Interprofessional collaboration on oral health for frail home-dwelling older people: a focus group study exploring the perspectives of home nurses, home care aides and cleaning aides

Interprofessional collaboration on oral health for frail home-dwelling older people: a focus group study exploring the perspectives of home nurses, home care aides and cleaning aides | 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 Interprofessional collaboration on oral health for frail home-dwelling older people: a focus group study exploring the perspectives of home nurses, home care aides and cleaning aides Natalie Hoste, Aster De Vleeschauwer, Ellen Baele, Fien Mertens, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8396075/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Older adults are at increased risk of deteriorating oral health, while dental attendance often declines over time among frail, home-dwelling older people (FHOP), leading to a substantial burden of untreated oral disease. Interprofessional collaboration is considered crucial in addressing oral health problems in ageing populations, with potential contributions from primary care professionals (e.g., home nurses, home care aides) and non-health professionals (e.g., cleaning aides). However, little is known about (a) the current engagement of these professionals in FHOPs’ oral health and (b) the needs and barriers they encounter in interprofessional collaboration. Therefore, this study aims to (a) explore the current oral health engagement of home nurses, home care aides, and cleaning aides – collectively referred to as home care workers (HCWs) - in FHOPs’ oral health, and (b) identify perceived needs and barriers to interprofessional collaboration in this context. Methods Between February and December 2023, seven focus groups were conducted in Flanders, Belgium: two with home nurses, two with home care aides, two with cleaning aides, and one mixed group, involving 50 participants in total. Discussions were analysed using a reflexive thematic approach. Results HCWs’ engagement in FHOPs’ oral health is limited. Most participants recognise their potential role, but multiple barriers exist, including limited knowledge, time constraints, low oral health awareness and prioritisation among FHOP and HCWs, oral health being a sensitive topic, intimacy of assisting with brushing, and FHOPs’ resistance to accept help. Quality of relationships with FHOP was a facilitator. Participants recommended integrating oral health into intake procedures, providing informative leaflets, and offering additional training. Barriers to interprofessional collaboration included financial structures and unclear role responsibilities. Conclusions This study provides novel insights into HCWs’ engagement in and collaboration on FHOPs’ oral health and underscores the need for coordinated action at multiple levels to enable HCWs to realise their potential role and to improve interprofessional collaboration: e.g., enhancing awareness and knowledge (micro level), increasing prioritisation and establishing guidelines (meso level), organising oral health campaigns and reorganising financial structures (macro level). Older adults frailty oral health interprofessional collaboration primary care home nurses home care aides cleaning aides qualitative research Figures Figure 1 Figure 2 BACKGROUND In Western countries, older people prefer to age in place for as long as possible and are encouraged to do so ( 1 , 2 ). Systematic reviews indicate that over 50% of these home-dwelling older people experience multimorbidity ( 3 ), which increases the risk of frailty ( 4 ). One of the morbidities associated with this ageing population is poor oral health, with an estimated 280 million older adults worldwide affected by oral health conditions ( 5 ). This is partly attributable to the numerous barriers hindering this population to access oral healthcare ( 6 , 7 ) and frail home dwelling older peoples’ physical or cognitive decline often impeding the maintenance of adequate oral hygiene at home ( 8 ). Additionally, poor diet and dry mouth associated with polypharmacy, which is common in older adults with multimorbidity, may exacerbate oral health problems ( 9 , 10 ). However, oral health is not only a fundamental aspect of overall physical health but can also have a significant impact on the mental health and quality of life of older adults ( 11 ). Despite evident treatment needs identified by oral health professionals, the number of visits to these professionals generally decreases after the age of 65 ( 12 , 13 ), a phenomenon that is even more pronounced among frail older people ( 14 , 15 ). This illustrates the inverse care law, which states that populations with greater clinical needs receive less care ( 16 ). Literature indicates that primary care professionals such as General practitioners (GPs) and pharmacists could play a vital role in monitoring the oral health of frail home-dwelling older people (FHOP) ( 17 , 18 ). They are highly accessible and typically establish trusting relationships with older patients. Furthermore, FHOP generally have more frequent contact with these professionals as they age, suggesting GPs and pharmacists could play a pivotal role in monitoring FHOPs oral health. However, a recent study indicates that GPs and pharmacists currently devote little attention to oral health, facing multiple barriers such as a lack of knowledge and responsibility, time constraints, low outcome expectations, limited prioritisation of oral health by older people, and the perception of oral health as a sensitive topic ( 19 ). Furthermore, it is well recognised that the likelihood of older people receiving support from home nurses, home care aides, and cleaning aides (hereafter jointly referred to as home care workers or HCWs) increases with age. The assistance of HCWs includes a range of activities, such as nursing care and (instrumental) activities of daily living (i)ADL, like washing, dressing, shopping, cooking, and cleaning. The WHO report on health and ageing states that HCWs should play a crucial role in addressing the challenges of ageing societies, and that existing care models should be reoriented to prioritise primary and community-based care ( 20 ). This is particularly relevant in the context of rising care dependency ratios and the growing pressure on family caregivers ( 21 ), whose essential role will persist given their unique position in bridging FHOP and formal care providers and the substantial workload on healthcare professionals ( 22 , 23 ). Regarding oral health, literature indicates that HCWs can play a vital role across multiple domains: firstly, as frontline monitors of the oral health status who can recognise when a referral to oral health professionals is necessary; and secondly, in supporting oral health routines, such as assisting with tooth brushing and facilitating preventive check-ups with oral health professionals ( 24 , 25 ). Literature primarily discusses the role of HCWs without explicitly mentioning non-health professionals (such as cleaning aides). However, the Vision report 2030 by the World Dental Federation adopts a broader approach, emphasising that both non-dental health professionals (e.g. home nurses and home care aides) and non-health professionals (e.g. cleaning aides) can contribute meaningfully to the oral health of this patient group ( 26 ). Additionally, there is growing recognition that cleaning aides can play a more important role beyond only cleaning, and that there is overlap between cleaning and caring ( 27 ). Moreover, like home care aides, cleaning aides tend to spend more time with FHOP than nurses and, often before medical issues arise, frequently fostering close relationships and substantial trust with their clients ( 28 , 29 ). Additionally, the importance of interprofessional collaboration among dental and non-dental primary care professionals is well recognized as essential for improving population oral health ( 24 , 25 , 30 ). Recent studies also highlight the need for enhanced task delegation and delineation among home care professionals ( 31 , 32 ) and fostering effective collaboration between formal and informal caregivers to optimise care delivery ( 33 ). While some studies have explored the engagement, needs, and barriers to contributing and collaborating on the oral health of older people experienced by HCWs in residential settings, or those working in both home care and residential care ( 24 , 34 – 39 ), very little research has been conducted specifically in home care settings ( 40 , 41 ). Common barriers reported in the literature include a lack of knowledge, skills, and confidence, limited time, patient refusal of care, and unclear responsibilities. Frequently expressed needs include more oral health education and a greater focus on oral health in the workplace. Additionally, only a few studies examine the role of home care aides in this context ( 37 , 40 , 42 ), and to date no studies have explored the role of cleaning aides. Considering the gaps in literature outlined above, this study aims to (a) explore the current engagement of home nurses, home care aides and cleaning aides in the oral health of FHOP and (b) identify the needs and barriers they encounter to engagement in, and interprofessional collaboration on, oral health for FHOP. The findings could (a) inform strategies to enhance engagement and interprofessional collaboration by addressing these needs and barriers, and (b) support the development of policy recommendations to improve interprofessional collaboration on oral health for FHOP. METHODS Given the exploratory nature of this study, a qualitative approach was employed, using semi-structured focus groups to investigate HCWs’ experiences and perspectives. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist ( 43 ), the completed checklist can be found in Additional file 1. Setting in Belgium In Flanders, Belgium, approximately 20% of older adults utilise some form of home care ( 44 ). The first category comprises home nurses, who are fully qualified healthcare professionals authorised to perform all nursing interventions listed in the national nomenclature, including technical procedures, care planning, and clinical decision-making ( 45 ). They operate primarily under prescription and may work independently or as employees within home-care organisations and can delegate a limited set of clearly defined tasks to a second category of home care workers: recognised home care aides, who are typically employed by organisations ( 46 ). Home care aides provide personal care, assistance with daily activities (e.g., shopping, meal preparation), and specific delegated nursing tasks, but are not permitted to administer injections, manage open wounds, or perform other high-risk procedures. Cleaning aides, also primarily employed by organisations, provide domestic support only and are legally prohibited from performing any medical or nursing tasks ( 47 ). Older adults have direct access to these home care workers, often without referral or prescription; however, reimbursement policies differ substantially. Many home nursing services are reimbursed by the National Institute for Health and Disability Insurance (RIZIV/INAMI) when prescribed or funded via third-party payer schemes, frequently resulting in no out-of-pocket costs ( 48 ). Reimbursement does not generally extend to services provided by home care or cleaning aides. Partial reimbursement for these services depends on the individual’s health insurance fund and eligibility criteria, with some older adults able to access a ‘care budget for adults with care needs’( 49 ). Additionally, some cleaning aides may be employed through tax-deductible service vouchers ( 50 ) . Participants Participants included three groups of HCWs – nurses, aides, and cleaning aides – working within two primary care zones (PCZs) in Flanders, Belgium. These PCZs promote collaboration among primary care professionals to deliver coordinated, accessible services, thereby enhancing care quality, patient outcomes, and community health management. The first PCZ (Scheldekracht) is more urban with a higher density of health professionals, including oral health professionals, whereas the second PCZ (RITS) is more rural. Eligibility criteria were: (a) employment within one of the two involved PCZs, (b) having professional contact with FHOP, and (c) fluency in Dutch. Purposive sampling was used to recruit HCWs through different channels, including (a) our stakeholder group representing organisations dedicated to the care for older adults, (b) personal outreach to home care organisations and independent HCWs. Data collection Prior to conducting the focus groups, semi-structured interview guides were developed based on existing literature ( 51 , 52 ) and tailored to each professional group. The guides were discussed within the interdisciplinary research team, refined based on feedback from oral health experts, and piloted with a home nurse, a home care aide, and a cleaning aide. The key topics addressed included: (a) the perceived importance of oral health for FHOP within their profession, (b) current (inter)professional practices on oral health, (c) perceived needs and barriers to engagement in and collaboration on oral health of FHOP, and (d) optimal organisation of oral health care for this patient group. The final interview guides are available in additional files 2–4. Data were collected from February to December 2023. To facilitate open discussions regarding interprofessional collaboration, we attempted to organise homogeneous focus groups by professional group. Efforts were made to organise the discussions in person when feasible, often at the location of their organisation to minimise disruption of their activities. Each discussion