functions, such as attitudes towards dental health, irritation from impressions, self-limitation of social contacts because of dental problems, and insecurity about oral health; discomfort or pain, including the mouth discomfort or use of medications (Bianco et al., 2021). Bianco et al. (2021) indicate that GOHAI attaches great importance to the functional state and discomfort. Moreover, Zhi et al. (2021) state that the index places more emphasis on subjective oral health with less clinical alteration and direct clinical aspects. In turn, Bianco et al. (2021) describe one more index related to oral health — OIDP, which was developed by Adulyanon in 1996. OIDP represents one of the characteristics of oral health-related quality of life scales (Wong et al., 2021). These instruments evaluate psychometric features admissible to the elderly (Wong et al., 2021). It consists of nine items that assess the severity and prevalence of problems with dentures or teeth found in the last six months and what effect they have had on older people’s daily activities as per Zhi et al. (2021). In such a way, the source examines GOHAI and OIDP as well as studies how these scales evaluate the impact of oral hygiene and health on quality of life.

Oral Health and Quality of Life

Oral health is essential to good overall health and well-being. The Surgeon General of the United States and the World Health Organization (WHO) have urged preventive public health practices and improved access to oral care (Schensul et al., 2021). The elderly experience great disparities in both mainly because of the limited access to quality dental care and insufficient opportunities to get preventive education that would assist in addressing such diseases as edentulism, periodontal disease, and caries (Schensul et al., 2021). Mittal et al. (2019) try to identify causes resulting in poor oral health among older adults. According to the authors, the use of dental services among the elderly is low due to multiple barriers (Mittal et al., 2019). At the same time, there is no single factor that serves as the biggest barrier to accessing dental services among the elderly. The location of the facilities, the cost of dental care, limited income, the lack of specialists, and the lack of awareness of the services provided are the most common barriers to the use of dental services by older adults (Mittal et al., 2019). In addition, the lack of perceived need for care, oral hygiene literacy, and disability are significant factors that have a substantial impact on dental visits by the elderly (Gunpinar & Meraci, 2022). Apart from this, Lee et al. (2022) claim that oral health literacy is influenced by various demographic factors, such as the level of education, age, diet, monthly income, and activities of daily living. Moreover, Assari and Bazargan (2019) pay attention to socioeconomic status, especially a high level of education. According to the authors, this status promotes access to dental services and protects against insufficient oral health (Assari & Bazargan, 2019). Nonetheless, all people should be as knowledgeable about their healthcare needs as their physicians (Denis et al., 2021). All the barriers mentioned above affect oral health-related quality of life.

Many sources focus on such a phenomenon as oral health-related quality of life (OHRQoL). For instance, Top et al. (2019) state that OHRQoL is applied as an important metric to evaluate and measure health outcomes and treatment management. Mouth and teeth diseases are considered an important public health problem today and OHRQoL can help to evaluate outcomes of oral services and care. Reisine et al. (2021(b)) state that much attention to the quality of life can be associated with the definition of health proposed by the WHO. According to the WHO, health can be defined as “a complete state of physical, mental, and social well-being and not just the absence of disease” (Reisine et al., 2021(a), p 2). Therefore, quality of life has been included in the professional framework for oral health, hence supporting the notion that, in order to assess oral health in people or the results of clinical trials, clinical indicators are not enough (Reisine et al., 2021(a)). The authors affirm that OHRQoL serves as a highly significant construct for determining oral health and is applied as an outcome measure in adult dental clinical trials (Reisine et al., 2021 (a). Zhenget al. (2021) indicate that OHRQoL can be applied for measuring and assessing the effect of oral hygiene and health on a people’s quality of life. It implies a subjective perception of the state of the oral cavity and a subjective assessment of the psychological function, physical function, and aspects of the social activity of oral health (Sermsuti-Anuwat & Pongpanich, 2021). In addition, OHRQoL has the potential to evaluate the association between overall health and oral health from experience and subjective perspectives (Zhenget al., 2021).

