Developing a Meal Assistance and Oral Care Training Program for Caregivers in Indonesia

Developing a Meal Assistance and Oral Care Training Program for Caregivers in Indonesia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Developing a Meal Assistance and Oral Care Training Program for Caregivers in Indonesia Lisna Agustina, Susiana Nugraha, Misako Hiyashijima, Koichi Aramaki, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6442097/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 20 You are reading this latest preprint version Abstract Background: In 2023, Indonesia's older adult population reached 11.75%, marking its transition into an aged society, following a path similar to Japan’s, now a super-aged country. The physiological and anatomical effects of aging are widely observed among older adults, irrespective of nationality. Thus, Indonesian caregivers can benefit from Japan’s well-established long-term care system by training in Japanese caregiving methods. This study focuses on meal assistance and oral care, crucial areas for preventing aspiration pneumonia, a leading health risk in nursing homes. Despite the importance of preventing aspiration pneumonia, few studies have assessed caregiver training programs in this field. Therefore, the authors developed and evaluated a meal assistance and oral care training program tailored to Indonesia’s cultural and social context. Methods: A training module on aspiration pneumonia prevention was designed and assessed using a 26-question questionnaire covering meal assistance and oral care. The program was implemented as an intervention study with 39 participants from private and public nursing homes in Java Island. Pre- and post-test results were analyzed using paired t-tests to determine the training’s impact. Results: Participants showed significant improvement in knowledge scores, from a pre-test mean of 18.87 (SD: 1.81) to 20.59 (SD: 1.71) in the post-test (p < 0.001), particularly among participants without a nursing background. Conclusions: The training program improved participants’ understanding of aging-related conditions, including dementia and dysphagia. Regardless of educational background, participants acquired essential knowledge to provide safe, appropriate, and comfortable meal assistance and oral care to older adults in Indonesia. Older adults Oral care Caregivers Indonesia Japan Aspiration pneumonia prevention Background The global older adult population continues to increase, with Asia and the Pacific aging at an unprecedented rate, though the timing and pace vary across the region. In Indonesia, the percentage of older people population (aged ≥ 60 years) was 11.75% in 2023, an increase from 10.48% in the previous year [ 1 ], which aligns with a life expectancy increase (from 72 years in 2022 to 73 years in 2023). As life expectancy rises, the focus on preventing early senescence and promoting healthy aging to maintain quality of life has become essential [ 2 ]. This increase in the number of older adults has had complex consequences. The challenges posed by population aging encompass almost every aspect of life. Aging in humans is a complex process marked by time-dependent functional decline, often reducing quality of life [ 3 ]. Older adults represent a vulnerable group experiencing physiological decline due to regenerative and aging processes. Aging is a gradual, irreversible pathophysiological process that leads to declines in tissue and cell functions and significantly increases the risk of aging-related diseases, including neurodegenerative, cardiovascular, metabolic, musculoskeletal, and immune-related diseases [ 4 ]. Older adults also experience reduced physical activity and dietary changes due to decreased metabolism, impacting nutrient absorption. They are also prone to decreased appetite due to illness, swallowing disorders, reduced salivary gland production, and periodontal diseases, which affect chewing [ 5 ]. Poor oral health may further impair nutrient intake, leading to malnutrition, frailty, reduced interest in oral hygiene, and decreased physical health [ 6 ]. Pneumonia is a chronic disease in older adults associated with malnutrition. The relationship between malnutrition and lung diseases has long been recognized. Malnutrition adversely impacts lung structure, elasticity, function, respiratory muscle strength and endurance, pulmonary immune defense mechanisms, and breath regulation [ 7 ]. In residential care settings, malnutrition is frequently worsened by factors like tooth loss, reduced appetite, and increased dysphagia prevalence [ 8 ]. It also contributes to oral colonization issues, as do smoking, poor oral hygiene, and dry mouth—all factors relevant to the pathogenesis of aspiration pneumonia [ 9 ]. A previous study has termed pneumonia occurring in older adults in nursing homes as nursing home-acquired pneumonia (NHAP) [ 10 ]. NHAP is a leading cause of death among older adults in nursing homes [ 11 ]. Efforts to address professional oral health care and daily oral care can effectively decrease NHAP risk [ 12 ]; therefore, caregivers’ oral health and hygiene practices are essential to understanding the quality of oral health services provided to residents [ 13 ]. A previous study indicated that oral health among older adults in nursing homes is generally poor [ 14 ]. Poor oral health is common in this population, impairing essential activities of daily living and contributing to frailty [ 15 ]. Similarly, a study in Indonesia reported poor oral health among nursing home residents, showing that approximately 72–78% of older individuals had high rates of caries, fillings, extractions, and denture fabrication [ 16 ]. Routine oral health practices, such as brushing teeth, are expected to meet the standards set by the Ministry of Health [ 17 ]. Poor oral hygiene triggers bacterial proliferation in the oral cavity, leading to aspiration pneumonia. As poor oral health is prevalent among nursing home residents, healthcare professionals report numerous barriers to providing oral care to care-dependent older adults, including limited oral health knowledge and skills [ 18 ]. Only one-fifth of residents maintain good oral hygiene, largely due to caregivers' insufficient training in long-term care facilities. Additionally, residents often experience significant oral inflammatory diseases, which can negatively impact general health, particularly respiratory function. Therefore, oral care education for caregivers is crucial [ 19 ]. Addressing health issues among older adults is essential to prevent complications, such as dental caries, oral mucosa infections, and aspiration pneumonitis. Colonization of the oral cavity of older adults by microorganisms associated with respiratory infections is reduced in individuals receiving professional oral care compared to those without such care [ 20 ]. Therefore, caregivers must possess the necessary skills to provide long-term care. Proper care is key to improving the quality of life in older adults, especially in preventing aspiration pneumonia risk. Due to low levels of knowledge about the importance of oral care among caregivers in Indonesian nursing homes, providing meal assistance and oral care training for staff is essential to improve oral health in older adults, which influences overall health, as well as chewing and swallowing functions [ 21 ]. Care work is a vital profession today because of the high overall life expectancy and number of older adults who require care. For example, Japan introduced certified care workers in 2000, coinciding with the enactment of the Long-Term Care Act. These certified workers possess specialized skills and knowledge in holistic care for individuals with physical, mental, or intellectual disabilities that hinder independent living [ 22 ]. In Indonesia, the concept of workers engaged in care is not commonly understood as an occupational category requiring expertise. A caregiver or support worker is a paid or unpaid person who helps an individual perform activities of daily living. Caregivers in Indonesia normally come from families, social workers, or kader who may not have specific professional training and are often described as informal caregivers [ 23 – 24 ]. Caregivers who assist older adults in nursing homes are considered domestic workers who do not have adequate educational backgrounds or caregiver training. Researchers believe that providing appropriate training programs for caregivers is useful. This is particularly true in the case of Indonesia, which sends migrant care workers to Japan through initiatives such as the Economic Partnership Agreement (EPA), the Technical Internship Training Program, and the Specified Skilled Workers scheme. Many returnees from Japan have noted the high quality of care provided in Japan [ 25 ]. As Indonesia transitions into an aging society, developing strategies to meet the challenges of an aging population is crucial, particularly in improving caregiver education. Caring for older adults requires specialized skills and knowledge since they are prone to health problems, including impaired swallowing, due to degenerative conditions. Given these circumstances, caregiver education in Indonesia is necessary to ensure proper oral care and reduce the incidence of aspiration pneumonia. Training programs in meal assistance and oral care can enhance caregivers’ knowledge and skills in maintaining the oral hygiene of older adults. Methods Design and Participants This study employed an intervention design with a crossover research method. Participants were chosen from two types of nursing homes, government- and private-run, reflecting differences in regulations governing nursing homes in Indonesia. Government nursing homes provide free care funded by the government for poor and neglected older adults. Therefore, caregivers in these facilities receive lower salaries compared to those working in private nursing homes. Additionally, private nursing homes offer better facilities and cleaner environments. The caregiver-to-resident ratio also differs significantly between private and government nursing homes. The participants signed informed consent after reading and understanding the research explanation and research ethics to the ethical considerations based on to the Declaration of Helsinki and standards established by the Ministry of Health in Indonesia. The participants were divided into two groups: those working