commenced with an introduction and the completion of the informed consent form and a demographic questionnaire covering gender, age, years of experience, work setting, primary care zone, and oral health training received during or after their education. For online focus groups, these documents were provided in advance by email and returned before the start. The focus groups were moderated by NH, trained in qualitative healthcare research. The discussions were audio recorded, while an observer from the research team (EB, ADV) took supplementary field notes. Data saturation was not strictly pursued, as the reflexive thematic approach by Braun and Clarke was adopted ( 53 ). They indicated that meaning is co-constructed through interpretation, and that determining saturation is inherently subjective and context-dependent ( 54 ). Data collection continued until the analyses revealed few new themes. Data analysis Focus groups were transcribed ad verbatim and analysed using NVivo 14 (© QSR International). Data analysis employed Braun and Clarke’s reflexive thematic approach ( 53 ), which emphasises researcher reflexitivity and an iterative process of theme development. This method facilitates in-depth exploration of data, nuanced interpretation, and the identification of meaningful patterns within complex qualitative datasets. The analysis comprised six steps. First, familiarisation with the data involved repeated reading of transcripts (Step 1). In Step 2, initial codes were generated through open coding. The first transcript was independently coded by four team members with diverse backgrounds (NH, EB, ADV, FM – speech therapist, health promotor, dentist and general practitioner), followed by collaborative discussion guided by an experienced qualitative researcher (FM). The goal of this discussion was to explore diverse perspectives through dialogue and reflection, rather than reaching a full consensus. These multidisciplinary discussions enriched insights, sometimes broadening the researchers’ perspectives when coding subsequent transcripts. Two researchers (NH + ADV, EB or FM) first independently coded the remaining transcripts, followed by discussing discrepancies to acknowledge different perspectives rather than reach full agreement. Throughout the analysis, the coding framework was iteratively refined. In Step 3, codes were grouped into initial themes and illustrative quotes were selected by NH. These themes and quotes were reviewed (Step 4) by the multidisciplinary research team (including two general practitioners, two oral health professionals, a psychologist and a health promoter), to enhance robustness through investigator triangulation. Subsequently, final themes were defined and descriptively named (Step 5). In the 6th and final step, NH integrated these themes into a coherent narrative. Causal loop diagrams were also developed as an intermediary phase in our analytical process, to move beyond unidimensional linear causal thinking. These diagrams were incorporated into the results where interactions were too complex to clarify through text alone. Finally, findings were contextualised within the Rainbow Model for Integrated Care, a comprehensive framework specifically developed for primary care and designed to understand and improve integrated care across health systems ( 55 ). The model distinguishes two core aspects: normative integration (e.g. shared vision, culture, and values) and functional integration (e.g. practical coordination and alignment of services). Additionally, the model emphasises the interconnectedness between the micro (health services), meso (professionals and organisations), and macro levels (policy and system). RESULTS Seven focus groups were conducted: two with home nurses (one comprising autonomous home nurses working within the same group practice, and the other with salaried nurses employed within the same care organisation), two with home care aides, two with cleaning aides, and one mixed group that included both home nurses and home care aides. This mixed group collaborated on the care for residents of a single assisted facility. The average number of participants per focus group was seven, with a minimum of five and a maximum of eight. Table 1 presents an overview of the focus group characteristics. Table 1 Overview of focus-group characteristics in the chronological order of the discussions. Focus group Number of participants Professional group Primary Care Zone FG1 8 Employed home nurses 2 FG2 8 Cleaning aides 2 FG3 8 Home care aides 2 FG4 8 Home care aides 1 FG5 8 Cleaning aides 1 FG6 6 Independent home nurses and home care aides 1 FG7 4 Independent home nurses 1 A total of 50 participants were recruited, comprising 17 home nurses, 17 home care aides, and 16 cleaning aides. Participants did not opt in individually; instead, managers of HCWs or coordinators within group practices invited staff to join a focus group, with on-site sessions arranged during working hours. One focus group with independent home nurses was conducted via MS Teams due to their demanding schedules. The average focus group duration was 72 minutes (range 61–91 minutes). Table 2 presents a summary of the participants’ demographic profiles, education and work context. All participants had daily interactions with FHOP. Regarding their employment status, all home care aides and cleaning aides were employed by an organisation. Among the community nurses, ten were employed by an organisation, six were self-employed, and one nurse combined self-employment with organisational work. Table 2 A summary of participants’ demographic profiles, education and work context. Professional group Home nurses (n = 17) Home care aides (n = 17) Cleaning aides (n = 16) Variable n (%) n (%) n (%) Sex Female 15 (88) 17 (100) 15 (94) Male 2 ( 12 ) 0 (0) 1 ( 6 ) Primary care zone in Flanders (Belgium) PCZ RITS 8 ( 47 ) 8 ( 47 ) 8 ( 50 ) PCZ Scheldekracht 9 ( 53 ) 9 ( 53 ) 8 ( 50 ) Perception of the extent to which oral health was addressed in their basic training Not at all addressed 1 ( 5 ) 2 ( 12 ) 16 (100) Addressed to a limited extent 12 ( 71 ) 13 ( 76 ) 0 (0) Addressed in depth 4 ( 24 ) 2 ( 12 ) 0 (0) Has followed an extra oral health training Yes 4 ( 24 ) 4 ( 24 ) 0 (0) No 13 ( 76 ) 13 ( 76 ) 16 (100) Years of work experience in current profession 30 1 ( 5 ) 2 ( 12 ) 0 (0) We clustered and presented the inductively identified themes according to the initial research questions, resulting in two main themes: ( 1 ) engagement of HCWs (including home nurses, home care aides and cleaning aides) in oral health of FHOP, and ( 2 ) barriers and needs for interprofessional collaboration. Theme 1: ENGAGEMENT OF HOME CARE WORKERS IN ORAL HEALTH OF FHOP Subtheme 1: Perceived roles and willingness to engage Overall, participating nurses, care aides and cleaning aides recognised a potential role for themselves in the oral health of FHOP and most participants expressed a willingness to fulfil this role. However, the degree of engagement varied by professional group. Most participants believed that supporting oral health falls to the person responsible for daily care – whether a nurse or care aide. This contrasted with their reluctance to approach FHOP about suspected oral health problems, which most participants perceived as a very difficult topic to raise. Cleaning aide 5: Would you say to your friend: “Your teeth aren’t clean?” It’s one thing to tell someone to wash their armpits because they’re a bit smelly, but telling someone they have to clean their teeth is different. I think that’s still a bit of a taboo. Among the professional groups, care aides appeared most inclined to address oral health; however, it is important to emphasise that this was highly individual and not solely dependent on their profession. Care aides particularly underscored their motivation to assist and advise on oral health, citing its importance for the overall well-being of FHOP, and their wish that attention will be given to their own oral health as they age. Care aide 6: It’s in my routine to ask patients for their dentures too and clean them. It’s because I would also want a clean mouth for myself after eating and before going to bed, even when I’m older… Cleaning aides also recognised their potential role in advising FHOP on oral health and expressed a willingness to assist with cleaning denture containers. Some noted that they would also be willing to help FHOP clean their dentures if no other support was available. Cleaning aide 13: I clean out their denture containers when I’m in the bathroom. It seems to me they don’t do this often enough themselves, and I feel it’s my job to take care of that as well. They don’t ask me to do it, but it feels almost automatic to me..." In contrast, participating nurses – particularly independent nurses – were more hesitant to assist with daily oral hygiene. They preferred to intervene only under specific conditions, emphasising that their role is to empower FHOP rather than to take over care. Nurse 3: It is also our role to encourage self-care. Everything they can still do for themselves is really important as well. It’s like: “Oh, I can still manage that on my own”. Despite most participants’ stated willingness to take on a role in FHOPs’ oral health, several overarching barriers to their fulfilment of this role were identified. These included limited oral health knowledge, insufficient time, and high workloads. The latter two frequently led HCWs to prioritise other aspects of care perceived as more acute or tasks that FHOP seemed to deem more important. Nurse 12: Sometimes you have to make choices. We’re understaffed, and there’s so little time for each patient. It’s not an excuse, it’s the reality… Subtheme 2: Prioritisation of oral health by FHOP Building on the preceding theme, nurses and care aides perceived that oral health occupies a low priority on FHOPs’ agenda, which in turn reduced their own engagement in FHOPs’ oral health. Across all focus groups, participants attributed this low prioritisation to oral health not being emphasised during the upbringing of this generation, although some observed a more positive trend among younger FHOP compared with the oldest cohort. Nurse 12: It’s also because FHOP themselves don’t really find it that important, so we don’t really find it that important either. We focus on what they ask, and that already fills our time… Care aide 6: Especially the generation over 80, they don’t see it as important. We weren’t allowed to go to bed without brushing our teeth, but that wasn’t drilled into that generation. Nurse 12: You have to search for a toothbrush in the back drawer and then they say: ‘I’d rather have you wash my hair.’ Sometimes you have to make choices, it’s a fact that we’re understaffed and that there’s so little time per care recipient. It’s not an excuse, but it is like that. If they would say: Let’s brush my teeth, we would all do it. Participants from all professional groups indicated that this lack of prioritisation became clear because FHOP rarely addressed this topic or requested assistance with oral health, despite having no difficulty doing so for other (health) problems. Participants also believed this was partly attributable to ( 1 ) embarrassment about their oral hygiene and ( 2 ) FHOPs’ unawareness that HCWs could offer assistance with oral health. Care aide 11: Those older people don’t ask for help with their oral health. For the patients I do assist, I’ve had to ask myself: how are your teeth? While the first two subthemes addressed overarching barriers to HCWs engagement with FHOPs’ oral health, the subsequent subthemes will delve deeper into the oral health-related actions HCWs undertake, and the specific barriers and needs they encountered in performing these actions. Subtheme 3: Oral health awareness from intake to follow-up Despite their willingness to engage in oral health, most nurses and care aides noted that oral health received minimal attention in their professional interactions with FHOP, as other concerns often seemed more urgent. Nurse 3: My gut feeling tells me that I’m not paying enough attention to it. I’m thinking about all my patients, and honestly, I really don’t know how things are with the oral health of five of my patients. Many nurses and care aides indicated that this lack of attention partly stemmed from oral health being largely overlooked during the intake process – typically conducted by their supervisors – which resulted in limited awareness of clients’ oral health status. In the rare instances where oral health was assessed at the outset, it was seldom followed up, despite this patient group being at increased risk of rapid deterioration. Nurse 14 – Independent Nurse: ‘I don’t really ask about their oral health at the start. I just assume that they will ask if they need help…’ Nurse 3: I think that it often gets forgotten. Sometimes it’s asked at the start, but we should also reevaluate it because patients also decline. I have to admit that it’s something I do sometimes forget. Towards the end of the focus groups, several participants indicated that they should routinely consider their clients’ oral health, rather than assuming that FHOP would seek assistance when necessary. Subtheme 4: Hesitance to assist and resistance from FHOP All HCWs reported occasionally offering FHOP advice on performing daily oral hygiene. In terms of assisting, cleaning aides primarily focused on keeping denture storage containers clean, while care aides and nurses also assisted some clients with tooth brushing or denture cleaning; however, they reported rarely assisting with the hygiene of natural teeth. Care aide 6: There is a big difference between dentures and real teeth. With dentures, they can just take them off, it’s easier and they ask for help much quicker. With natural