In contrast to Reisine et al. (2021(a)), Zhenget al. (2021) pay attention to college students and not the elderly. According to Zhenget al. (2021), college students should have a good quality of OHRQoL since they become future agents of social progress and play a highly important role in the future development of the country. If compare them with people of the middle age, college students are in a period of dynamic growth and their health, behavior, lifestyle, and social psychology are more likely to alter. In turn, poor OHRQoL can have an adverse impact on the state of the oral cavity in students and their general health and well-being in the future (Zhenget al., 2021). Even though the source focuses on young people rather than older adults, it is still highly useful since it describes the theory of knowledge, attitudes, and practices (KAP). It is a theoretical model applied to alter an individual’s behavior associated with health. According to this model, healthy knowledge serves as the basis for the formation of healthy behavior and positive attitudes, which are the motive power behind behavior alteration (Zhenget al., 2021). Apart from this, the KAP theory affirms that the promotion of healthy behavior is the most important purpose. The authors state that there is a direct relationship between practice, attitudes, and knowledge (Zhenget al., 2021). In contrast, a traditional multivariate statistical method can reveal factors that have an impact on practice, attitudes, and knowledge. At the same time, it cannot explain causal relationships engaged in this process. For comparison, structural equation modeling represents a more advanced statistical technique, thus compensating for the shortcomings of traditional statistical methods (Zhenget al., 2021). This method of multivariate statistical analysis can work simultaneously with measurement errors, observation indices, and potential variables. Moreover, it can quantify the indirect and direct impacts of variables and investigate causal relationships between potential variables (Zhenget al., 2021). Currently, structural equation modeling is widely applied in behavioral and social sciences, psychology, management, biomedicine, and other fields.

Oral Health and Interventions

The use of indexes and scales mentioned earlier are part of oral health promotion programs. Oral health promotion programs are highly effective for older adults (Seo & Kim, 2019). In terms of health promotion and prevention, oral health promotion programs should be implemented before oral dysfunction and oral health problems emerge (Seo & Kim, 2019). Thus, these programs should be provided at an early stage before oral problems develop. Scheerman et al. (2020) state that people should follow an oral hygiene regimen involving the use of fluoride toothpaste and rinses, which could prevent the development and progression of dental problems. For example, doctors recommend different mechanical methods, such as flossing, brushing, and other interdental cleaning devices, to control the accumulation of plaque biofilm (Milleman et al., 2022). Moreover, Bosma et al. (2022) pay particular attention to flossing, hence claiming that it is a highly useful component of recommended daily oral care regimens. According to Bosma et al. (2022), the Food and Drug Administration classifies dental floss as a Class I medical device aimed at removing food particles between teeth and plaque for reducing caries. Nonetheless, the authors state that patients tend to find this component difficult to perform effectively on a regular basis (Bosma et al., 2022). A great majority of older adults prefer toothbrushing (Bosma et al., 2022). At the same time, flossing together with toothbrushing is considered more effective compared to toothbrushing only in reducing plaque and interproximal bleeding (Bosma et al., 2022). Adherence to oral hygiene regimens is extremely low, in particular among older adults living independently (Scheerman et al., 2020). Further, Gallie (2019) states that many older adults who live alone neglect oral hygiene. This fact points to the necessity for interventions aimed at improving oral health behavior. According to Scheerman et al. (2020), different functions of mobile phones make them useful for health promotion programs. They provide an opportunity to introduce behavioral programs into significant real-life contexts, involving people’s health decisions and the obstacles they experience while changing behavior (Saxena & Gunjal, 2021).Mobile health can be applied as an additional component to improve oral hygiene and gain oral health knowledge (Scheerman et al., 2020). However, the use of mobile phones for different health promotion programsmay be difficult for older adults, in particular those living independently.