in private-run nursing homes (Group 1) and those working in government-run nursing homes (Group 2). Group 1 initially included two nurses, while Group 2 included one nurse. Each group began with 25 participants; however, 11 dropped out for not completing either the pre- or post-test. Consequently, 17 participants from Group 1 and 22 from Group 2 remained eligible for the study. Participants were selected based on the following criteria: willingness to participate, good health to minimize the COVID-19 infection risk, and the ability to read, write, and communicate effectively. The Indonesian Oral Care Module used in this study was developed by the authors adapted from a book [ 26 ], which consists nine topics: 1) the aging process, 2) anatomy and physiology of the digestive system, 3) effects of aging on swallowing, 4) swallowing problems, 5) examination and treatment of swallowing disorders, 6) proper positioning for feeding assistance, 7) provision of safe and appropriate feeding assistance, 8) introduction to utensils for eating and drinking activities for older adults, and 9) exercises to maintain swallowing function modified to suit the conditions in Indonesia [ 27 ]. The training program involved a pre- and post-test, with participants answering questions related to oral care for preventing aspiration pneumonia, based on the module’s contents. Training sessions were conducted over 2 days, totaling 16 hours of instruction. Questionnaire The effectiveness of the Meal Assistance Training was evaluated using a pre/post-test assessment questionnaire. The questionnaire consists of 26 questions, which was originally developed by the authors of this study, by referring to the previous study on developing check list for aspiration pneumonia prevision by the authors [ 28 ]. The questionnaire has not been published elsewhere. An English version of the questionnaire is attached as a supplementary file. The following are included in the questionnaire. General knowledge Questions about general functions and eating capabilities (four questions) Before meal period Assessment of the older adult’s condition before meals. Questions include changes in movement, poor condition/sleep deprivation, fever, coughing, and differences in blood pressure (higher or lower) and pulse (bradycardia, tachycardia) (four questions), Meal preparation period : Evaluates waiting time before the arrival and serving of food. Questions assess whether the older adult can sit stably, their consciousness level, and whether they appear calm (five questions). During eating period : The assessment focuses on bodily coordination and challenges during eating. It includes difficulties with setting up the dining table, using utensils (e.g., inability to hold or use a spoon), and maintaining attention to food and the environment. Other questions assess problems placing food into the mouth (e.g., hand tremors or food falling), issues with eating speed, and improper food quantities. The questionnaire also evaluates whether the older adult can ask for help when encountering difficulties or if they refuse assistance (e.g., refusing to open their mouth or feed themselves) (seven questions). Swallowing period : This section assesses challenges older adults face during swallowing. It examines difficulties in smooth food intake (e.g., lips do not close properly, or food falls from the mouth) and issues with chewing (e.g., insufficient chewing, avoidance of hard foods, preference for soft foods, or prolonged chewing). Questions also address problems with chewing food into suitable sizes for swallowing and hoarding food in the mouth (e.g., storing food without swallowing). Additionally, it evaluates swallowing difficulties (e.g., inability to swallow or delayed swallowing), signs of swallowing disorders (e.g., food not entering the esophagus or fluid sounds in the esophagus), and choking incidents. It further assesses whether the older adult exhibits coughing when choking, their overall eating time, signs of fatigue while eating, posture maintenance (e.g., persistent slumped posture), and whether they can complete a full portion of food (five questions), After meal period This section contains one question that evaluates whether caregivers clean the older adult’s mouth cavity after a meal to prevent food or foreign objects from entering the respiratory tract (one question). Assessment is conducted by awarding 1 point for correct answers and 0 points for incorrect ones. The total score ranges from 0 to 26 points. The training program was implemented in the DKI Jakarta, West Java, and Banten Province. Ethical Consideration This research adhered to the ethical considerations based on the Declaration of Helsinki and standards established by the Ministry of Health in Indonesia. An Ethical Review was obtained from Nagasaki University (no: 19111497, dated November 14, 2019) and Universitas Respati Indonesia No;153/KE/UNV/IX/2018. All participants signed informed consent forms indicating their agreement to participate in the study. Data Analysis The effectiveness of meal assistance and oral care training was evaluated by comparing pre- and post-test scores among caregivers in private- and government-run nursing homes. Within-group differences were analyzed using chi-square and paired t-tests, with statistical significance set at p < 0.05. Data were analyzed using IBM SPSS Statistics version 25. Results Table 1.1 Demographic Characteristics (n = 39) Variable Mean ± SD (range) n Percentage (%) Ages 36.5 ± 11.34 (21–64) Sex Female 26 66.7 Male 13 33.3 Education Non-College Degree 23 59.0 College Degree 16 41.0 Type of Nursing Home Public 20 51.3 Private 19 48.7 The participant’s average age was 36.5 years (SD, ± 11.34 SD; range, 21–64 years). Two-thirds of participants were female and 51% were engaged in care work in public nursing homes. Table 1.2 Test Result Distribution Test Mean SD Range Pre-test 18.87 ± 1.8 14–23 Post-test 20.59 ± 1.7 16–23 Score changes 1.72 ± 2.26 -2 to 7 The participants’ average knowledge regarding oral care before and after training was 18.87 (SD, 1.8) and 20.59 (SD, 1.7), respectively. Table 1.3 Independent Sample T-Test for Each Group Group Category Pre-test Post-test Changes Mean p-value Mean p-value Mean p-value Training Group Group 1 18.47 0.228 20.35 0.455 1.88 0.695 Group 2 19.18 20.77 1.59 Sex Female 18.92 0.806 20.88 0.130 1.96 0.348 Male 18.77 20.00 1.23 Education College Degree 18.56 0.380 21.00 0.217 2.44 0.098 Non-College Degree 19.09 20.30 1.22 Type of Nursing Home Private 19.10 0.426 20.55 0.884 1.45 0.455 Public 18.63 20.63 2.00 Table 1.3 shows no difference in study participant’s scores for the pre and post-tests and score changes between the pre- and post-test across training group categories, sex, education background, and nursing home type. Table 1.4 Paired Sample Pre- and Post-test by Group Group Knowledge Score Mean SD N Δ (diff) p-value All Pre-test 18.87 1.809 39 1.72 < 0.001 Post-test 20.59 1.712 Group 1 Pre-test 18.47 1.375 17 1.88 0.007 Post-test 20.35 1.656 Group 2 Pre-test 19.18 2.062 22 1.59 0.002 Post-test 20.77 1.771 Table 1.4 shows that participants’ mean score pre-test knowledge in all groups (39 participants) was 18.87 (SD, 1.809) which increased to 20.59 (SD, 1.712) post-test (p < 0.001). Tables 1.5 indicate the participants' scores for each question. Between the pre- and post-test, 10 of 26 questions were significantly different. Two questions (Questions 6 and 12) notably found a significant decrease. Table 1.5 Paired Sample Pre-test and Post-test by Each Question (All samples) No Item Pre-test score Correct answer rate(%) e Post-test score correct answer rate P value General knowledge R1 The movement of swallowing muscles is based only on conscious movement 12 30.77 20 51.28 0.066 2 Decreased visual function can impair eating ability 16 41.03 36 92.31 0.001 3 Most people have swallowing reflexes 32 82.05 38 97.44 0.025 R4 Decreased olfactory function due to aging will not have an impact on reducing salivary gland production 21 53.85 33 84.62 0.003 Before meal period 24 One of the goals of mouth and facial exercises is to maintain and increase the strength of the tongue, lips and cheeks muscles. 38 97.44 39 100 0.314 11 Proper position when providing feeding assistance can prevent aspiration 32 82.05 39 100 0.006 R13 The right position in providing feeding assistance to the older adults should have the neck upturned and leaning forward 12 30.77 28 71.79 0.001 25 Due to a decrease in finger and hand muscles, many older adults are unable to be independent and hold a spoon or chopsticks properly 38 97.44 38 97.44 1 Meal preparation period 10 Cutting food into smaller pieces will help prevent choking 37 94.87 39 100 0.152 R19 Spoon with a flat surface is suitable for patients with wrists movement difficulties 25 64.1 22 56.41 0.488 20 When choosing eating utensils, the most important thing to consider is its strength/durability, cleanliness, and safety when used 39 100 38 97.44 0.314 21 A good eating aid is one that can make it easier for the older adults to eat independently 38 97.44 39 100 0.314 R23 The right dining table is one that cannot be adjusted in height. 28 71.79 30 76.92 0.604 During meal period R12 When feeding people with severe dementia or dysphagia, it is better to provide feeding assistance from the patient's side 16 41.03 7 17.95 0.025 14 The readiness of the older adults to receive food can be seen when it is time to enter food, the mouth opens, and the tongue is on the back of the teeth 29 74.36 31 79.49 0.591 15 For older adults with dentures, if the dentures are not in place, the spoon must be positioned at the base of the rounded tongue 31 79.49 34 87.18 0.326 16 If the food to be given is in the form of porridge, do not put the whole spoon into the mouth; instead, place the spoon on the lower lip 31 79.49 34 87.18 0.326 17 The right time to pluck/remove the spoon is when the upper and lower lips are closing 29 74.36 28 71.79 0.799 18 Among older adults who are easily tired and have difficulty opening their mouths, it is better to use a small teaspoon/spoon 38 97.44 35 89.74 0.165 22 In older adults with impaired upper body muscle decline from the elbow to the forearm, it is best to use a supporter to stabilize the hand position. 