teeth, it must feel really strange for them, and they don’t always accept help… Hesitance in home care workers Many nurses and care aides perceived helping with natural teeth to be even more intimate than providing personal hygiene care. In every focus group, participants even reported feelings of disgust when cleaning dentures or storage containers. Care aide 9: I find it harder to help with oral hygiene than with intimate personal care. Perhaps it’s because we do it more often, making it a habit. Oral hygiene isn’t part of the routine. However, it becomes easier with regular practice. Nurse 2: Cleaning these dentures, often laying in that same dirty water…it really grosses me out sometimes. Additionally, most nurses highlighted that they only took over daily oral care in specific conditions or situations (e.g., highly dependent or palliative patients, patients with significant cognitive decline, …) because they believe it is their role to empower FHOP to maintain independence for as long as possible. Nurses indicated that taking over oral hygiene tasks for FHOP would create an internal conflict if they had not requested help and were still able to manage it themselves. Nurse 14 – Independent nurse: In palliative care, we pay more attention to oral health, because it’s really important for them to have a fresh mouth. Nurse 3: It is also our role to encourage self-care. Everything they can still do for themselves is really important as well. It really lifts them up to think: “Oh, that’s something I can still manage on my own”. HCWs’ perception to have insufficient knowledge about oral health was identified not only as an overall barrier for engagement in FHOPs oral health but also repeatedly cited by participants as a specific obstacle to assisting and advising on oral health. Cleaning aides reported receiving no education on this topic. Recently qualified nurses and care aides have received training in oral health during their education, whereas their more experienced colleagues indicated that this topic was only touched upon very briefly in their training. The majority of participating nurses, care aides, and cleaning aides indicated that their lack of knowledge left them feeling uncertain about giving advice or assisting with daily oral hygiene. Nurse 3: In my training 24 years ago, I certainly didn’t see anything about oral health… Consequently, nearly all participants indicated that additional training in oral health would improve their confidence in this context. They expressed particular interest in learning more about denture maintenance, supporting toothbrushing, using adhesive denture paste and mouthwash, and understanding the costs and reimbursement of dental treatments. They noted that improved knowledge would enable them to provide more consistent and confident oral health guidance and would likely increase the credibility FHOP attributed to them regarding oral health. Nurse 7: I think all nurses would welcome additional training on this matter. It would also bring a bit of uniformity in our approach and enable us to properly inform patients when they have questions. Care aide 13: Additional training would be beneficial, however, then it also has to be communicated to clients during intake that we can assist with oral care… Cleaning aide 4: It would be great to receive more information on helping clients with oral health when we see they’re struggling. It would make it easier for us to respond to their questions and they would appreciate it if we can give tips. Resistance from FHOP Additionally, participants from all professional groups reported that they often encountered resistance from FHOP when providing assistance with or advice on oral hygiene. They highlighted that FHOP generally preferred to manage their own oral health and adhered to their established routines, and they often perceived that FHOP lacked trust in the methods suggested by HCWs. Nurse 7: Oral hygiene is very personal. Much like washing their face, people prefer to do it themselves if they can. Care aide 6: Many FHOP maintain their dentures incorrectly. But when you give advice, they say: ‘we’ve been doing it this way our whole lives. Who are you to come and tell me how to do it..’ So yeah, that’s where it ends… Furthermore, most nurses and care aides were convinced that it must be very uncomfortable and strange for FHOP to have someone else brushing their teeth. Care aides indicated that brushing FHOPs’ dentures during night shifts was easier, since FHOP remove their dentures at night, thereby avoiding the embarrassment of requesting them to remove their teeth. Participants also noted that the dynamic and resistance differs from a residential setting; they are in the clients’ homes, which is their territory, and FHOP prefer to maintain control over their care. Nurse 11: It’s not like in a hospital where you say: ‘now this needs to happen, and now that needs to happen.’ There’s a different hierarchy when you’re in their home, you’re on their territory. However, care aides and cleaning aides indicated that this was also dependent on the personalities of FHOP; and as they visited more regularly and built trust, they became more open to accepting HCWs’ help and advice. Care aide 15: The longer you visit FHOP and the more they trust you, the more they allow you to do. Furthermore, especially cleaning aides and some care aides felt that FHOP also showed resistance because they were unaware that these professionals could play a role in their oral health. They believed FHOP did not see oral health as part of their job. Cleaning aide 15: You don’t really ask that as a cleaning aide, do you? “Have you cleaned your teeth?” I mean... For some people we’re ‘just’ the cleaning aides… To reduce resistance from FHOP, most participants suggested that the intake process for new clients – typically conducted by supervisors of HCWs – should include oral hygiene, accompanied by a leaflet on daily oral care that could also be discussed with current clients by HCWs. They believed this would clarify that HCWs can support clients in this area, potentially leading to greater acceptance of oral health advice and encouraging clients to seek assistance more promptly when necessary. However, care aides expressed concerns about addressing oral health during intake, highlighting that it takes time to establish trust with FHOP. Nurse 4: We really need a leaflet with information. Without it, convincing FHOP will be tough. If they’ve used toothpaste on their dentures for years, they may not believe us when we suggest to do it with soap. Care aide 5: Some clients don’t realise we want to help with oral hygiene. If they would know this from the beginning, it would make a difference… Subtheme 5: Bridging observation and conversation on suspected oral health problems Although oral health is seldom discussed by those responsible for intake during the initial assessment, most HCWs frequently observed signs of poor oral health when visiting FHOP (e.g., non-use of dentures, unused or worn toothbrushes, dirty storage containers, bad breath, avoidance of hard foods). However, most HCWs rarely initiated conversations about FHOPs’ oral health, finding it very challenging since oral health remains a highly sensitive topic for them. Care aide 13: I find that really difficult… I once visited an older lady whose breath smelled very unpleasant. I had to turn my head away while she spoke, but it’s so difficult to address that. I even find it easier to mention a urine smell… You really have to visit them a while before you dare to say something about their oral health. Some HCWs occasionally engaged in such conversations, but their confidence in doing so largely depended on their relationship with FHOP and FHOPs’ personalities. Cleaning aide 6: It really depends on the person… I have a client who is very proud; I don’t think I could say anything to her. Cleaning aide 1: When you spend more time with a client, you become a trusted figure, making them more likely to accept your input. Some participating care aides and most cleaning aides expressed fear of potentially offending clients by initiating this conversation and creating an impression of intrusiveness. Because they believed FHOP do not expect action from them in this area, cleaning aides and care aides regarded it as primarily the role of family caregivers and nurses to initiate this discussion. Cleaning aide 1: I don’t think that’s our primary role to address that, and we don’t want to offend them, you know…If we notice something’s wrong, it’s our job to tell it to our supervisors. But to be honest, that almost never involves oral health… Most participants reiterated the potential benefits of providing a leaflet that would promote discussions about oral health, and advocated for including oral health within the intake process to inform clients that, alongside nurses, care aides and cleaning aides can offer support in this area. Cleaning aide 15: With a little leaflet, you have a starting point to have that conversation… Participating nurses, care aides and cleaning aides did report suspected health problems to their supervisors. Nevertheless, most participants indicated that this rarely pertained to oral health. Cleaning aide 15: We are also quite important, as we sometimes spend four hours there, and therefore we might notice more quickly if they’re showing signs of dementia or start to wobble, just to give an example. Our supervisors expect that we communicate that. I do think we can do that. And then our supervisor passes that on to the home care team and they pay more attention to that. Subtheme 6: Overcoming access barriers and low outcome expectations When FHOP did approach HCWs with oral health concerns, most participants reported referring them to a dentist or GP, though they reiterated that enhanced oral health knowledge is needed to facilitate smoother referrals. Nurses and care aides also expressed a preference for referring FHOP to general practitioners, citing ( 1 ) the limited availability of oral health professionals – especially for FHOP who often lack a regular dentist - and ( 2 ) greater FHOP familiarity with their GP. Care aide 13: "Dentists are so hard to reach these days, and getting FHOP there is challenging. Honestly, I’ve never called a dentist in twelve years. I’d rather buy them some mouthwash and in the worst case, I’d contact the GP.” However, most HCWs reported low outcome expectations regarding FHOP visiting a dentist after referral, even when dental appointments would be more accessible. Beyond the broader lack of prioritisation of oral health in this patient group, they cited many reasons why FHOP would not attend dental visits, including: unfamiliarity with dental care from their upbringing, the belief that seeking oral healthcare is no longer worthwhile at their age, mobility issues, cost concerns, fear of pain associated with dental treatments, and the prosect of navigating a lengthy, burdensome process. Nurse 15 – Independent nurse: "These patients only visit the dentist when they have problems; they don’t see the need otherwise. Regular check-ups make sense to us because it was ingrained in our upbringing, but not to them—they act only when in pain." Cleaning aide 7: I just think they’re not thinking about their oral health. If there is a problem with their teeth, they just mash their potatoes and they can still eat, so they don’t see the problem. Despite these doubts, participants described several strategies to engage FHOP in the oral health circuit. First, they suggested that conducting preventive oral health screenings at home or in local service centres could be beneficial. Some participants argued that these could be performed by dental hygienists, noting that preventive tasks should be delegated to this professional group to allow dentists to devote more time to dental treatments. Cleaning aide 3: Home visits for preventive check-ups would be excellent. If hairdressers and doctors can come to their house, why not dentists? Second, they suggested low-cost initiatives similar to bowel cancer screenings and mammograms, with invitations sent to FHOP. Participating HCWs saw a role for them in encouraging FHOPs attendance. Cleaning aide 4: They would come to us with these invitation letters. If we could explain it to them and motivate them a bit, they’ll be more likely to do it. Finally, some participants suggested raising awareness among FHOP about the importance of oral health and oral health screenings; however, most believed that FHOP are very hard to reach with preventive measures. Nurse 16 – Independent nurse: "Prevention? These people aren’t thinking about that; they’re focused on dying, not on going to the dentist." Subtheme 7: Practical barriers and family-induced obstacles Concerning support for FHOP in arranging dental appointments, care aides and cleaning aides occasionally assisted in scheduling these appointments or communicated with their superiors for this purpose. In contrast, nurses typically delegated this responsibility to family caregivers, citing a lack of time, whereas family caregivers’ greater availability and better insight into suitable appointments were noted. Cleaning aide 6: "Sometimes we make an appointment for them. They don’t want to ask their children because they already have so much to do." Nurse 15 – Independent nurse : "There are FHOP who ask to make an appointment, but I usually refer them to their family. We can’t take that on us." Care aides reported occasionally accompanying clients to dental appointments, recognising that this support is valued by clients and helped FHOP feel more at ease with the dentist. Care aide 9: They appreciate it if we can join them to the dentist. Because they know their GP, but they might not have seen a dentist for years, so they don’t know what to expect and then they really appreciate our company. However, they also faced a range of practical and organisational challenges, frequently requiring them to adjust their own working hours to accompany clients. Additionally, they often encountered resistance from family caregivers who judged a dental visit unnecessary for FHOP or who were reluctant to provide financial resources. Care aide 15: You can’t just bypass the family and say ‘I’m taking you to the dentist.’ Some FHOP don’t have any money at home; everything has to go through the family… Sometimes you have more trouble with the family than with FHOP themselves. Figure 1 . Causal loop diagram illustrating the interactions among factors that facilitate or hinder HCWs’ engagement in the oral health of FHOP. Positive arrows indicate facilitating relationships, while negative arrows indicate inhibiting ones. Solid arrows represent relationships identified in the focus groups; dashed arrows indicate additional links anticipated by the research team. The section above the title shows overarching facilitators and barriers to HCW engagement, whereas the section below lists specific factors cited by participants, corresponding to particular behaviours shown in bold. Theme 2: Needs and barriers for interprofessional collaboration on oral health Subtheme 1: Unclear oral health responsibilities among home care workers From the focus groups, it became clear that oral health responsibilities – and their distribution among HCWs – were perceived as unclear by participating HCWs, a situation they attributed to several factors. Awareness of oral health needs and the potential need for assistance Some nurses and care aides noted that awareness of FHOPs’ oral health needs must be established before collaboration can commence. While all participating HCWs agreed that monitoring oral health primarily falls to the individual responsible for daily hygiene, most nurses and care aides reported that oral health was rarely addressed at intake. As previously indicated, the necessary follow-up in this already vulnerable patient group was generally lacking when oral health was addressed at intake. This resulted in limited awareness of ( 1 ) FHOPs’ oral health status, ( 2 ) whether FHOP could manage their oral health independently, and ( 3 ) whether oral health assistance was already provided by others (e.g. family caregivers or other supportive HCWs of the client). Furthermore, most participants noted uncertainty regarding the activities of other HCWs when visiting FHOP. Nurse 17 – Independent nurse: What care aides do when they visit our patients, we don’t really know. They’re mainly there for household tasks. I know some who struggle with just putting in eye drops. I don’t think there’s much actual care work going on there… However, regarding oral health, most participants were convinced that it was not addressed by other HCWs. Cleaning aide 9: Usually we’re already there when the nurse arrives, and patients already have their dentures in, but I never noticed nurses checking their dentures… Care aide 5: I don’t think nurses pay attention to their teeth… I believe it often gets neglected, because when we arrive at the start with a new client, you can really see that those teeth are often quite dirty. Formal and informal communication and coordination among HCWs Furthermore, participants indicated that the above lack of awareness about FHOPs’ oral health needs and the potential need for assistance led to minimal ( 1 ) communication concerning oral health and ( 2 ) coordination regarding oral health tasks. This occurred both among colleagues within the same discipline and between HCWs of different disciplines. For instance, nurses, care aides, and cleaning aides visiting the same FHOP often held internal meetings, yet oral health was rarely addressed during these discussions. Nurse 16 – Independent nurse: I think that we only communicate this to the teams in palliative care, if they have a really dry mouth. I think that otherwise, oral health hardly comes up in briefings. Care aides and nurses indicated that efforts to coordinate task division between the two professional groups – aiming at enabling nurses to focus on medical responsibilities – had some success with individual clients. However, outcomes were highly dependent on individual care aides and families of FHOP, who did not always consent due to financial reasons (see next theme). Nurse 8: It somewhat depends on who the care aide is and what the patient allows… Some patients prefer that we do it instead of having to pay care aides to do it, even if it means we’re spending our 15 minutes on it … Some care aides mentioned initiatives at the organisational level to redistribute tasks between themselves and nurses but noted that these were halted by the nursing management because the proposed redistribution of tasks would have affected nurses’ salaries. Care aide 11: We had a meeting with nurses to take on more tasks from them, so they could focus on medical tasks, and we would take over the intimate care. In the Netherlands, that’s the norm. But here in Belgium, it doesn’t work like that. It’s all about the money after all. Every little task is also income for them. In addition to formal agreements, participants reported that making informal agreements with other HCWs was also challenging. Firstly, opportunities for spontaneous interaction are scarce, as FHOP and their families schedule HCWs’ visits to prevent overlaps. Secondly, although communication notebooks are often used, cleaning aides and care aides expressed hesitation to write in them, due to negative reactions where their input was dismissed as interference by other HCWs, FHOP, or their family caregivers. Additionally, cleaning aides indicated that they preferred to inform their supervisor rather than directly report issues to other HCWs, due to ( 1 ) not perceiving themselves as healthcare professionals, ( 2 ) experiencing a lack of respect from nurses, care aides and family caregivers, and ( 3 ) concerns about offending their clients or breaching their privacy. Cleaning aide 6: You don’t have much time to communicate with them [other HCWs] to be honest, because they’re always quickly back outside. – Cleaning aide 3: And if the client is there, you can’t start talking about them either… So, it’s quite difficult. Cleaning aide 10: If you write something in these notebooks, they [other HCWs] feel attacked quite easily. After a while, you don’t dare to say anything anymore, you just hold back. Once, they wrote as an answer: You are just a cleaning aide . Guidelines and organisational focus Furthermore, especially nurses and care aides, noted that their organisation offered very limited guidelines on oral health and rarely emphasised its importance, both towards FHOP (e.g., during intake) and them as HCWs (e.g., during team meetings). Some participants suggested that increased organisational focus could enhance their attention to oral health with clients and reduce resistance to assistance in FHOP. Additionally, some participants indicated that a few individual dentists provided FHOP with checklists with concise oral-care instructions for HCWs, which motivated care aides and nurses to dedicate more attention to their patients’ oral health. Subtheme 2: Financial structures hindering interprofessional collaboration Another subtheme identified during analysis was how current financial structures appear to hinder ( 1 ) HCW engagement in oral health of FHOP and ( 2 ) interprofessional collaboration between HCWs. Regarding the first point, nurses noted the lack of reimbursement codes for daily oral hygiene activities, which diminished organisational incentives to prioritise oral health and consequently affects the attention nurses allocated to it within FHOP. Nurse 3: What will the organisation get out of it if we suddenly start paying attention to oral health? We don’t receive money for that from RIZIV. If it means I have to work longer tomorrow to observe their oral health, my bosses have to pay me for it, but they wouldn’t like doing that… If you help someone putting on their compression socks, you get an extra penny for that, but that’s not the case for brushing teeth or cleaning dentures… Furthermore, both care aides and nurses indicated that financial structures hindered interprofessional collaboration. Both professional groups believed that supporting daily oral hygiene should primarily fall to care aides, indicating that they typically spend more time with clients, often had stronger trust relationships with FHOP, and could assist with purchasing suitable oral hygiene products. However, as previously mentioned, FHOPs and their families did not always agree with this division. They tended to prefer nurses to handle daily oral care, since no co-payment is required for the services of nurses employed by an organisation, unlike the services of care aides. Some nurses added that making these services free is not advisable, as it results in family caregivers delegating tasks they would otherwise perform themselves. Nurse 7: Quite often, when you try to make arrangements with care aides, FHOP say: “You shouldn’t ask them, because we have to pay for them, and you do it for free.” It’s like that for washing their feet, cleaning their dentures, … We try to pass that on to care aides because they have more time, but patients quickly say: ‘oh no, I have to pay for them’. Cleaning aide 5: I have a feeling that care aides are much more focused on hygiene now, also on daily oral hygiene… But they [FHOP] rather let the nurse do it, because it’s for free… That plays a role for older people… Nurse 4: If I were to tell her daughter ‘It’s 2 euros to clean her teeth, she would quickly start cleaning her mother’s teeth herself. If they have to pay for it, suddenly they can do it themselves. Sometimes it’s not a good thing that it’s free; people have really gotten used to that… DISCUSSION This study identified multiple barriers, facilitators and needs experienced by HCWs regarding (a) engagement in oral health for FHOP (Theme 1) and (b) interprofessional collaboration on oral health for this patient group (Theme 2). Although research exists on HCWs’ engagement in oral health in residential care settings, this study is among the first to explore the perspectives and opinions of nurses and care aides within home care contexts. To our knowledge, it is also the first study to examine the potential roles and viewpoints of cleaning aides in the oral health of this population. The study primarily provides novel insights at the micro level and in relation to normative integration, enhancing understanding of the factors that impede HCWs’ engagement in the oral health of FHOP. It adopts a broader perspective on HCWs’ oral health-related behaviours than existing literature in residential settings, extending beyond the provision of daily oral hygiene assistance. Comparison with existing literature To facilitate the comparison with the existing literature, we summarised the findings in Fig. 2 in accordance with the Rainbow Model for Integrated Care ( 55 ). In the remainder of the discussion, the focus will be primarily on novel insights. At the micro level, most nurses and care aides involved in our study expressed a sense of responsibility for assisting in oral health, recognising it as an integral component of basic hygiene, as noted in prior work ( 38 , 56 ). They demonstrated a willingness to engage in oral care, primarily because they believe a fresh mouth supports FHOPs’ wellbeing and because they would like similar care for themselves as they age, in line with earlier research ( 38 , 41 ). Care aides in our study appeared to engage more actively in FHOPs’ daily oral hygiene than nurses and demonstrated a more positive attitude towards providing such assistance. This observation is consistent with a quantitative study in nursing homes, which also found that home care aides showed greater involvement in residents’ daily oral hygiene and exhibited more positive attitudes than nurses, who showed lower involvement but possessed greater knowledge of oral health ( 57 ). Previous research has also indicated that knowledge alone is insufficient to establish behavioural change ( 58 ). However, interventions aimed at enhancing knowledge and skills may strengthen not only care professionals’ knowledge, but also their beliefs about their capabilities and the consequences of their actions, both of which have been shown to predict behaviour ( 59 ). Similarly, increased involvement in daily oral hygiene may provide HCWs with opportunities for experiential learning, potentially enhancing their confidence and promoting more positive attitudes and behaviours towards assisting with oral care. Participants in our study also indicated that performing oral health tasks more frequently might reduce their reluctance to provide support and facilitate habit formation. Furthermore, nurses in our study indicated that empowering FHOP is a key aspect of their role, rather than merely taking over (oral) care. Previous research also suggests that older adults wish to remain independent in their oral health as long as possible ( 60 ), and that HCWs must balance the promotion of patient autonomy with the provision of necessary care ( 61 ). However, our findings raise the question of whether some nurses may be invoking the concept of autonomy as a justification for the limited attention currently given to oral health, as true empowerment would require systematic assessment of their oral health status and daily hygiene routines at intake, along with regular follow-up throughout the care pathway. A potentially more effective approach would be to involve HCWs in integrating daily oral hygiene into the prominence-gaining care concept of ‘reablement’. In this approach, FHOP