Practice Recommendations

Based on the literature review, the older adult population living alone needs to improve practices of maintaining oral health. The oral health education program will encourage this target group to change its attitude, behavior, knowledge, and perception of oral health (Scheerman et al., 2020). Evidence suggests oral health promotion program is efficient for the target population since it influences the quality of life. The approach has shown positive results in helping the older adult population to navigate some of the challenges they experience in old age. It is a method that can have a considerable impact when offered by trained health care personal, nurses, assistants and other healthcare personal in small groups following the HBM framework. Keyong et al. (2019) state that oral health education programs impact the older adult population’s understanding of disease severity and oral health risk. Furthermore, studies of caretakers’ post-oral health intervention programs indicate improvement in fluorides, denture care, oral hygiene, and the importance of dental checkups (Janto et al., 2022). In this project, oral health education programs will be implemented based on recommendations to improve the quality of life among the older population living independently.

One of the recommendations is to provide participants with in-person teachings, show audiovisual material as well as written information for them to keep to instruct them in the proper and effective way to provide oral care to themselves and improve their quality of life. Other recommendation is to apply mobile health reminders through Remind Application, to keep participant information confidential, as additional components in the oral health education program (Scheerman et al., 2020). The mobile reminders are an ideal choice for this intervention since they are easy to use. Nowadays, mobile devices are portable and widespread even among the older population. Moreover, educational material, and training videos can be shared to them to support the learning without place or time constraints. Saxena & Gunjal (2021) state that mobile applications offer an opportunity to incorporate behavioral programs into the real-life contexts of older adults. In addition, the mobile reminders could be used to improve their health decisions. Thus, mobile reminders are a perfect tool for assisting in the implementation of the oral health promotion program.

Another recommendation is, if they are available, involve the contribution of family and beloved ones in this project. Family can play a significant role in the oral health education program, hence allowing the older adult population support from them, and play an essential role in the oral health hygiene regimen by interacting with them and encouraging the older adults to follow different activities. They can follow up on the development of dental problems, processes of tooth brushing, flossing, and various interventions. The approach will encourage family involvement in the oral health promotion program, thus resulting in transparency and improved outcomes.

Project Setting

The project will take place in an Independent Residential Community in Miami Dade County. The clients will be tenants aged 55 to 62 years, both males and females. The health behaviors to look out for will be poor oral hygiene as well as psychosocial and physical functions.

The project will align with the mission of the Rental Community, offering remarkable living experiences for the older populations through community-inspired properties, exceptional customer service, and a passion-driven team (Richman Properties Services, n.d.). In addition, the project will align with the organization’s vision, which implies offering first-class residential services to everyone and putting the needs of the consumers first (Richman Properties Services, n.d). The organizational structure and culture will support the implementation of the project because the company has over 600 employees maintain a resident-focused culture from the landscape crew, maintenance staff, leasing agents, property manager, and housekeeping personnel. Thus, the project setting is ideal for the oral health promotion program (Richman Properties Services, n.d.).

The impact of the oral health education program on the quality of life will determine the organization’s need for the project. Project stakeholders will comprise older adult populations from Miami-Dade County, Florida. The estimated number of seniors in the region is 440,203 out of the 2,153,471 adult populations (World Population Review, n.d.). Families, healthcare practitioners, staff, and property managers are other stakeholders. The proof of organizational support will be ensured through Glassdoor reviews. Plans for sustainability will be implemented at the beginning through consultations with stakeholders to include them throughout the project.

A SWOT analysis (appendix 1) will be utilized to assess the strengths and weaknesses, review opportunities, and ascertain the threats of the project. The strengths of the project setting include the significant portfolio of properties and the number of seniors participating in the oral health promotion program. Its weaknesses imply the privately owned properties and social surroundings. On the other hand, the threats comprise patients’ and families’. Finally, the opportunities are the availability of the internet and resident-focused culture among the personnel.

Project Vision and Mission

The mission of the project is to help older adults living alone improve their oral health by focusing on their overall good health and wellbeing (OHRQoL) and reduce the prevalence of different dental diseases and conditions, such as periodontal disease, tooth loss, caries, and plaque buildup. The vision is to change the older adult population’s behavior, perception, and attitude so they can find oral health easy to accomplish. Notably, the project will take place at Independent Senior Community owned by Richman Property Services and located in Miami Dade County.