34 87.18 39 100 0.021 Swallowing period 5 Eating in a flexed neck position will increase the choking risk 33 84.62 38 97.44 0.048 R6 Older adults with dysphagia (impaired swallowing) are not necessarily at risk of choking 35 89.74 27 69.23 0.025 7 Aspiration occurs because food/foreign objects enter the respiratory tract 35 89.74 39 100 0.004 R8 People who are choking without a cough reflex are at lower risk of aspiration than those with a cough 21 53.85 14 35.9 0.111 9 Choking occurs due to the inability to breathe caused by a blockage in the throat or airways 36 92.31 38 97.44 0.305 After Meal period 26 Clean up the mouth cavity after a meal can prevent the remaining food/foreign objects from entering the respiratory tract 37 94.87 39 100 0.152 R: Reverse Coding Discussion This is one of the first studies to demonstrate the efficacy of oral care training programs for caregivers in nursing homes in Indonesia. Previous research has focused on knowledge of risk factors in older adults and their prevention, orientation, and control of tasks to be performed, facilities and tools needed for care, and knowledge of first aid [ 29 ]. However, previous studies did not specifically focus on oral care and knowledge of the importance of oral care. Sociodemographic of the Study Participants Of the study participants, 67% were female. Regarding educational background, over half of the participants did not complete a bachelor's degree. In Indonesia, formal education models for caregivers, especially those in nursing homes, are still needed. The characteristics of the current study's participants align with previous research findings on caregivers: predominantly female with lower education [ 30 ] [ 31 ]. In Indonesia, caregivers are individuals who have completed specific education or training to assist those unable to care for themselves due to physical or mental limitations [ 31 ] [ 32 ]. Caregivers’ level of education may be a factor affecting their learning ability and understanding of the directions they receive from health workers, which can affect the quality of care provided to older adults [ 33 ]. No significant differences were found in pre- and post-test scores and score changes between the pre- and post-test among the training group participants, regardless of socio-demographic characteristics such as sex, education level, or nursing home type. This result is partly attributed to the cross-over design, which minimizes potential biases from socio-demographic backgrounds. Notable Differences Between Pre/Post Tests This study found notable differences in oral health awareness scores between pre- and post-training. Based on the results of the pre-test assessment in both groups, caregivers were found to have relatively low knowledge regarding oral care and swallowing function (mean score, 18.87; SD, 1.809). This may be due to the limited awareness of meal assistance and dental care, especially among older adults in Indonesia. Oral health and meal assistance for older adults tend to be poorly maintained and are often neglected by caregivers, even though oral health significantly impacts general health and quality of life, especially in older adults [ 34 ] [ 35 ]. Knowledge of oral care and dysphagia among caregivers in Indonesia remains limited despite the importance of oral care in preventing aspiration pneumonia. Previous research in Probolinggo Koloran Hamlet also reported insufficient dental health awareness and its importance for older adults [ 36 ]. Another study reported that the average Indonesian caregivers lack the understanding needed to properly feed older adults, prepare appropriate foods, and maintain correct posture to prevent aspiration. Often, caregivers simply place food in the mouth without considering anatomical and physiological aspects [ 37 ]. They may also overlook the remaining abilities of older adults, which are essential for maintaining independence and engaging in social and physical activities [ 38 ]. Regarding the understanding of physical conditions as well as the risks of dementia and dysphagia, the participants at the initial stage seemed to be less likely to understand them. This does not contradict the results of this study. First, the results indicate that only 41.03% answered correctly about "Decreased visual function can impair eating ability (question no. 2)", and "Decrease olfactory function due to aging will not have an impact on reducing salivary gland production" (question no. 4: 53.85%), and "The right position in providing feeding assistance to the older adults should have the neck upturned and leaning forward" (question no. 13:30.77%) at the pre-test stage. However, after training, the knowledge of these caregivers significantly increased, as shown in Table 1.4 , increasing by 1.88 in Group 1 and 1.59 in Group 2. This may be partly due to the participants’ educational backgrounds, as most did not have a nursing background. Nurses are typically educated on swallowing function, such as the nervous system's role and connections between visual impairment and swallowing. Given these conditions, caregivers who obtain physiological and anatomical knowledge, as nurses do, are eligible to provide safe, appropriate, and comfortable meal assistance and oral care to older adults. For instance, explaining to visually impaired older adults that presenting the menu clockwise may stimulate salivary gland production and increase appetite [ 39 ]. Position Regarding the importance of maintaining a good position before and during eating, a significant increase was observed, as shown in questions 5, 11, and 13. In nursing homes in Indonesia, less attention is given to proper positioning during meals than in Japan, likely due to the relatively high activities of daily living among older adults in Indonesia compared to Japan. Therefore, caregivers may be less attentive to the positioning of older adults during meals. However, after attending the training, participants understood that older adults’ bodies should remain upright, their necks straight, and caregivers should be positioned beside or facing them, adjusted based on their needs, to facilitate swallowing. For older adults with weakened upper body muscles, particularly from the elbow to forearm, caregivers must help position their hands on the table and adjust their necks to an upright position to reduce the risk of choking and aspiration. Applying the proper trunk position has been shown to shorten oral and pharyngeal transit times in older adults with dysphagia in clinical settings [ 40 ]. This suggests that aspiration pneumonia can be prevented through interventions focusing on maintaining good posture. Therefore, maintaining good posture is suggested for stress management in nursing homes in Indonesia. Adverse Effects Notably, some questions revealed adverse effects after training. Regarding caregivers’ feeding positions relative to older adults (Assessed by Question 12), 16 participants (41.3%) answered correctly in the pre-test, but this decreased to seven (17.95%) post-test. Effective dysphagia management is crucial, especially for older adults recovering from a stroke or undergoing treatment for dementia. In such cases, caregivers must feed people with dementia or stroke sideways. In addition, Japanese people have a culture of not sitting facing each other because if their eyes meet, they will feel nervous, so Japanese people help them eat from the side. Therefore, in Japan, when care workers assist older adults in the dining room, they sit beside or diagonally to the older adult at eye level while supporting them so that they can observe the older adults and check that they are swallowing food appropriately [ 41 ]. The module was developed based on Japanese clinical practices, strongly reflecting these cultural aspects. Rather than positioning themselves directly in front, caregivers are shown sitting beside the patient’s unaffected side, placing food on the patient’s tongue, as described in relevant texts [ 26 ]. The authors believe participants’ lack of critical thinking regarding caregivers' positioning contributed to their confusion. Therefore, incorporating critical thinking methods into the module is recommended. Another adverse effect of the intervention study was found in question 6, "Older adults with dysphagia are not at risk for choking" ( tersedak ). Before the training, 35 participants (89.74%) answered the question correctly; however, after the training, it decreased to 27 (69.23%). In analyzing this, the authors of the current studies noticed the wording of the Indonesian language term " tersedak ," which can be translatable in choking, aspiration, or dysphagia. We assumed that before participating in the training program, the participants thought that choking and aspiration were the same. After the training, participants understood that choking is a condition where there is a foreign object blockage in the respiratory tract, namely the pharynx, hypopharynx, and trachea; the blockage can be total if all holes in the respiratory tract are closed [ 42 ], while aspiration occurs when something you swallow "goes the wrong way" and enters the respiratory tract (trachea or throat) or lungs. Aspiration: Unlike choking, the respiratory tract is not completely blocked. Hence, participants assume that individuals with strokes are prone to conditions like dysphagia, leading them to avoid hard foods to prevent choking. Further research is needed to accurately explain the anatomical and psychological characteristics of swallowing function among Indonesians. Limitation This study had some limitations. First, the nursing background of study participants was not investigated. Nursing education provides foundational knowledge in the anatomical and physiological aspects of meal assistance, making this information important for data analysis. Second, further studies must be implemented when the researchers introduce simulations during the training program [ 43 ] to mimic real clinical conditions better. Third, the researchers could not analyze the participants who dropped out during the implementation of the training program. Therefore, further investigation should explore reasons for dropouts and how to prevent participants from dropping out. Conclusion This study suggested that the meal assistance and oral care training program may offer benefits for caregivers in Indonesia, regardless of their educational background, sex, or the type of nursing home where they work. These were indicated by the significant increase in knowledge regarding the physical and anatomical aspects of aspiration prevention of this study. Yet further refinement of the module may enhance trainees' critical thinking skills in providing care for older adults. Abbreviations NHAP Nursing Home Acquired Pneumonia, EPA:Economic Partnership Agreement SD Standard deviation. Declarations Acknowledgements We thank the private and government nursing homes that have collaborated in providing respondents for this research. Authors’ contributions AL drafted the manuscript; NS conducted the analysis; HM, NS, AL, and HY developed the questionnaire and conducted the survey; and HM, NS, HY and AK provided advice to HY. All authors read and approved the final manuscript. Funding This research was supported by the Economic Research Institute for ASEAN and East Asia. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the ongoing study conditions but are available from the corresponding author on reasonable request. Ethics approval and consent to participate Nagasaki University (no: 19111497, dated November 14, 2019) and Universitas Respati IIndonesiaNo;153/KE/UNV/IX/2018 Consent for publication Not applicable. Competing interests That they have no competing interests. The author details Yuko O. 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Ministry of Health of the Republic of Indonesia. Pentingnya Kesehatan Gigi dan Mulut pada Lansia (The importance of dental and oral health in the older people). [Internet]. 2023. Available from: https://ayosehat.kemkes.go.id/pentingnya-kesehatan-gigi-dan-mulut-pada-lansia . Accessed 14 Oct 2024. Melbye EL, Bull VH, Hidle KS. Assessment of the smart journal intervention for improved oral care in nursing homes: protocol for a cluster randomized controlled trial. JMIR Res Protoc. 2023;12:e46926. 10.2196/46926 . Saarela RKT, Hiltunen K, Kautiainen H, Roitto HM, Mantyla P, Pitkala KH. Oral hygiene and health-related quality of life in institutionalized older people. Eur Geriatr Med. 2022;13:213–20. 10.1007/s41999-021-00547-8 . Khadka S, Khan S, King A, Goldberg LR, Crocombe L, Bettiol S. Poor oral hygiene, oral microorganisms and aspiration pneumonia risk in older people in residential aged care: a systematic review. Age Ageing. 2021;50:81–7. 10.1093/ageing/afaa102 . Ildarabadi EH, Armat MR, Motamedosanaye V, Ghanei F. Effect of oral health care program on oral health status of older people living in nursing homes: a quasi-experimental study. Mater Sociomed. 2017;29:263–7. 10.5455/msm.2017.29.263-267 . Japanese Law Translation: Certified social worker and certified care worker act, Tokyo [Internet]. 1987. Available from: https://www.japaneselawtranslation.go.jp/en/laws/view/3813 . Accessed 15 Oct 2024. Hirano YO, Komazawa O. Agents of care technology transfer trends and challenges of migration care workers across borders [Internet]. 2022. Available from: https://www.eria.org/research/agents-of-care-technology-transfer-trends-and-challenges-of-migration-care-workers-across-borders . Accessed 14 Oct 2024. Ministry of Health of the Republic of Indonesia. Panduan praktis untuk caregiver dalam perawatan jangka panjang bagi lansia (Practical guideline for caregiver in long term care for older people). Jakarta: Kemenkes; 2019. Hirano YO, Yoneno-Reyes M, Hiruma Y, Nugraha S. In: Hirano YO, Yoneno-Reyes M, editors. Foreign nurses working in Japan: assessments of the EPA program. Tokyo: University of Tokyo; 2021. pp. 217–37. Higashijima M, Watanabe N. Kyo-kara dekiru koreisya no goenshei haien yobo. (Aspiration pneumonia prevention from today). Tokyo: Ishiyaku; 2018. Higashijima M, Watanabe N, (Translated by, Nugraha S, Augutina L, editors.). Cegah pnemonia aspirasi pada lansia mulai hari ini (Aspiration pneumonia prevention from today). Jakarta: PT Elex Media Komputindo; 2024. Hirano YO, Nugraha S, Shiozu H, Higashijima M, Rahardjo TBW. Measuring attentiveness toward oral care needs: a comparative study of Indonesian care workers in Japan and Indonesia. Hum Resour Health. 2021;19:71. 10.1186/s12960-021-00614-y . Mena-Napoles E, Mena-La Rosa M, Vega-Fiol M, Córdova-Urgellés W, Pérez-Veriel S. Educative intervention for training elderly caregivers. Revista Información Científica. 2022;101(2):1–9. Sharma N, Chakrabarti S, Grover S. Gender differences in caregiving among family - caregivers of people with mental illnesses. World J Psychiatry. 2016;6:7–17. 10.5498/wjp.v6.i1.7 . Swinkels J, Tilburg TV, Verbakel E, Broese VGM. Explaining the gender gap in the caregiving burden of partner caregivers. J Gerontol B Psychol Sci Soc Sci. 2019;74:309–17. 10.1093/geronb/gbx036 . Mulyono S, Rekawati E, Rachmawati U. Pedoman Pendamping Lansia (Older people companion guidebook). Indonesia University Publishing; 2023. p.12 ISBN: 978-623-333-565-2. Aires M, Fuhrmann AC, Mocellin D, Pizzol F, Sponchiado LF, Marchezan CR, et al. Burden of informal caregivers of dependent elderlies in the community in small cities. Rev Gaucha Enferm. 2020;21:e201901. 10.1590/1983-1447.2020.20190156 . Imania A, Mulyanti S, Insanuddin I. Gambaran kondisi kesehatan gigi dan mulut pada lansia di bererapa kota Indonesia (Description of dental and oral health condition of older people in several cities of Indonesia). Jurnal Kesehatan Siliwangi [Internet]. 2020. Available from: https://www.jks.juriskes.com/index.php/jks/article/view/1698 . Accessed 15 Oct 2024. Nurfauziah H. Pelatihan kesehatan gigi dan mulut di Indonesia ramah lansia provinsi Jawa Barat Husnul Khatimah 2 wilayah cilodong depok (Dental and oral health training in nursing homes in Jawa Barat Husnul Khatimah 2 wilayah cilodong depok). Jurnal JUARA. 2023;1:22–9. Baitia M, Isnanto HS. Karakteristik dan penegtahuan lansia tentang kesehatan gigi dan mulut di dusun Koloran Kabupaten Probolinggo (Characteristics and knowledge of older people about dental and oral heatlh in Koloran Kabupaten Probolinggo). IJOHM. 2021;1:224–30. Nugraha S, Hirano YO. Developing an oral care checklist. In Hirano YO, Komazawa O. Agents of care technology transfer: trends and challenges of migration care workers across borders [Internet]. 2022. Available from: https://www.eria.org/publications/agents-of-care-technology-transfer-trends-and-challenges-of-migration-care-workers-across-borders . Accessed 14 Oct 2024. Kusumawaty J, Supriadi D, Sukmawati I, Nurapandi A. Dukungan keluarga bagi kemandirian lansia (Family support for the independence of the older people). Jurnal Keperawatan Silampari. 2023;6. 10.31539/jks.v6i2.5708 . Nin K. Keitoh kangogaku kouza senmonbunya I (Systematic nursing course specialty field Ⅰ). Tokyo: Igakushoin; 2013. Higashijima ༭. Influence of age and bolus size on swallowing function: basic data and assessment method for care and preventive rehabilitation. Am J Occup Ther. 2010;64:88–94. 10.5014/ajot.64.1.88 . Nugraha S, Agustina L. Pedoman oral care untuk pencegahan aspirasi pneumonia pada lansia (Oral care guideline for prevention of aspiration pneumonia amongst older people). Jakarta: Pena Persada; 2022. Humaera TY. Bagaimana pencegahan dan tatalaksana choking/tersedak? (Who prevent and treat choking?) [Internet]. 2022. Available from: https://rsa.ugm.ac.id/2022/06/bagaimana-pencegahan-dan-tatalaksana-choking-tersedak/ (2022). Accessed 14 Oct 2024. Nakazawa A, Iwamoto M, Kurazume R, Nunoi M, Kobayashi M, Honda M. Augmented reality-based affective training for improving care communication skill and empathy. PLoS ONE. 2023;18:e0288175. 10.1371/journal.pone.0288175 . Additional Declarations No competing interests reported. Supplementary Files MealAssistanceQuestionnairefinal.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 Mar, 2026 Reviews received at journal 28 Aug, 2025 Reviews received at journal 25 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviews received at journal 18 Aug, 2025 Reviewers agreed at journal 16 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 15 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers agreed at journal 12 Aug, 2025 Reviews received at journal 31 Jul, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers agreed at journal 30 Jul, 2025 Reviewers invited by journal 30 Jul, 2025 Editor invited by journal 27 Jun, 2025 Editor assigned by journal 19 Jun, 2025 Submission checks completed at journal 15 Jun, 2025 First submitted to journal 15 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Hirano","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYBACA2YwZQPlHpCAMngIakkjRQuEOgzTQoTDzNl5H34uqDifx9+/+PGHH2csGAwOMD/8wCBzB6cWy2Z2Y+kZZ24XS9x4ZibZc0MCqIXNWIKB5xluhx1mY5Dmbbud2HDjgBkDzweJ+g0HGMyAfjmMTwvzb962c4nzbxz//PHPB5At7N8IaWED2nIgccP5HgNpHrDDeAjawmbNcyY5ceMNnjJpmTMSDJKHeYolEvD55fwx5ts8FXaJ884f3/zxzbE6Br7j7Rs/fOzBHWIIIJEAZYAiN7HnABFa+FEU/SBGyygYBaNgFIwQAADyA1W09WcaeAAAAABJRU5ErkJggg==","orcid":"","institution":"Nagasaki University","correspondingAuthor":true,"prefix":"","firstName":"Yuko","middleName":"O.","lastName":"Hirano","suffix":""}],"badges":[],"createdAt":"2025-04-14 03:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6442097/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6442097/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88260854,"identity":"fd1ef0c7-eaae-4978-9437-dd265466a051","added_by":"auto","created_at":"2025-08-04 15:21:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1155381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6442097/v1/ddbf401d-a4cd-4c99-8d4e-1ed4cc3fd042.pdf"},{"id":88258782,"identity":"36017c39-17e3-40a4-a713-6f3c512d2950","added_by":"auto","created_at":"2025-08-04 14:57:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":74166,"visible":true,"origin":"","legend":"","description":"","filename":"MealAssistanceQuestionnairefinal.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6442097/v1/31656922881cdcf667fb330e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Developing a Meal Assistance and Oral Care Training Program for Caregivers in Indonesia","fulltext":[{"header":"Background","content":"\u003cp\u003eThe global older adult population continues to increase, with Asia and the Pacific aging at an unprecedented rate, though the timing and pace vary across the region. In Indonesia, the percentage of older people population (aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years) was 11.75% in 2023, an increase from 10.48% in the previous year [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], which aligns with a life expectancy increase (from 72 years in 2022 to 73 years in 2023).