receive intensive, short-term support based on a comprehensive assessment by a multidisciplinary team, with the aim of maximising their independence and achieving sustained improvements in both activity performance and satisfaction with the performance over the long term ( 62 ). Although the Vision Report 2030 suggests that non-health professionals, such as cleaning aides, could play a significant role in the oral health of this group ( 26 ), to our knowledge this study is the first to explore the potential willingness of cleaning aides to take on such a role. Our findings indicate that some cleaning aides already perceive it as their responsibility to signal suspected (oral) health problems to their supervisors. Furthermore, with appropriate support – including oral health training, organisational backing, and respect and support from other primary care professionals, family caregivers and FHOP themselves – some cleaning aides would be willing to provide oral health advice, facilitate appointments with oral health professionals, and some would be willing to assist with daily oral hygiene when FHOP lack other support. It is noteworthy that, whereas current Belgian legislation ( 47 ) prescribes that cleaning aides should perform only cleaning tasks and no care tasks, none of the participating cleaning aides mentioned this during the focus groups. Perhaps signalling suspected problems, giving advice and facilitating appointments do not fall under care tasks in their view. Additionally, some of the participating cleaning aides indicated that they would be happy to learn more about oral health and play a role in this area. This could be in line with the Job Characteristics Model, which suggests that giving mentally challenging work can increase job satisfaction, although this also depends on an individual’s desire for personal development at work ( 63 ). Given the high workload faced by primary care professionals and the possibility that involving cleaning aides in oral health could enhance job satisfaction for some, policymakers could consider whether there could be a signal function for cleaning aides in case of suspected (oral) health problems. It was also notable that, towards the end of each focus group, participants expressed the view that oral health warranted greater attention and the intention to be more mindful of it in their future practice. This may reflect a combination of evolving understanding developed through discussion and a degree of social desirability bias among colleagues. This raises the question whether the inclusion of oral health topics in continuing professional education sessions might already enhance oral health awareness among HCWs. Even though most participants were willing to play a role in the oral health of FHOP, participants in our study acknowledged that they often don’t pay attention to their oral health needs, which is consistent with existing literature ( 41 , 51 ). Several functional barriers to overall engagement in oral health identified by our participants align with existing literature (often in residential settings), with insufficient knowledge and training and time constraints occurring particularly frequently ( 37 , 38 , 41 , 42 , 52 , 56 ). In addition, several normative barriers – such as the low prioritisation of oral health within FHOP ( 51 ), FHOPs’ resistance when assistance with daily oral hygiene is offered (particularly early on in the professional care relationship when trust has not yet been established ( 37 , 41 ), and the perception of oral care assistance as an unpleasant and even repulsive task relative to other nursing activities ( 36 , 37 , 39 ) – also correspond with previous findings. Care aides and nurses in our study also emphasised that assisting with denture cleaning is considerably easier than assisting with brushing natural teeth, in line with earlier research in residential settings ( 64 ). Our participants indicated that they perceived brushing someone else’s teeth as more intimate than performing personal hygiene and toileting. Given that FHOP aim to stay at home longer and are increasingly retaining their natural teeth ( 65 ), it is essential to address both the barriers faced by FHOP in accepting assistance, as well as the challenges faced by HCWs in providing support. Furthermore, care aides in our study noted that denture cleaning is easier in the evening, when many FHOP remove their dentures, which can help overcome barriers such as embarrassment and resistance that arise when explicitly asking FHOP to hand over their dentures. Henni et al. (2023) also reported that timing matters when assisting in daily oral hygiene ( 41 ), and Ek et al. (2018) found that some older people were reluctant to receive oral health assistance in the mornings due to nausea or other personal factors ( 38 ). From these findings, it follows that timing should be considered in task allocation discussions among HCWs. While earlier literature has mainly examined barriers to assisting with daily oral hygiene itself ( 37 , 39 ), our study also identified barriers related to other oral-health promoting behaviours of HCWs. For example, our participants identified barriers to initiating oral health conversations with FHOP. Nurses, care aides and cleaning aides all perceive oral health as a highly sensitive topic to approach. This has been previously documented among GPs and pharmacists ( 19 ). Participating home care aides, and especially cleaning aides in our study feared being seen as intrusive, believing older adults are unaware that they can offer support and advice, and thus do not expect them to initiate such discussions. Many HCWs assume FHOP would not appreciate conversations about their oral hygiene. However, a study by Blasi ( 60 ) indicates that, although older adults prefer to manage their oral care independently for as long as possible, they do expect HCWs to support them once they can no longer do so themselves. A recent interview study with Flemish FHOP also revealed that older adults themselves were reluctant to seek help with oral health, in part because they recognise that HCWs face time constraints and do not wish to impose additional burdens, and partly because they consider oral care to be an intimate matter and believe HCWs would be reluctant to perform this task ( 66 ). To address oral health in FHOP, concerted efforts are required to move oral health out of the taboo sphere, as both parties currently seem reluctant to start the conversation. Furthermore, our participants also identified several barriers when attempting to support FHOP in accessing dental care. First, many HCWs express low expectations of positive outcomes from their efforts to refer FHOP to the dentist, primarily due to the limited availability of dentists and the numerous barriers this target group faces in accessing dental care, which have been previously documented in literature ( 39 , 51 , 67 ) Second, while care aides sometimes attempt to accompany FHOP to the dentist, they express a desire for greater autonomy to do so without consulting family caregivers, often facing resistance – particularly over financial resources. However, earlier studies exploring family caregivers’ perspectives show they highly value the support of HCWs ( 68 ), while also wishing to be involved in care planning and decision-making ( 33 , 69 ). Other studies further emphasised that families can serve as both facilitators and barriers ( 69 ), underscoring the importance of relationship-building, role negotiation, and knowledge-sharing between family and professional caregivers to foster effective collaboration and improve care quality for FHOP ( 33 ). Given that participants in our study reported limited opportunities for interaction with family caregivers, it prompts the question of whether improved communication could enhance collaboration between HCWs and family caregivers. At the meso level, in terms of normative integration, many HCWs in this study reported that oral health was given low priority within their organisations, aligning with previous findings ( 40 , 41 , 51 , 70 ). This limited prioritisation was evident in the absence of oral health topics during FHOP intake procedures and the lack of oral health guidelines for HCWs. Consequently, HCWs perceived not only a lack of expectations from older adults but also an absence of organisational expectations to act on oral health. However, research on diabetes care has shown that healthcare professionals’ perceptions of expectations to perform certain behaviours were strongly linked to their intentions, which subsequently predicted their professional behaviour ( 71 ). Similar perceptions of expectations may also influence HCWs’ oral health–related behaviours. Furthermore, evidence from residential settings indicated that organisational context factors - such as leadership and culture - influenced care aides’ adherence to best practices, suggesting that targeting these factors may be a powerful approach when developing interventions ( 72 ). Future research could examine whether establishing clear organisational expectations on oral health might likewise enhance HCWs’ engagement in supporting FHOPs’ oral health. Furthermore, our participants experienced uncertainty about their role in oral healthcare for FHOP, aligning with earlier findings ( 39 , 40 ). HCWs highlighted the need for clearer role definitions, task delegation among HCWs and improved interprofessional communication and collaboration. However, cleaning aides and care aides reported reluctance to communicate on FHOP’s health with other HCWs due to previous negative experiences, citing feelings of disrespect and negative reactions from HCWs, family caregivers or FHOP. In contrast with findings from other countries, where HCWs appear to seek greater collaboration with oral health professionals ( 40 ), our participants did not report this trend. Nurses perceived their role primarily as advising the target group to consult a dentist, while care aides and cleaning aides were satisfied with the current process, which involves reporting suspected problems to a supervisor who then contacts the GP or dentist as needed. A first possible explanation for this difference compared with other countries is the structural separation between home-care services and dental professionals in our country. By contrast, in Norway, public dental service units and home-care services jointly determine how collaboration is organised to ensure that older adults receive the oral health support to which they are entitled by law ( 41 ). Although Henni et al. note that improved collaboration is necessary, it remains plausible that policy-driven expectations, together with enabling conditions, could empower home-care professionals to engage more actively with oral health professionals. Another potential explanation is the pronounced hierarchy within our home-care services, which may deter HCWs from contacting dentists. A third possibility is that HCWs have attempted to contact dentists but ceased doing so after negative experiences, linked to the shortage of dentists in our country and the tendency for this patient group not to have a regular dentist. At the macro level, participants in our study primarily indicated that current financial structures hinder engagement in oral health and collaboration among various HCWs. A systematic review by Flodgren et al. ( 73 ) suggests that – although evidence is limited - financial incentives are generally effective in improving care processes, including referrals and admissions. Additionally, Gilles et al. emphasise that addressing financial barriers is important but must be undertaken alongside organisational improvements to effectively facilitate interprofessional collaboration within integrated care initiatives ( 74 ). Strengths and limitations Adopting a qualitative approach with a multidisciplinary team experienced in qualitative research enabled in-depth discussions and thorough analyses of this complex topic. While the lack of member checks may restrict the credibility of the results, researcher triangulation was utilised to address this issue. Recruitment was limited to two primary care zones in Belgium, with only 16 or 17 participants from each professional group, which may have influenced the richness of the data and the transferability of the findings. Although the homogeneous composition of the focus groups aimed to promote open and in-depth discussions on interprofessional collaboration, the presence of colleagues may have increased the risk of socially desirable responses. Despite these limitations, the findings align with existing literature, indicating a reasonable level of transferability. Recommendations for practice Operational level Although assisting with daily oral hygiene primarily falls within the scope of nurses and care aides, consideration should be given to the potential role of cleaning aides and the delineation of responsibilities among all HCWs in activities such as providing oral health advice, initiating conversations about oral health, making referrals to oral health professionals, GPs or pharmacists, and alerting supervisors in case of oral health problems. Oral health should be systematically documented by HCWs or their supervisors during initial assessments, with regular follow-up and recording in the patient’s file, as the (oral) health of this population can decline rapidly. Home care organisations should place greater emphasis on the importance of oral health, establish clear guidelines and communicate to FHOP that nurses, home care aides and cleaning aides can play a role in maintaining and improving oral health. This could help older adults seek help earlier or accept assistance more readily. Additionally, concise oral-care instructions for HCWs provided by dentists could