The project’s mission and vision will align with the vision and mission of the residential community. The mission of the Independent Senior Community is to offer remarkable living experiences for the older populations living independently through community-inspired properties, exceptional customer service, and a passion-driven team. The vision is to provide first-class residential services to everyone and put the needs of the consumers first (Richman Properties Services, n.d). The project will accomplish its mission in the project setting by ensuring that the remarkable service equates to improving the overall good health, wellbeing, and quality of life of the older adult population. Accordingly, the project vision will be accomplished in the project setting by putting the health needs of the consumers first.

Project goals will be divided into short-term and long-term. The short-term objectives include awareness of the different mechanical methods recommended by healthcare professionals, such as brushing, flossing, and using interdental cleaning devices to minimize plaque accumulation. In addition, the project will aim to improve oral health in four weeks among the older adult population living independently. The long-term objectives are to reduce the occurrences of dental diseases and conditions, minimize the impact of the effects of oral health among the older adult population, improve the oral health-related quality of life (OHRQoL), and, in the long run, change the knowledge, attitudes, and behaviors.

There is not know any risks or discomforts for the participants in this research study, except fatigue or tiredness when completing the questionnaire, and/or the participants may experience stress from receiving information and thinking about it. But if at some point during the investigation process, the participant does not feel comfortable with the questions or information and decide not to continue being part of the study, the participant can leave the project at any time, without any retaliation or penalty.

Project Objectives

Analyze the Impact of the Oral Health Education Program on Older Individuals Oral Health Who Live Independently in Older Adults’ Facilities in Miami, Florida

The research question’s purpose is crucial because it will reveal whether or not the oral health education program successfully enhances the oral health of elderly individuals living independently in a Miami, Florida, adult living facility. Older persons living in adult living facilities would benefit from better dental health. It is crucial since poor dental hygiene affects many older persons and can cause tooth decay, gum disease, and other issues (Drachev et al., 2022). Additionally, the objective would help identify any potential improvements that could be made to the program to improve participants’ oral health further. An education program that includes educational materials, such as handouts and videos, to teach the participants on proper oral hygiene habits would be used to implemented to achieve the objective. The program would also include a series of practical activities, such as brushing and flossing demonstrations, that would help the participants practice the new habits they have learned.

To Conduct Oral Health Assessments and Determine the Prevalence of Periodontal Disease, Plaque, Visible Tooth Decay, and Ulcers

Meeting the objective is paramount, as it would help determine how prevalent oral health issues are among the elderly living independently. The procedure to determine the research question’s findings would involve conducting oral health assessments in participants and determining the prevalence of periodontal disease, plaque, visible tooth decay, and ulcers. The results of the research will assist in decision making on the effectiveness of the four-week oral health education scheme in alleviating the oral well-being of the elderly.

Provide an Oral Health Kit (Toothbrush, Floss, Toothpaste, Mouth Wash) to Motivate People to Take Care of Their Oral Health

The objective is crucial to meet, as it offers ways of measuring the effect of oral health education programs among elderly individuals. The oral health kits would be distributed to the participants in the study and then measure the oral health of the participants before and after four weeks. The health belief model is based on the belief that people make decisions on their health based on their perceptions of the risks and benefits of particular health behavior (Sanaeinasab et al., 2022). To meet the objective of providing an oral health kit to motivate people to take care of their oral health, there is a need to assess the perceived susceptibility, severity, benefits, and barriers to oral health among the older adults living in the adult living facility. Once these factors have been assessed, one can provide the oral health kit to those most likely to benefit from it.

Create an Oral Health Educational Material to Be Distributed to Improve Oral Health (Flossing, Tooth Brushing, Mouth Washing, Avoiding Sweets)

Oral health is an integral part of overall health and well-being. Unfortunately, many older persons living independently in adult facilities lack access to services or proper oral health education. Poor dental health and higher risk of illness can result from this. The study’s main goal is to enhance the dental health of the elderly. It would be accomplished by providing research participants with educational materials on oral health. The material would cover flossing, tooth brushing, mouth washing, and avoiding sweets. The research would also involve oral health and answer residents’ questions. It would improve the participants’ oral health and help them maintain their oral health for longer.