\u003c/p\u003e\u003cp\u003eAs life expectancy rises, the focus on preventing early senescence and promoting healthy aging to maintain quality of life has become essential [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This increase in the number of older adults has had complex consequences. The challenges posed by population aging encompass almost every aspect of life. Aging in humans is a complex process marked by time-dependent functional decline, often reducing quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOlder adults represent a vulnerable group experiencing physiological decline due to regenerative and aging processes. Aging is a gradual, irreversible pathophysiological process that leads to declines in tissue and cell functions and significantly increases the risk of aging-related diseases, including neurodegenerative, cardiovascular, metabolic, musculoskeletal, and immune-related diseases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Older adults also experience reduced physical activity and dietary changes due to decreased metabolism, impacting nutrient absorption. They are also prone to decreased appetite due to illness, swallowing disorders, reduced salivary gland production, and periodontal diseases, which affect chewing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Poor oral health may further impair nutrient intake, leading to malnutrition, frailty, reduced interest in oral hygiene, and decreased physical health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePneumonia is a chronic disease in older adults associated with malnutrition. The relationship between malnutrition and lung diseases has long been recognized. Malnutrition adversely impacts lung structure, elasticity, function, respiratory muscle strength and endurance, pulmonary immune defense mechanisms, and breath regulation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In residential care settings, malnutrition is frequently worsened by factors like tooth loss, reduced appetite, and increased dysphagia prevalence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It also contributes to oral colonization issues, as do smoking, poor oral hygiene, and dry mouth\u0026mdash;all factors relevant to the pathogenesis of aspiration pneumonia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A previous study has termed pneumonia occurring in older adults in nursing homes as nursing home-acquired pneumonia (NHAP) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. NHAP is a leading cause of death among older adults in nursing homes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Efforts to address professional oral health care and daily oral care can effectively decrease NHAP risk [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; therefore, caregivers\u0026rsquo; oral health and hygiene practices are essential to understanding the quality of oral health services provided to residents [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA previous study indicated that oral health among older adults in nursing homes is generally poor [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Poor oral health is common in this population, impairing essential activities of daily living and contributing to frailty [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, a study in Indonesia reported poor oral health among nursing home residents, showing that approximately 72\u0026ndash;78% of older individuals had high rates of caries, fillings, extractions, and denture fabrication [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Routine oral health practices, such as brushing teeth, are expected to meet the standards set by the Ministry of Health [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Poor oral hygiene triggers bacterial proliferation in the oral cavity, leading to aspiration pneumonia.\u003c/p\u003e\u003cp\u003eAs poor oral health is prevalent among nursing home residents, healthcare professionals report numerous barriers to providing oral care to care-dependent older adults, including limited oral health knowledge and skills [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Only one-fifth of residents maintain good oral hygiene, largely due to caregivers' insufficient training in long-term care facilities. Additionally, residents often experience significant oral inflammatory diseases, which can negatively impact general health, particularly respiratory function. Therefore, oral care education for caregivers is crucial [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Addressing health issues among older adults is essential to prevent complications, such as dental caries, oral mucosa infections, and aspiration pneumonitis. Colonization of the oral cavity of older adults by microorganisms associated with respiratory infections is reduced in individuals receiving professional oral care compared to those without such care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, caregivers must possess the necessary skills to provide long-term care. Proper care is key to improving the quality of life in older adults, especially in preventing aspiration pneumonia risk.\u003c/p\u003e\u003cp\u003eDue to low levels of knowledge about the importance of oral care among caregivers in Indonesian nursing homes, providing meal assistance and oral care training for staff is essential to improve oral health in older adults, which influences overall health, as well as chewing and swallowing functions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Care work is a vital profession today because of the high overall life expectancy and number of older adults who require care. For example, Japan introduced certified care workers in 2000, coinciding with the enactment of the Long-Term Care Act. These certified workers possess specialized skills and knowledge in holistic care for individuals with physical, mental, or intellectual disabilities that hinder independent living [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In Indonesia, the concept of workers engaged in care is not commonly understood as an occupational category requiring expertise. A caregiver or support worker is a paid or unpaid person who helps an individual perform activities of daily living. Caregivers in Indonesia normally come from families, social workers, or \u003cem\u003ekader\u003c/em\u003e who may not have specific professional training and are often described as informal caregivers [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Caregivers who assist older adults in nursing homes are considered domestic workers who do not have adequate educational backgrounds or caregiver training.\u003c/p\u003e\u003cp\u003eResearchers believe that providing appropriate training programs for caregivers is useful. This is particularly true in the case of Indonesia, which sends migrant care workers to Japan through initiatives such as the Economic Partnership Agreement (EPA), the Technical Internship Training Program, and the Specified Skilled Workers scheme. Many returnees from Japan have noted the high quality of care provided in Japan [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As Indonesia transitions into an aging society, developing strategies to meet the challenges of an aging population is crucial, particularly in improving caregiver education.\u003c/p\u003e\u003cp\u003eCaring for older adults requires specialized skills and knowledge since they are prone to health problems, including impaired swallowing, due to degenerative conditions. Given these circumstances, caregiver education in Indonesia is necessary to ensure proper oral care and reduce the incidence of aspiration pneumonia. Training programs in meal assistance and oral care can enhance caregivers\u0026rsquo; knowledge and skills in maintaining the oral hygiene of older adults.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign and Participants\u003c/h2\u003e\u003cp\u003eThis study employed an intervention design with a crossover research method. Participants were chosen from two types of nursing homes, government- and private-run, reflecting differences in regulations governing nursing homes in Indonesia. Government nursing homes provide free care funded by the government for poor and neglected older adults. Therefore, caregivers in these facilities receive lower salaries compared to those working in private nursing homes. Additionally, private nursing homes offer better facilities and cleaner environments. The caregiver-to-resident ratio also differs significantly between private and government nursing homes.\u003c/p\u003e\u003cp\u003e The participants signed informed consent after reading and understanding the research explanation and research ethics to the ethical considerations based on to the Declaration of Helsinki and standards established by the Ministry of Health in Indonesia. The participants were divided into two groups: those working in private-run nursing homes (Group 1) and those working in government-run nursing homes (Group 2). Group 1 initially included two nurses, while Group 2 included one nurse. Each group began with 25 participants; however, 11 dropped out for not completing either the pre- or post-test. Consequently, 17 participants from Group 1 and 22 from Group 2 remained eligible for the study. Participants were selected based on the following criteria: willingness to participate, good health to minimize the COVID-19 infection risk, and the ability to read, write, and communicate effectively.\u003c/p\u003e\u003cp\u003eThe Indonesian Oral Care Module used in this study was developed by the authors adapted from a book [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], which consists nine topics: 1) the aging process, 2) anatomy and physiology of the digestive system, 3) effects of aging on swallowing, 4) swallowing problems, 5) examination and treatment of swallowing disorders, 6) proper positioning for feeding assistance, 7) provision of safe and appropriate feeding assistance, 8) introduction to utensils for eating and drinking activities for older adults, and 9) exercises to maintain swallowing function modified to suit the conditions in Indonesia [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The training program involved a pre- and post-test, with participants answering questions related to oral care for preventing aspiration pneumonia, based on the module\u0026rsquo;s contents. Training sessions were conducted over 2 days, totaling 16 hours of instruction.