motivate care aides and nurses to dedicate more attention to patients’ oral health. Furthermore, HCWs should be encouraged to communicate more actively and collaborate effectively regarding the (oral) health of individual patients. Additionally, strategies should be developed to optimise collaboration with the family caregivers of FHOP. Education Providing (additional) oral health training for nurses, home care aides and cleaning aides would increase their confidence in giving oral health advice and assisting in daily oral care. Given the sensitivity of the topic, they should be equipped with tools to facilitate conversations about oral health. Especially care aides and cleaning aides would appreciate having a leaflet they can discuss with clients, to inform older people that they are trained and qualified to provide support in this area. Practical tips to assist in daily oral hygiene are particularly needed to help FHOP with natural teeth, as FHOP increasingly retain their natural dentition, and both HCWs and FHOP themselves often experience reluctance to assist with daily oral hygiene, accept help or initiate a conversation regarding assistance with oral hygiene. Additionally, it would be valuable to organise joint (oral health) trainings for local home nurses and home care aides, which could give them the opportunity to understand each other’s perspectives more fully and potentially enhance interprofessional collaboration. Policy Policymakers should consider establishing clear guidelines to enhance the responsibility of home care organisations for oral health and to clarify the division of tasks among different HCWs. It may also be worth reconsidering whether the strict prohibition on cleaning aides performing care-related tasks is necessary. Reorganizing financing systems to enhance collaboration between HCWs is also essential, and cooperation among HCWs should be actively encouraged. Creating awareness campaigns highlighting that HCWs can provide support and advice on oral health might reduce the resistance of FHOP. Raising public awareness about the importance of oral health may also encourage individuals to prioritise maintaining good oral hygiene. Intervention development This study confirms that interventions targeting functional aspects alone are insufficient; strategies at the normative level are also essential when developing effective interventions to enhance the integration of oral health care into primary care ( 19 , 75 , 76 ). Our findings also confirm the interconnectedness of barriers and needs across different levels, consistent with the Rainbow Model of Integrated Care ( 55 ). For example, the absence of oral health guidelines within organisations (meso level- functional integration) appears linked to HCWs’ low oral health engagement at the micro level (normative integration). Consequently, interventions at one level can substantially influence other levels, underscoring the need for a thorough examination of the dynamic interplay between different levels of integration to develop an effective intervention strategy. Directions for future research Based on the discussion in this paper, several directions for future research can be suggested. First, further investigation and quantification of the extent to which identified needs and barriers influence engagement and interprofessional collaboration regarding oral health are needed to inform targeted interventions. In addition, given that care aides and cleaning aides in our study reported not collaborating directly with oral health professionals or GPs on oral health, but instead relaying information through their supervisors, it may be valuable to explore the experiences and the needs and barriers these supervisors encounter in this collaboration. CONCLUSIONS There is a need for coordinated efforts across micro-, meso-, and macrolevels to enable HCWs to (a) engage in and (b) collaborate on the oral health of FHOP, with the aim of achieving functional and normative integration of oral health into primary care. Although HCWs are willing to engage in the oral health of FHOP, they currently face numerous barriers across various levels. Enhanced financial structures at the macro level and higher oral health prioritisation and clear guidelines at both macro and meso levels could strengthen their capacity and confidence to take an active role in the oral health of FHOP and facilitate effective collaboration on oral health with other HCWs. LIST OF ABBREVIATONS FHOP: frail home-dwelling older people HCWs: home care workers GP: general practitioner Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the independent Committee for Medical Ethics of Ghent University Hospital (reference number ONZ-2022-0369). This study was conducted in accordance with Good Clinical Practice guidelines and the Declaration of Helsinki, established to safeguard participants in clinical studies. After receiving verbal and written information about the study, all participants gave written consent for participation and for recording the focus groups. Consent for publication This is not applicable. Prior to the focus groups, all participants provided written informed consent. They agreed that their data would be pseudonymised for the study. The consent form included information about privacy and how the data would be stored. Availability of data and materials The datasets generated and analysed during this study are not publicly available owing to the potential for participants to be identified. The pseudonymised transcripts are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was part of the Gerodent Plus project, funded by the Flemish Agency for Care and Health, and published with the support of the University Foundation of Belgium. LP was supported by a Research Foundation – Flanders (FWO) Postdoctoral Fellowship – junior (12ZF122N). Authors’ contributions Conceptualisation: FM, PP, BJ, NH Methodology: EB, ADV, FM, LP, BJ, PP, NH Data collection: EB, ADV, FM, NH Software: NH Formal analysis: EB, ADV, FM, NH Writing – original draft preparation: NH Writing – review and editing: EB, ADV, FM, LP, BJ, PP, NH Visualisation: NH Supervision: FM, LP, BJ, PP Acknowledgements We would like to express our gratitude to the participating HCWs and organisations for sharing their perspectives and experiences. We also wish to acknowledge our collaborating partners for their contributions to participant recruitment and the refinement of the interview guides. References World Health Organization. World report on ageing and health. Geneva. https://www.who.int/publications/i/item/9789241565042. Accessed 10 Sept 2025. Roy N, Dubé R, Després C, Freitas A, Légaré F. Choosing between staying at home or moving: A systematic review of factors influencing housing decisions among frail older adults. 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1","display":"","copyAsset":false,"role":"figure","size":150534,"visible":true,"origin":"","legend":"\u003cp\u003eCausal loop diagram illustrating the interactions among factors that facilitate or hinder HCWs’ engagement in the oral health of FHOP. Positive arrows indicate facilitating relationships, while negative arrows indicate inhibiting ones. Solid arrows represent relationships identified in the focus groups; dashed arrows indicate additional links anticipated by the research team. The section above the title shows overarching facilitators and barriers to HCW engagement, whereas the section below lists specific factors cited by participants, corresponding to particular behaviours shown in bold.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8396075/v1/352dedf89c71eb7caad719ad.png"},{"id":100600163,"identity":"6d577c8d-3f16-493b-9015-8e1fb2a46caa","added_by":"auto","created_at":"2026-01-19 14:46:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":329088,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBarriers, facilitators and needs for engagement in and interprofessional collaboration on oral health in FHOP experienced by home nurses, home care aides and cleaning aides. \u003c/strong\u003eThe findings from the focus groups are\u003cstrong\u003e \u003c/strong\u003eclassified according to the Rainbow Model for Integrated Care, highlighting needs (+), facilitators (*) and barriers (-) across the micro, meso, and macro levels, as well as distinguishing normative aspects (e.g. shared values, a common mission and vision) from functional aspects (these are practical and operational processes and structures).\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8396075/v1/0ffa1a36aea6fc23f579143d.png"},{"id":100804104,"identity":"3bf54052-d1c1-4371-a78b-48639f704067","added_by":"auto","created_at":"2026-01-21 14:37:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1741172,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8396075/v1/37ce73b0-7fb3-40de-b6b5-f4b3fa2dd34c.pdf"},{"id":100600042,"identity":"a45084a3-a0e4-48a7-899d-634adcd08ba6","added_by":"auto","created_at":"2026-01-19 14:46:02","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":214694,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2Interviewguidehomenursesandhomecareaides.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8396075/v1/e81c10526304f1899f819f64.pdf"},{"id":100599508,"identity":"043dfd20-53b1-4286-9bdc-a54280a79a81","added_by":"auto","created_at":"2026-01-19 14:43:37","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":147728,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1COREQchecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8396075/v1/21acd5224566fd36a952a7d1.pdf"},{"id":100600027,"identity":"43c50bca-2c4b-4196-8b1e-6afbc1cf7275","added_by":"auto","created_at":"2026-01-19 14:45:53","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":227829,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3Interviewguidecleaningaides.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8396075/v1/98f6d87d42429afda5e90368.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Interprofessional collaboration on oral health for frail home-dwelling older people: a focus group study exploring the perspectives of home nurses, home care aides and cleaning aides","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eIn Western countries, older people prefer to age in place for as long as possible and are encouraged to do so (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Systematic reviews indicate that over 50% of these home-dwelling older people experience multimorbidity (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e3\u003c/span\u003e), which increases the risk of frailty (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e4\u003c/span\u003e). One of the morbidities associated with this ageing population is poor oral health, with an estimated 280\u0026nbsp;million older adults worldwide affected by oral health conditions (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This is partly attributable to the numerous barriers hindering this population to access oral healthcare (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and frail home dwelling older peoples\u0026rsquo; physical or cognitive decline often impeding the maintenance of adequate oral hygiene at home (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Additionally, poor diet and dry mouth associated with polypharmacy, which is common in older adults with multimorbidity, may exacerbate oral health problems (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, oral health is not only a fundamental aspect of overall physical health but can also have a significant impact on the mental health and quality of life of older adults (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite evident treatment needs identified by oral health professionals, the number of visits to these professionals generally decreases after the age of 65 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e13\u003c/span\u003e), a phenomenon that is even more pronounced among frail older people (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This illustrates the inverse care law, which states that populations with greater clinical needs receive less care (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Literature indicates that primary care professionals such as General practitioners (GPs) and pharmacists could play a vital role in monitoring the oral health of frail home-dwelling older people (FHOP) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e18\u003c/span\u003e). They are highly accessible and typically establish trusting relationships with older patients. Furthermore, FHOP generally have more frequent contact with these professionals as they age, suggesting GPs and pharmacists could play a pivotal role in monitoring FHOPs oral health. However, a recent study indicates that GPs and pharmacists currently devote little attention to oral health, facing multiple barriers such as a lack of knowledge and responsibility, time constraints, low outcome expectations, limited prioritisation of oral health by older people, and the perception of oral health as a sensitive topic (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, it is well recognised that the likelihood of older people receiving support from home nurses, home care aides, and cleaning aides (hereafter jointly referred to as home care workers or HCWs) increases with age. The assistance of HCWs includes a range of activities, such as nursing care and (instrumental) activities of daily living (i)ADL, like washing, dressing, shopping, cooking, and cleaning. The WHO report on health and ageing states that HCWs should play a crucial role in addressing the challenges of ageing societies, and that existing care models should be reoriented to prioritise primary and community-based care (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This is particularly