Compare Participants’ Oral Health before and after the Four-Week Program

The study’s objective is to compare participants’ oral health before and after the four-week program. An education program would be carried out among the participants for four completed weeks. The program would include oral hygiene. At the end of the four weeks, the participants would be given a final oral health examination. The research findings would be used to implement educational programs on oral health.

Assess the Program’s Impact on Participants’ Knowledge, Attitudes, and Behaviors Related to Oral Health

The objective would be met by conducting a pre- and post-test with the participants. Knowledge, attitudes, and behavior would be assessed before implementation of the intervention. After completing the four-week oral health educational program, the participants would receive a post-test. Knowledge, attitudes, and behavior would be assessed after implementation of the intervention. The contrast seen between pre and post-tests will be used to measure the program’s influence on participants’ oral health knowledge, sentiments, and habits.

Project Plan: ADKAR change model

The ADKAR change model (Awareness, desire, knowledge, ability, reinforcement) implies that, for any change to occur, individuals must agree to change and be willing to change. This model was created by Jeff Hiatt to focus on individual change by guiding people through a five-change model and addressing any barriers along the way (Kaminski, 2022). The purpose of selecting this change model is explained by its approach to initiating change at an individual level. Oral health is an individual initiative that requires individual effort rather than an organizational effort to instigate change. Therefore, the model fits the context of this study by identifying the ability of older adults living independently to implement changes towards improving their oral health. Nonetheless, the model outlines the goals and outcomes of successful change, which enables older people to identify and focus on activities that will drive change at an individual level to achieve results. Moreover, the model helps to predict any barriers to change, which makes it easier to support the target population in their progression through the change. Kachian et al. (2018) mention that, for any sustainable change to occur, one must identify the ability of the individual to accept and implement the change. The ADKAR change model’s five stages of change help to identify the ability of older people to make changes at a personal level, which will determine the success of the oral health change program (Kachian et al., 2018). Therefore, the model ensures the change among the target population and addresses the barrier and strengths required to achieve successful outcomes. In implementing the change of the oral health intervention program, the ADKAR change model follows five steps. These steps include awareness, desire, knowledge, ability, and reinforcement.

Step 1: Awareness

The first phase of change, according to the ADKAR change model, is awareness. This step involves making sure that every participant involved in the change program understands the need for change. This step will involve presenting the idea of oral health to the older adults and describing how the issue affects different spheres of their life. Current studies have identified that older people are more often misinformed or under-informed when it comes to aspects of dental health and hygiene. Therefore, this phase will focus on informing the target group about the need to adopt the change and explain the consequences of neglecting the change (Kachian et al., 2018). For example, the older adult will be informed of the negative and positive outcomes of oral health hygiene, hence addressing issues that cause tooth decay, gum disease, and other oral health problems. This stage is designed to make the older adult aware of the importance of oral hygiene and influence their desire to implement the change at a personal level.

Step 2: Desire

The second phase of change is desire, which involves making sure that the change appeals to the interest of the older people and drives them to accept the change. This will be achieved by accessing and changing individual attitudes toward oral health. In this stage, a personal oral health assessment, which is based on a questionnaire directed to identify current oral hygiene conditions and establishing possible threats to health if the participants do not embrace the change, will be provided (Balluck et al., 2020). The elderly must understand that oral health is important in maintaining their overall wellness. This idea will push them to adopt the change program for various benefits including social and health welfare.

Step 3: Knowledge

The third phase involves providing each person with the information they need to accomplish part of their change process. It is acknowledged that older people living independently lack access to services and oral health education resources and materials. Therefore, this stage of change focuses on providing people with educational material and resources that increase their knowledge of oral health (Kaminski, 2022). The material would explain how to maintain oral health, its causes, and its importance. For example, education on the use of toothbrushes, mouthwash, flossing, and precaution measures, such as avoiding sweets, will help to maintain oral health.