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQuestionnaire\u003c/h3\u003e\n\u003cp\u003eThe effectiveness of the Meal Assistance Training was evaluated using a pre/post-test assessment questionnaire. The questionnaire consists of 26 questions, which was originally developed by the authors of this study, by referring to the previous study on developing check list for aspiration pneumonia prevision by the authors [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The questionnaire has not been published elsewhere. An English version of the questionnaire is attached as a supplementary file. The following are included in the questionnaire.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eGeneral knowledge\u003c/strong\u003e\u003cp\u003eQuestions about general functions and eating capabilities (four questions)\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eBefore meal period\u003c/strong\u003e\u003cp\u003eAssessment of the older adult\u0026rsquo;s condition before meals. Questions include changes in movement, poor condition/sleep deprivation, fever, coughing, and differences in blood pressure (higher or lower) and pulse (bradycardia, tachycardia) (four questions),\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeal preparation period\u003c/b\u003e: Evaluates waiting time before the arrival and serving of food. Questions assess whether the older adult can sit stably, their consciousness level, and whether they appear calm (five questions).\u003c/p\u003e\u003cp\u003e\u003cb\u003eDuring eating period\u003c/b\u003e: The assessment focuses on bodily coordination and challenges during eating. It includes difficulties with setting up the dining table, using utensils (e.g., inability to hold or use a spoon), and maintaining attention to food and the environment. Other questions assess problems placing food into the mouth (e.g., hand tremors or food falling), issues with eating speed, and improper food quantities. The questionnaire also evaluates whether the older adult can ask for help when encountering difficulties or if they refuse assistance (e.g., refusing to open their mouth or feed themselves) (seven questions).\u003c/p\u003e\u003cp\u003e\u003cb\u003eSwallowing period\u003c/b\u003e: This section assesses challenges older adults face during swallowing. It examines difficulties in smooth food intake (e.g., lips do not close properly, or food falls from the mouth) and issues with chewing (e.g., insufficient chewing, avoidance of hard foods, preference for soft foods, or prolonged chewing). Questions also address problems with chewing food into suitable sizes for swallowing and hoarding food in the mouth (e.g., storing food without swallowing). Additionally, it evaluates swallowing difficulties (e.g., inability to swallow or delayed swallowing), signs of swallowing disorders (e.g., food not entering the esophagus or fluid sounds in the esophagus), and choking incidents. It further assesses whether the older adult exhibits coughing when choking, their overall eating time, signs of fatigue while eating, posture maintenance (e.g., persistent slumped posture), and whether they can complete a full portion of food (five questions),\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAfter meal period\u003c/strong\u003e\u003cp\u003eThis section contains one question that evaluates whether caregivers clean the older adult\u0026rsquo;s mouth cavity after a meal to prevent food or foreign objects from entering the respiratory tract (one question).\u003c/p\u003e\u003c/p\u003e\u003cp\u003eAssessment is conducted by awarding 1 point for correct answers and 0 points for incorrect ones. The total score ranges from 0 to 26 points.\u003c/p\u003e\u003cp\u003eThe training program was implemented in the DKI Jakarta, West Java, and Banten Province.\u003c/p\u003e\n\u003ch3\u003eEthical Consideration\u003c/h3\u003e\n\u003cp\u003e This research adhered to the ethical considerations based on the Declaration of Helsinki and standards established by the Ministry of Health in Indonesia. An Ethical Review was obtained from Nagasaki University (no: 19111497, dated November 14, 2019) and Universitas Respati Indonesia No;153/KE/UNV/IX/2018. All participants signed informed consent forms indicating their agreement to participate in the study.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe effectiveness of meal assistance and oral care training was evaluated by comparing pre- and post-test scores among caregivers in private- and government-run nursing homes. Within-group differences were analyzed using chi-square and paired t-tests, with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Data were analyzed using IBM SPSS Statistics version 25.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1.1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic Characteristics (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.34 (21\u0026ndash;64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-College Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Nursing Home\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eThe participant\u0026rsquo;s average age was 36.5 years (SD, \u0026plusmn;\u0026thinsp;11.34 SD; range, 21\u0026ndash;64 years). Two-thirds of participants were female and 51% were engaged in care work in public nursing homes.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1.2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTest Result Distribution\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u0026ndash;23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u0026ndash;23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScore changes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-2 to 7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe participants\u0026rsquo; average knowledge regarding oral care before and after training was 18.87 (SD, 1.8) and 20.59 (SD, 1.7), respectively.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1.3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIndependent Sample T-Test for Each Group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup Category\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePost-test\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eChanges\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTraining Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.228\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.455\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.695\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGroup 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.348\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.217\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.098\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-College Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Nursing Home\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.884\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.455\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1.3\u003c/span\u003e shows no difference in study participant\u0026rsquo;s scores for the pre and post-tests and score changes between the pre- and post-test across training group categories, sex, education background, and nursing home type.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1.4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePaired Sample Pre- and Post-test by Group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eKnowledge Score\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026Delta; (diff)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.809\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.375\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.656\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" rowspan=\"2\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.771\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1.4\u003c/span\u003e shows that participants\u0026rsquo; mean score pre-test knowledge in all groups (39 participants) was 18.87 (SD, 1.809) which increased to 20.59 (SD, 1.712) post-test (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003eTables 1.5 indicate the participants\u0026apos; scores for each question. Between the pre- and post-test, 10 of 26 questions were significantly different. Two questions (Questions 6 and 12) notably found a significant decrease.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1.5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePaired Sample Pre-test and Post-test by Each Question (All samples)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePre-test score\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCorrect answer rate(%) e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePost-test score\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ecorrect answer rate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGeneral knowledge\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe movement of swallowing muscles is based only on conscious movement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDecreased visual function can impair eating ability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMost people have swallowing reflexes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDecreased olfactory function due to aging will not have an impact on reducing salivary gland production\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore meal period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOne of the goals of mouth and facial exercises is to maintain and increase the strength of the tongue, lips and cheeks muscles.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eProper position when providing feeding assistance can prevent aspiration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe right position in providing feeding assistance to the older adults should have the neck upturned and leaning forward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDue to a decrease in finger and hand muscles, many older adults are unable to be independent and hold a spoon or chopsticks properly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeal preparation period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eCutting food into smaller pieces will help prevent choking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSpoon with a flat surface is suitable for patients with wrists movement difficulties\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.488\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWhen choosing eating utensils, the most important thing to consider is its strength/durability, cleanliness, and safety when used\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eA good eating aid is one that can make it easier for the older adults to eat independently\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe right dining table is one that cannot be adjusted in height.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuring meal period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eWhen feeding people with severe dementia or dysphagia, it is better to provide feeding assistance from the patient\u0026apos;s side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe readiness of the older adults to receive food can be seen when it is time to enter food, the mouth opens, and the tongue is on the back of the teeth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFor older adults with dentures, if the dentures are not in place, the spoon must be positioned at the base of the rounded tongue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIf the food to be given is in the form of porridge, do not put the whole spoon into the mouth; instead, place the spoon on the lower lip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eThe right time to pluck/remove the spoon is when the upper and lower lips are closing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.799\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAmong older adults who are easily tired and have difficulty opening their mouths, it is better to use a\u0026nbsp;small teaspoon/spoon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eIn older adults with impaired upper body muscle decline from the elbow to the forearm, it is best to use a supporter to stabilize the hand position.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eSwallowing period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eEating in a flexed neck position will increase the choking risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e84.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOlder adults with dysphagia (impaired swallowing) are not necessarily at risk of choking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eAspiration occurs because food/foreign objects enter the respiratory tract\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eR8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePeople who are choking without a cough reflex are at lower risk of aspiration than those with a cough\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eChoking occurs due to the inability to breathe caused by a blockage in the throat or airways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e97.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter Meal period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eClean up the mouth cavity after a\u0026nbsp;meal can prevent the remaining food/foreign objects from entering the respiratory tract\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eR: Reverse Coding\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is one of the first studies to demonstrate the efficacy of oral care training programs for caregivers in nursing homes in Indonesia. Previous research has focused on knowledge of risk factors in older adults and their prevention, orientation, and control of tasks to be performed, facilities and tools needed for care, and knowledge of first aid [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, previous studies did not specifically focus on oral care and knowledge of the importance of oral care.\u003c/p\u003e\n\u003ch3\u003eSociodemographic of the Study Participants\u003c/h3\u003e\n\u003cp\u003eOf the study participants, 67% were female. Regarding educational background, over half of the participants did not complete a bachelor's degree. In Indonesia, formal education models for caregivers, especially those in nursing homes, are still needed. The characteristics of the current study's participants align with previous research findings on caregivers: predominantly female with lower education [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In Indonesia, caregivers are individuals who have completed specific education or training to assist those unable to care for themselves due to physical or mental limitations [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Caregivers\u0026rsquo; level of education may be a factor affecting their learning ability and understanding of the directions they receive from health workers, which can affect the quality of care provided to older adults [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNo significant differences were found in pre- and post-test scores and score changes between the pre- and post-test among the training group participants, regardless of socio-demographic characteristics such as sex, education level, or nursing home type. This result is partly attributed to the cross-over design, which minimizes potential biases from socio-demographic backgrounds.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eNotable Differences Between Pre/Post Tests\u003c/h2\u003e\u003cp\u003eThis study found notable differences in oral health awareness scores between pre- and post-training. Based on the results of the pre-test assessment in both groups, caregivers were found to have relatively low knowledge regarding oral care and swallowing function (mean score, 18.87; SD, 1.809). This may be due to the limited awareness of meal assistance and dental care, especially among older adults in Indonesia. Oral health and meal assistance for older adults tend to be poorly maintained and are often neglected by caregivers, even though oral health significantly impacts general health and quality of life, especially in older adults [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eKnowledge of oral care and dysphagia among caregivers in Indonesia remains limited despite the importance of oral care in preventing aspiration pneumonia. Previous research in Probolinggo Koloran Hamlet also reported insufficient dental health awareness and its importance for older adults [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Another study reported that the average Indonesian caregivers lack the understanding needed to properly feed older adults, prepare appropriate foods, and maintain correct posture to prevent aspiration. Often, caregivers simply place food in the mouth without considering anatomical and physiological aspects [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. They may also overlook the remaining abilities of older adults, which are essential for maintaining independence and engaging in social and physical activities [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding the understanding of physical conditions as well as the risks of dementia and dysphagia, the participants at the initial stage seemed to be less likely to understand them. This does not contradict the results of this study. First, the results indicate that only 41.03% answered correctly about \"Decreased visual function can impair eating ability (question no. 2)\", and \"Decrease olfactory function due to aging will not have an impact on reducing salivary gland production\" (question no. 4: 53.85%), and \"The right position in providing feeding assistance to the older adults should have the neck upturned and leaning forward\" (question no. 13:30.77%) at the pre-test stage.\u003c/p\u003e\u003cp\u003eHowever, after training, the knowledge of these caregivers significantly increased, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e1.4\u003c/span\u003e, increasing by 1.88 in Group 1 and 1.59 in Group 2. This may be partly due to the participants\u0026rsquo; educational backgrounds, as most did not have a nursing background. Nurses are typically educated on swallowing function, such as the nervous system's role and connections between visual impairment and swallowing. Given these conditions, caregivers who obtain physiological and anatomical knowledge, as nurses do, are eligible to provide safe, appropriate, and comfortable meal assistance and oral care to older adults. For instance, explaining to visually impaired older adults that presenting the menu clockwise may stimulate salivary gland production and increase appetite [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePosition\u003c/h2\u003e\u003cp\u003eRegarding the importance of maintaining a good position before and during eating, a significant increase was observed, as shown in questions 5, 11, and 13. In nursing homes in Indonesia, less attention is given to proper positioning during meals than in Japan, likely due to the relatively high activities of daily living among older adults in Indonesia compared to Japan. Therefore, caregivers may be less attentive to the positioning of older adults during meals.\u003c/p\u003e\u003cp\u003eHowever, after attending the training, participants understood that older adults\u0026rsquo; bodies should remain upright, their necks straight, and caregivers should be positioned beside or facing them, adjusted based on their needs, to facilitate swallowing. For older adults with weakened upper body muscles, particularly from the elbow to forearm, caregivers must help position their hands on the table and adjust their necks to an upright position to reduce the risk of choking and aspiration. Applying the proper trunk position has been shown to shorten oral and pharyngeal transit times in older adults with dysphagia in clinical settings [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This suggests that aspiration pneumonia can be prevented through interventions focusing on maintaining good posture. Therefore, maintaining good posture is suggested for stress management in nursing homes in Indonesia.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAdverse Effects\u003c/h2\u003e\u003cp\u003eNotably, some questions revealed adverse effects after training. Regarding caregivers\u0026rsquo; feeding positions relative to older adults (Assessed by Question 12), 16 participants (41.3%) answered correctly in the pre-test, but this decreased to seven (17.95%) post-test.