Step 4: Ability

In this stage of change, the older people will be assessed on their skills, strength, and weakness, as well as trained on effective approaches to accomplish the change process. They will be provided with oral health kits (Toothbrush, Floss, Toothpaste, Mouth Wash) and observed on whether they can use them effectively. The budgeted cost is explained in Appendix 3. Those with challenges or weaknesses in how to perform individual oral hygiene will be trained using the kit. The ADKAR change model implies that, for change to happen, people must demonstrate the ability to perform the change and cope with its outcome at an individual level (Kaminski, 2022). Thus, in order to meet the goal of the change, challenges and barriers must be identified at this stage, which include the any barrier to understand the oral education and the inability to perform self-care due to frailty associated with old age. These challenges, strengths, and weaknesses will help to determine the success or failure of the change initiative, based on the ability of the older people to integrate the program into their lives.

Step 5: Reinforcement

The last stage of the ADKAR change model is to ensure that older people continue to follow the oral health program and remain consistent with the activities associated with the new intervention. Therefore, a post-assessment evaluation will be conducted to measure their attitudes, perceptions, and outcomes of the change (Balluck et al., 2020). The reinforcement will be facilitated through the assistance of personal care assistance at the facility, who will monitor how the older people continue to implement oral health and hygiene even after the educational program.

Barriers and Facilitators

The process of implementing change could face some barriers that affect the outcome of the intervention. One of the major barriers is the unwillingness or inability to participate in the program. The intervention focuses on older adults, some older people may not have the ability to participate due to various reasons, such as frailty or individual beliefs and values. Other barriers include miscommunication and misunderstanding, which are facilitated by the language barrier. Older people tend to be very traditional and cultural, which means that some of them will have a challenge in reading and speaking the English language. The facilitator of the project will be educator and family members who help in oral health education and activities.

Project Process Plan

The recruitment and selection of participants followed a systematic approach based on the inclusion and exclusion criteria (Kang & Deng, 2020).The inclusion criteria for the recruitment of the participants was adults between the ages of 55-62 living in an independent adult residential community within the City of Miami located in Miami Dade County. The exclusion criteria was adults under the age of 55 or over 62, not living that particular independent adult residential community within the City of Miami located in Miami Dade County.

The project was implemented in an independent adult residential community within Miami Dade County, a letter of support was requested and signed by the site mentioned. For the purpose of recruiting the participants, invitation flyers (Appendix 6) were posted in different locations within the residential community, and those interested in participating in the research project contacted the principal investigator for more information. A date and time was set to meet with all those interested in the research project, the meeting took place in a private space at the residential community, information and instructions were provided by the principal investigator. The expected number of participants was between 25-50.

Participation in the study was voluntary, but if at some point during the investigation process, the participant didn’t feel comfortable with the questions or information and decide not to continue being part of the study, the participant was able to leave the project at any time, without any retaliation or penalty.The program adhered to research ethics by providing all the participants with an informed consent form.The participant consent was obtained the day the principal investigator met with the potential participants. To make sure that the participants understood the study in its entirety, it was done with feedback questions about the explanation of the content of the information sheet, the purpose of the study, its duration and procedure. In this way I made sure that the participants have understood the information provided.The document did not contain any participant information, it was anonimous, received only one number as a statistical measure to gather the result before and after the test in each one of them.

All information related to identity was handled in a private and confidential manner and was always protected. Under no circumstances will the participant’s information be shared with third parties. The collected data is being stored in a private, secure, and locked place. Any document collected is being stored in the principal investigator’s office in sealed envelopes under extreme security for a period of five (5) years. They will be under the tutelage of the principal investigator. Confidentiality is and will be protected to a 100% and data collected won’t be accessible to other parties. After five (5) years, all related documentation will be destroyed by Jorge Trapaga, using a paper shredder. All electronic storage devices will be destroyed using a blunt object Only the principal investigator and mentor will have access to the information obtained.Individual privacy and confidentiality will be protected to ensure that all information is used for this program only. Additional safeguards will be provided to protect against coercion or undue influence.

There was not know any risks or discomforts for the participants in this research study, except fatigue or tiredness when completing the questionnaire, and/or the participants may experience stress from receiving information and thinking about it. Some of the potential benefits the participants might experience will be to maintain their teeth and gums healthy, prevent bad breath, and avoid gum disease. Additionally, good oral health can help them avoid harmful bacteria inside the mouth and maintain a healthy overall appearance. The educational meeting contributed to demonstrate the need to increase the level of knowledge among older adults about the importance of good oral care.

Pre-test questionnaire with 15 questions, was used as an instrument for data collection. The pre-test was done during an encounter with each participant and the principal investigator before the educational meeting took place at the residential community.A basic oral health assessment, which was based on a questionnaire directed to identify current oral hygiene conditions in participants and determining the prevalence of periodontal disease, plaque, visible tooth decay, and ulcers.

The educational meeting took place at the residential community and contributed to demonstrate the need to increase the level of knowledge among older adults about the importance of good oral care. The education program included educational materials, such as handouts and videos, to teach the participants on proper oral hygiene habits would be used to implemented to achieve the objective. The program also included a series of practical activities, such as brushing and flossing demonstrations, that helped the participants practice the new habits they have learned. The education meeting lasted approximately 20-30 minutes.

Post-test and pre-test had the same information. The data collected in the post-intervention will assist to determine if after the four-week oral health education program participants changed their oral health behaviors and their oral well-being improved.All data collected did not contain any participant information, it was anonymous, received only one number as a statistical measure to gather the result before and after the test in each one of them.

The plan of practice change is going to be evaluated using a summative approach, which will be conducted to measure how the participants have managed to achieve or accomplish the identified PICOT outcome, namely, improvement of oral health in four weeks (for project schedule see Appendix 4). The approach involved presenting the older people with a test after the accomplishment of the program and checking how effective they applied the routine and their adherence to the content they learned about oral health.

The evaluation design was based on a qualitative approach where data was obtained through primary data for comparison groups. The tools that were used for the primary data collection were interviews and responses from questionnaires (See appendix 2) (Kang & Deng, 2020).The purpose of using a questionnaire was to assess the participants’ knowledge, attitudes, beliefs, and behaviors related to oral health. The data collected before and after the study will help us determine if the educational program was effective or not. The use of a questionnaire was done to ensure a more accurate sample to gather targeted results in which to draw conclusions.After the pretest the participant received a meeting education through a power point presentation and in another encounter, they received the post test. The evaluation was based on nominal data, which makes it easy to collect and present qualitative information, as well as label the variables without providing numerical values.

The extraneous variables were controlled by ensuring that the activities took place in the participants’ environment, namely, in an adult living facility in Miami, Florida. The planned analysis for the evaluation of data involves the integration of qualitative data obtained from the primary sources and analysis through the use of a simple descriptive system where data will be presented in simple tables, graphs, and charts (Dzwigol, 2020). Data will be analyzed using a paired samples t-test. The analysis will be based on a qualitative approach by evaluating themes observed from the primary sources to identify patterns or variables that are coded and presented in tables, graphs, and charts.

The educational meeting contributed to demonstrate the need to increase the level of knowledge among older adults about the importance of good oral care.The result of this project will demonstrate how health care providers can contribute to increase this knowledge by applying educational meetings to the elderly population and adults in general.

Plans for Dissemination

The practice change project oral health promotion program to improve the quality of life in older adults living independently seeks to give the older people a chance at better lives in their old age. Better quality of life offers them a longer life span because they receive the care they need.

The results of the findings will be presented at the Ana G. Mendez University, those invited will include the Dean, Heads of the different departments, professors, and students. The information will be presented in print to the present people, and the presentation will be done on a whiteboard from a projector, showing step-by-step measures in the change program. This allows for any raised issues to be addressed immediately. Research findings will be distributed to other colleagues in the medical field because the change project involves them and their work. In addition, the plans for dissemination will include a face-to-face audiovisual and written presentation of the findings to the stakeholders at a community meeting because the presentation is about their well-being.

The practice change project will be published in the International Journal of Nursing Studies because it is the top-ranked nursing journal and has strong ties to the nursing faculty. The journal reaches many nurses and addresses current health issues and nursing concerns.