\u003c/p\u003e\u003cp\u003eEffective dysphagia management is crucial, especially for older adults recovering from a stroke or undergoing treatment for dementia. In such cases, caregivers must feed people with dementia or stroke sideways. In addition, Japanese people have a culture of not sitting facing each other because if their eyes meet, they will feel nervous, so Japanese people help them eat from the side. Therefore, in Japan, when care workers assist older adults in the dining room, they sit beside or diagonally to the older adult at eye level while supporting them so that they can observe the older adults and check that they are swallowing food appropriately [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe module was developed based on Japanese clinical practices, strongly reflecting these cultural aspects. Rather than positioning themselves directly in front, caregivers are shown sitting beside the patient\u0026rsquo;s unaffected side, placing food on the patient\u0026rsquo;s tongue, as described in relevant texts [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The authors believe participants\u0026rsquo; lack of critical thinking regarding caregivers' positioning contributed to their confusion. Therefore, incorporating critical thinking methods into the module is recommended.\u003c/p\u003e\u003cp\u003eAnother adverse effect of the intervention study was found in question 6, \"Older adults with dysphagia are not at risk for choking\" (\u003cem\u003etersedak\u003c/em\u003e). Before the training, 35 participants (89.74%) answered the question correctly; however, after the training, it decreased to 27 (69.23%). In analyzing this, the authors of the current studies noticed the wording of the Indonesian language term \"\u003cem\u003etersedak\u003c/em\u003e,\" which can be translatable in choking, aspiration, or dysphagia. We assumed that before participating in the training program, the participants thought that choking and aspiration were the same. After the training, participants understood that choking is a condition where there is a foreign object blockage in the respiratory tract, namely the pharynx, hypopharynx, and trachea; the blockage can be total if all holes in the respiratory tract are closed [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], while aspiration occurs when something you swallow \"goes the wrong way\" and enters the respiratory tract (trachea or throat) or lungs. Aspiration: Unlike choking, the respiratory tract is not completely blocked. Hence, participants assume that individuals with strokes are prone to conditions like dysphagia, leading them to avoid hard foods to prevent choking. Further research is needed to accurately explain the anatomical and psychological characteristics of swallowing function among Indonesians.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitation\u003c/h2\u003e\u003cp\u003eThis study had some limitations. First, the nursing background of study participants was not investigated. Nursing education provides foundational knowledge in the anatomical and physiological aspects of meal assistance, making this information important for data analysis. Second, further studies must be implemented when the researchers introduce simulations during the training program [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] to mimic real clinical conditions better. Third, the researchers could not analyze the participants who dropped out during the implementation of the training program. Therefore, further investigation should explore reasons for dropouts and how to prevent participants from dropping out.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study suggested that the meal assistance and oral care training program may offer benefits for caregivers in Indonesia, regardless of their educational background, sex, or the type of nursing home where they work. These were indicated by the significant increase in knowledge regarding the physical and anatomical aspects of aspiration prevention of this study. Yet further refinement of the module may enhance trainees' critical thinking skills in providing care for older adults.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNHAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNursing Home Acquired Pneumonia, EPA:Economic Partnership Agreement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard deviation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the private and government nursing homes that have collaborated in providing respondents for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAL drafted the manuscript; NS conducted the analysis; HM, NS, AL, and HY developed the questionnaire and conducted the survey; and HM, NS, HY and AK provided advice to HY. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Economic Research Institute for ASEAN and East Asia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the ongoing study conditions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNagasaki University (no: 19111497, dated November 14, 2019) and Universitas Respati IIndonesiaNo;153/KE/UNV/IX/2018\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThat they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe author details\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYuko O. Hirano, [email protected], Nagasaki University JP\u003c/p\u003e\n\u003cp\u003eLisnaAgustina, [email protected], Sekolah Tinggi Ilmu Kesehatan Medistra Indonesia ID\u003c/p\u003e\n\u003cp\u003eSusianaNugraha, [email protected], University of Respati ID\u003c/p\u003e\n\u003cp\u003eMisako Hiyashijima, [email protected] Nishikyushu University JP\u003c/p\u003e\n\u003cp\u003eKoichi Aramaki, [email protected] Nagasaki University JP\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCentral Statistical Agency of the Republic of Indonesia. Statistik Penduduk Lanjut Usia (statistics on the older people population) [Internet]. 2022. 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PLoS ONE. 2023;18:e0288175. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0288175\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0288175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Older adults, Oral care, Caregivers, Indonesia, Japan, Aspiration pneumonia prevention","lastPublishedDoi":"10.21203/rs.3.rs-6442097/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6442097/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e In 2023, Indonesia's older adult population reached 11.75%, marking its transition into an aged society, following a path similar to Japan’s, now a super-aged country. The physiological and anatomical effects of aging are widely observed among older adults, irrespective of nationality. Thus, Indonesian caregivers can benefit from Japan’s well-established long-term care system by training in Japanese caregiving methods. This study focuses on meal assistance and oral care, crucial areas for preventing aspiration pneumonia, a leading health risk in nursing homes.\u003c/p\u003e\n\u003cp\u003eDespite the importance of preventing aspiration pneumonia, few studies have assessed caregiver training programs in this field. Therefore, the authors developed and evaluated a meal assistance and oral care training program tailored to Indonesia’s cultural and social context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA training module on aspiration pneumonia prevention was designed and assessed using a 26-question questionnaire covering meal assistance and oral care. The program was implemented as an intervention study with 39 participants from private and public nursing homes in Java Island. Pre- and post-test results were analyzed using paired t-tests to determine the training’s impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eParticipants showed significant improvement in knowledge scores, from a pre-test mean of 18.87 (SD: 1.81) to 20.59 (SD: 1.71) in the post-test (p \u0026lt; 0.001), particularly among participants without a nursing background.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The training program improved participants’ understanding of aging-related conditions, including dementia and dysphagia. Regardless of educational background, participants acquired essential knowledge to provide safe, appropriate, and comfortable meal assistance and oral care to older adults in Indonesia.\u003c/p\u003e","manuscriptTitle":"Developing a Meal Assistance and Oral Care Training Program for Caregivers in Indonesia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 14:57:11","doi":"10.21203/rs.3.rs-6442097/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-07T03:47:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-28T06:23:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T13:11:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T16:17:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157881928481383460534907423753021163242","date":"2025-08-19T05:41:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T13:52:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142815022043867126992472408708266668033","date":"2025-08-16T14:24:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124249742132663133244698244489910669236","date":"2025-08-15T19:44:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204461617583344951851282247647646497805","date":"2025-08-15T09:35:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138127392284642207753248631828829268642","date":"2025-08-14T22:32:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95590746705517287374134757927027467435","date":"2025-08-13T10:45:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277961928502193387374005210827611328406","date":"2025-08-12T22:04:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T17:29:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132860501833961379289839263682694897947","date":"2025-07-30T17:26:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"311247081604717109837815089492190418129","date":"2025-07-30T14:30:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-30T13:47:59+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-27T09:05:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-19T11:16:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-15T07:22:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-06-15T07:19:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"361d39af-7fa7-44de-a00d-743ea07db6e7","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T14:57:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 14:57:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6442097","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6442097","identity":"rs-6442097","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}