Conclusion

All in all, oral health is crucial in attaining the overall health of an individual. It is a significant problem, especially among elderly individuals. One of the main factors contributing to increased oral health issues among these individuals is the lack of education and inadequate resources to promote oral health. It contributes significantly to deteriorating dental health and higher risk of illness. The main objective of the research is to improve the health status of the elderly individuals. It would be accomplished by producing teaching materials on oral health and providing them to research participants. The material would cover flossing, tooth brushing, mouth washing, and avoiding sweets. As the researcher, one should also communicate on oral health and answer any questions residents may have. It would improve the participants’ oral health and help them maintain their oral health for longer.

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Appendix 1

SWOT analysis

Strengths	Weaknesses
Many seniors will take part in the oral health promotion program A significant portfolio of properties across different states	Privately owned properties might be subject to specific regulations High affluent neighborhoods less likely to attract poor seniors
Threats	Opportunities
Some seniors might decline to take part in the project Families might object or have to seek permission from doctors to allow some seniors to participate in the project	Resident focused culture among the staff will be ideal for implementing the oral health promotion program Availability of Wi-Fi services in the area

Appendix 2

The purpose of the research study “Oral Health Promotion to Improve the Quality of Life in Older Adults Living Independently” is to examine the relationship between oral health and quality of life. The general objectives of the study are to analyze the impact of an oral health education program on adult individuals who live independently; to determine the presence of tooth decay, plaque, or mouth diseases; to motivate people to take care of their oral health; and to assess the participant’ knowledge, attitudes, and behaviors related to oral health. Participation in this study is voluntary and if the participant does not feel comfortable with the questions or information and decide not to continue being part of the study, the participant can leave the project at any time, without any retaliation or penalty.

Next you will find 15 questions related to the topic in this study that will help us gather data regarding your oral health knowledge and overall oral health. In each question, please choose only one answer.

Oral health questionnaire

Sex: (Please choose one)

Male
Female
Refused to answer

How would you rate the health in your mouth?

Very good
Good
Fair
Poor

How important do you think the health of your mouth is? (Please choose one)

Very important
Somewhat important
Not important
Don’t know

Do you regularly visit a dentist for a check-up? (Please choose one)

Once a year or more often
Once every few years or when there is pain
No Visits

Do you know possible consequences of poor oral health? (Please choose one)

Yes
No
Don’t know

Do you wear dental prosthetics? (Please choose one)
- No
- Yes

Do you have toothaches? (Please choose one)

No aches at all
Yes

Do you have sensitive teeth, to cold or hot temperatures? (Please choose one)

No aches at all
Yes

Are there any cavities in your teeth that you are aware of? (Please choose one)

No cavities at all
1-2 cavities
Three cavities or more
Don’t know

Do you have a bad smell from your mouth? (Please choose one)

No
Yes
Don’t know

Do you eat sugary products frequently (Ex: candies, gum, sodas)? (Please choose one)

How many times during the day you brush your teeth? (Please choose one)

Twice a day or more
Once a day or less

Do your gums bleed when you wash your teeth? (Please choose one)

Always
Often
Occasionally
Never

Do you floss your teeth? (Please choose one)

Always
Often
Occasionally
Never

Do you use mouth wash? (Please choose one)

Always
Often
Occasionally
Never

Appendix 4

Project Schedule

Steps	Activity	Timeframe	Evaluation
Awareness	Update on the need for change	Week 1	Formative
Desire	Educate on the benefit of change	Week 1	Formative
Knowledge	Provide change-based knowledge	Week 2	Formative
Ability	Introducing activities involved in oral health directly	Week 3	Formative and summative
Reinforcement	Provide post-activity assessment and monitoring of individual oral health and hygiene	Week 4-5	Summative

Appendix 5

Budget

Activity	Amount	Budget
Health Kit (Oral care supplies like toothpaste, floss, mouth wash, and toothbrush)	50	$8-10 per participant
Educational material and tools (pens, paper, printed educational material)	50	$100
Transportation	1	$40
Audiovisual equipment	1	$75

Appendix 6

Project Evaluation Tool

Tool	Validity	Reliability
Interview	The interview is conducted on a one-to-one basis	All the participants were provided the same interview question