relevant in the context of rising care dependency ratios and the growing pressure on family caregivers (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e21\u003c/span\u003e), whose essential role will persist given their unique position in bridging FHOP and formal care providers and the substantial workload on healthcare professionals (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding oral health, literature indicates that HCWs can play a vital role across multiple domains: firstly, as frontline monitors of the oral health status who can recognise when a referral to oral health professionals is necessary; and secondly, in supporting oral health routines, such as assisting with tooth brushing and facilitating preventive check-ups with oral health professionals (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Literature primarily discusses the role of HCWs without explicitly mentioning non-health professionals (such as cleaning aides). However, the Vision report 2030 by the World Dental Federation adopts a broader approach, emphasising that both non-dental health professionals (e.g. home nurses and home care aides) and non-health professionals (e.g. cleaning aides) can contribute meaningfully to the oral health of this patient group (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Additionally, there is growing recognition that cleaning aides can play a more important role beyond only cleaning, and that there is overlap between cleaning and caring (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Moreover, like home care aides, cleaning aides tend to spend more time with FHOP than nurses and, often before medical issues arise, frequently fostering close relationships and substantial trust with their clients (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdditionally, the importance of interprofessional collaboration among dental and non-dental primary care professionals is well recognized as essential for improving population oral health (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Recent studies also highlight the need for enhanced task delegation and delineation among home care professionals (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and fostering effective collaboration between formal and informal caregivers to optimise care delivery (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile some studies have explored the engagement, needs, and barriers to contributing and collaborating on the oral health of older people experienced by HCWs in residential settings, or those working in both home care and residential care (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37 CR38\" citationid=\"CR36\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e), very little research has been conducted specifically in home care settings (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Common barriers reported in the literature include a lack of knowledge, skills, and confidence, limited time, patient refusal of care, and unclear responsibilities. Frequently expressed needs include more oral health education and a greater focus on oral health in the workplace. Additionally, only a few studies examine the role of home care aides in this context (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e42\u003c/span\u003e), and to date no studies have explored the role of cleaning aides.\u003c/p\u003e \u003cp\u003e Considering the gaps in literature outlined above, this study aims to (a) explore the current engagement of home nurses, home care aides and cleaning aides in the oral health of FHOP and (b) identify the needs and barriers they encounter to engagement in, and interprofessional collaboration on, oral health for FHOP. The findings could (a) inform strategies to enhance engagement and interprofessional collaboration by addressing these needs and barriers, and (b) support the development of policy recommendations to improve interprofessional collaboration on oral health for FHOP.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eGiven the exploratory nature of this study, a qualitative approach was employed, using semi-structured focus groups to investigate HCWs\u0026rsquo; experiences and perspectives. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e43\u003c/span\u003e), the completed checklist can be found in Additional file 1.\u003c/p\u003e \u003cp\u003eSetting in Belgium\u003c/p\u003e \u003cp\u003eIn Flanders, Belgium, approximately 20% of older adults utilise some form of home care (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The first category comprises home nurses, who are fully qualified healthcare professionals authorised to perform all nursing interventions listed in the national nomenclature, including technical procedures, care planning, and clinical decision-making (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e45\u003c/span\u003e). They operate primarily under prescription and may work independently or as employees within home-care organisations and can delegate a limited set of clearly defined tasks to a second category of home care workers: recognised home care aides, who are typically employed by organisations (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Home care aides provide personal care, assistance with daily activities (e.g., shopping, meal preparation), and specific delegated nursing tasks, but are not permitted to administer injections, manage open wounds, or perform other high-risk procedures. Cleaning aides, also primarily employed by organisations, provide domestic support only and are legally prohibited from performing any medical or nursing tasks (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOlder adults have direct access to these home care workers, often without referral or prescription; however, reimbursement policies differ substantially. Many home nursing services are reimbursed by the National Institute for Health and Disability Insurance (RIZIV/INAMI) when prescribed or funded via third-party payer schemes, frequently resulting in no out-of-pocket costs (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Reimbursement does not generally extend to services provided by home care or cleaning aides. Partial reimbursement for these services depends on the individual\u0026rsquo;s health insurance fund and eligibility criteria, with some older adults able to access a \u0026lsquo;care budget for adults with care needs\u0026rsquo;(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Additionally, some cleaning aides may be employed through tax-deductible service vouchers (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e50\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eParticipants included three groups of HCWs \u0026ndash; nurses, aides, and cleaning aides \u0026ndash; working within two primary care zones (PCZs) in Flanders, Belgium. These PCZs promote collaboration among primary care professionals to deliver coordinated, accessible services, thereby enhancing care quality, patient outcomes, and community health management. The first PCZ (Scheldekracht) is more urban with a higher density of health professionals, including oral health professionals, whereas the second PCZ (RITS) is more rural. Eligibility criteria were: (a) employment within one of the two involved PCZs, (b) having professional contact with FHOP, and (c) fluency in Dutch. Purposive sampling was used to recruit HCWs through different channels, including (a) our stakeholder group representing organisations dedicated to the care for older adults, (b) personal outreach to home care organisations and independent HCWs.\u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003ePrior to conducting the focus groups, semi-structured interview guides were developed based on existing literature (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e52\u003c/span\u003e) and tailored to each professional group. The guides were discussed within the interdisciplinary research team, refined based on feedback from oral health experts, and piloted with a home nurse, a home care aide, and a cleaning aide. The key topics addressed included: (a) the perceived importance of oral health for FHOP within their profession, (b) current (inter)professional practices on oral health, (c) perceived needs and barriers to engagement in and collaboration on oral health of FHOP, and (d) optimal organisation of oral health care for this patient group. The final interview guides are available in additional files 2\u0026ndash;4.\u003c/p\u003e \u003cp\u003eData were collected from February to December 2023. To facilitate open discussions regarding interprofessional collaboration, we attempted to organise homogeneous focus groups by professional group. Efforts were made to organise the discussions in person when feasible, often at the location of their organisation to minimise disruption of their activities. Each discussion commenced with an introduction and the completion of the informed consent form and a demographic questionnaire covering gender, age, years of experience, work setting, primary care zone, and oral health training received during or after their education. For online focus groups, these documents were provided in advance by email and returned before the start. The focus groups were moderated by NH, trained in qualitative healthcare research. The discussions were audio recorded, while an observer from the research team (EB, ADV) took supplementary field notes. Data saturation was not strictly pursued, as the reflexive thematic approach by Braun and Clarke was adopted (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e53\u003c/span\u003e). They indicated that meaning is co-constructed through interpretation, and that determining saturation is inherently subjective and context-dependent (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Data collection continued until the analyses revealed few new themes.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFocus groups were transcribed ad verbatim and analysed using NVivo 14 (\u0026copy; QSR International). Data analysis employed Braun and Clarke\u0026rsquo;s reflexive thematic approach (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e53\u003c/span\u003e), which emphasises researcher reflexitivity and an iterative process of theme development. This method facilitates in-depth exploration of data, nuanced interpretation, and the identification of meaningful patterns within complex qualitative datasets. The analysis comprised six steps. First, familiarisation with the data involved repeated reading of transcripts (Step 1). In Step 2, initial codes were generated through open coding. The first transcript was independently coded by four team members with diverse backgrounds (NH, EB, ADV, FM \u0026ndash; speech therapist, health promotor, dentist and general practitioner), followed by collaborative discussion guided by an experienced qualitative researcher (FM). The goal of this discussion was to explore diverse perspectives through dialogue and reflection, rather than reaching a full consensus. These multidisciplinary discussions enriched insights, sometimes broadening the researchers\u0026rsquo; perspectives when coding subsequent transcripts.\u003c/p\u003e \u003cp\u003e Two researchers (NH\u0026thinsp;+\u0026thinsp;ADV, EB or FM) first independently coded the remaining transcripts, followed by discussing discrepancies to acknowledge different perspectives rather than reach full agreement. Throughout the analysis, the coding framework was iteratively refined. In Step 3, codes were grouped into initial themes and illustrative quotes were selected by NH. These themes and quotes were reviewed (Step 4) by the multidisciplinary research team (including two general practitioners, two oral health professionals, a psychologist and a health promoter), to enhance robustness through investigator triangulation. Subsequently, final themes were defined and descriptively named (Step 5). In the 6th and final step, NH integrated these themes into a coherent narrative.\u003c/p\u003e \u003cp\u003eCausal loop diagrams were also developed as an intermediary phase in our analytical process, to move beyond unidimensional linear causal thinking. These diagrams were incorporated into the results where interactions were too complex to clarify through text alone. Finally, findings were contextualised within the Rainbow Model for Integrated Care, a comprehensive framework specifically developed for primary care and designed to understand and improve integrated care across health systems (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e55\u003c/span\u003e). The model distinguishes two core aspects: normative integration (e.g. shared vision, culture, and values) and functional integration (e.g. practical coordination and alignment of services). Additionally, the model emphasises the interconnectedness between the micro (health services), meso (professionals and organisations), and macro levels (policy and system).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eSeven focus groups were conducted: two with home nurses (one comprising autonomous home nurses working within the same group practice, and the other with salaried nurses employed within the same care organisation), two with home care aides, two with cleaning aides, and one mixed group that included both home nurses and home care aides. This mixed group collaborated on the care for residents of a single assisted facility. The average number of participants per focus group was seven, with a minimum of five and a maximum of eight. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents an overview of the focus group characteristics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of focus-group characteristics in the chronological order of the discussions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocus group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfessional group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary Care Zone\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmployed home nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCleaning aides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHome care aides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHome care aides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCleaning aides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent home nurses and home care aides\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFG7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent home nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 50 participants were recruited, comprising 17 home nurses, 17 home care aides, and 16 cleaning aides. Participants did not opt in individually; instead, managers of HCWs or coordinators within group practices invited staff to join a focus group, with on-site sessions arranged during working hours. One focus group with independent home nurses was conducted via MS Teams due to their demanding schedules. The average focus group duration was 72 minutes (range 61\u0026ndash;91 minutes). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents a summary of the participants\u0026rsquo; demographic profiles, education and work context.\u003c/p\u003e \u003cp\u003eAll participants had daily interactions with FHOP. Regarding their employment status, all home care aides and cleaning aides were employed by an organisation. Among the community nurses, ten were employed by an organisation, six were self-employed, and one nurse combined self-employment with organisational work.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA summary of participants\u0026rsquo; demographic profiles, education and work context.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eProfessional group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome nurses (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHome care aides (n\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCleaning aides (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003en (%) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 (94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePrimary care zone in Flanders (Belgium)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCZ RITS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCZ Scheldekracht\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePerception of the extent to which oral health was addressed in their basic training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot at all addressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAddressed to a limited extent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAddressed in depth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eHas followed an extra oral health training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eYears of work experience in current profession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e56\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe clustered and presented the inductively identified themes according to the initial research questions, resulting in two main themes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) engagement of HCWs (including home nurses, home care aides and cleaning aides) in oral health of FHOP, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) barriers and needs for interprofessional collaboration.\u003c/p\u003e \u003cp\u003eTheme 1: ENGAGEMENT OF HOME CARE WORKERS IN ORAL HEALTH OF FHOP\u003c/p\u003e \u003cp\u003eSubtheme 1: Perceived roles and willingness to engage\u003c/p\u003e \u003cp\u003e Overall, participating nurses, care aides and cleaning aides recognised a potential role for themselves in the oral health of FHOP and most participants expressed a willingness to fulfil this role. However, the degree of engagement varied by professional group. Most participants believed that supporting oral health falls to the person responsible for daily care \u0026ndash; whether a nurse or care aide. This contrasted with their reluctance to approach FHOP about suspected oral health problems, which most participants perceived as a very difficult topic to raise.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 5: Would you say to your friend: \u0026ldquo;Your teeth aren\u0026rsquo;t clean?\u0026rdquo; It\u0026rsquo;s one thing to tell someone to wash their armpits because they\u0026rsquo;re a bit smelly, but telling someone they have to clean their teeth is different. I think that\u0026rsquo;s still a bit of a taboo.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Among the professional groups, care aides appeared most inclined to address oral health; however, it is important to emphasise that this was highly individual and not solely dependent on their profession. Care aides particularly underscored their motivation to assist and advise on oral health, citing its importance for the overall well-being of FHOP, and their wish that attention will be given to their own oral health as they age.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 6: It\u0026rsquo;s in my routine to ask patients for their dentures too and clean them. It\u0026rsquo;s because I would also want a clean mouth for myself after eating and before going to bed, even when I\u0026rsquo;m older\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Cleaning aides also recognised their potential role in advising FHOP on oral health and expressed a willingness to assist with cleaning denture containers. Some noted that they would also be willing to help FHOP clean their dentures if no other support was available.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 13: I clean out their denture containers when I\u0026rsquo;m in the bathroom. It seems to me they don\u0026rsquo;t do this often enough themselves, and I feel it\u0026rsquo;s my job to take care of that as well. They don\u0026rsquo;t ask me to do it, but it feels almost automatic to me...\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e In contrast, participating nurses \u0026ndash; particularly independent nurses \u0026ndash; were more hesitant to assist with daily oral hygiene. They preferred to intervene only under specific conditions, emphasising that their role is to empower FHOP rather than to take over care.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 3: It is also our role to encourage self-care. Everything they can still do for themselves is really important as well. It\u0026rsquo;s like: \u0026ldquo;Oh, I can still manage that on my own\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Despite most participants\u0026rsquo; stated willingness to take on a role in FHOPs\u0026rsquo; oral health, several overarching barriers to their fulfilment of this role were identified. These included limited oral health knowledge, insufficient time, and high workloads. The latter two frequently led HCWs to prioritise other aspects of care perceived as more acute or tasks that FHOP seemed to deem more important.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 12: Sometimes you have to make choices. We\u0026rsquo;re understaffed, and there\u0026rsquo;s so little time for each patient. It\u0026rsquo;s not an excuse, it\u0026rsquo;s the reality\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSubtheme 2: Prioritisation of oral health by FHOP\u003c/p\u003e \u003cp\u003e Building on the preceding theme, nurses and care aides perceived that oral health occupies a low priority on FHOPs\u0026rsquo; agenda, which in turn reduced their own engagement in FHOPs\u0026rsquo; oral health. Across all focus groups, participants attributed this low prioritisation to oral health not being emphasised during the upbringing of this generation, although some observed a more positive trend among younger FHOP compared with the oldest cohort.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 12: It\u0026rsquo;s also because FHOP themselves don\u0026rsquo;t really find it that important, so we don\u0026rsquo;t really find it that important either. We focus on what they ask, and that already fills our time\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 6: Especially the generation over 80, they don\u0026rsquo;t see it as important. We weren\u0026rsquo;t allowed to go to bed without brushing our teeth, but that wasn\u0026rsquo;t drilled into that generation.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 12: You have to search for a toothbrush in the back drawer and then they say: \u0026lsquo;I\u0026rsquo;d rather have you wash my hair.\u0026rsquo; Sometimes you have to make choices, it\u0026rsquo;s a fact that we\u0026rsquo;re understaffed and that there\u0026rsquo;s so little time per care recipient. It\u0026rsquo;s not an excuse, but it is like that. If they would say: Let\u0026rsquo;s brush my teeth, we would all do it.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Participants from all professional groups indicated that this lack of prioritisation became clear because FHOP rarely addressed this topic or requested assistance with oral health, despite having no difficulty doing so for other (health) problems. Participants also believed this was partly attributable to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) embarrassment about their oral hygiene and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) FHOPs\u0026rsquo; unawareness that HCWs could offer assistance with oral health.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 11: Those older people don\u0026rsquo;t ask for help with their oral health. For the patients I do assist, I\u0026rsquo;ve had to ask myself: how are your teeth?\u003c/em\u003e \u003c/p\u003e \u003cp\u003e While the first two subthemes addressed overarching barriers to HCWs engagement with FHOPs\u0026rsquo; oral health, the subsequent subthemes will delve deeper into the oral health-related actions HCWs undertake, and the specific barriers and needs they encountered in performing these actions.\u003c/p\u003e \u003cp\u003eSubtheme 3: Oral health awareness from intake to follow-up\u003c/p\u003e \u003cp\u003e Despite their willingness to engage in oral health, most nurses and care aides noted that oral health received minimal attention in their professional interactions with FHOP, as other concerns often seemed more urgent.\u003c/p\u003e \u003cp\u003e\u003cem\u003eNurse 3: My gut feeling tells me that I\u0026rsquo;m not paying enough attention to it. I\u0026rsquo;m thinking about all my patients, and honestly, I really don\u0026rsquo;t know how things are with the oral health of five of my patients.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Many nurses and care aides indicated that this lack of attention partly stemmed from oral health being largely overlooked during the intake process \u0026ndash; typically conducted by their supervisors \u0026ndash; which resulted in limited awareness of clients\u0026rsquo; oral health status. In the rare instances where oral health was assessed at the outset, it was seldom followed up, despite this patient group being at increased risk of rapid deterioration.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Nurse 14 \u0026ndash; Independent Nurse: \u0026lsquo;I don\u0026rsquo;t really ask about their oral health at the start. I just assume that they will ask if they need help\u0026hellip;\u0026rsquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 3: I think that it often gets forgotten. Sometimes it\u0026rsquo;s asked at the start, but we should also reevaluate it because patients also decline. I have to admit that it\u0026rsquo;s something I do sometimes forget.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Towards the end of the focus groups, several participants indicated that they should routinely consider their clients\u0026rsquo; oral health, rather than assuming that FHOP would seek assistance when necessary.\u003c/p\u003e \u003cp\u003eSubtheme 4: Hesitance to assist and resistance from FHOP\u003c/p\u003e \u003cp\u003e All HCWs reported occasionally offering FHOP advice on performing daily oral hygiene. In terms of assisting, cleaning aides primarily focused on keeping denture storage containers clean, while care aides and nurses also assisted some clients with tooth brushing or denture cleaning; however, they reported rarely assisting with the hygiene of natural teeth.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 6: There is a big difference between dentures and real teeth. With dentures, they can just take them off, it\u0026rsquo;s easier and they ask for help much quicker. With natural teeth, it must feel really strange for them, and they don\u0026rsquo;t always accept help\u0026hellip;\u003c/em\u003e \u003c/p\u003e\n\u003ch3\u003eHesitance in home care workers\u003c/h3\u003e\n\u003cp\u003e Many nurses and care aides perceived helping with natural teeth to be even more intimate than providing personal hygiene care. In every focus group, participants even reported feelings of disgust when cleaning dentures or storage containers.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Care aide 9: I find it harder to help with oral hygiene than with intimate personal care. Perhaps it\u0026rsquo;s because we do it more often, making it a habit. Oral hygiene isn\u0026rsquo;t part of the routine. However, it becomes easier with regular practice.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 2: Cleaning these dentures, often laying in that same dirty water\u0026hellip;it really grosses me out sometimes.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Additionally, most nurses highlighted that they only took over daily oral care in specific conditions or situations (e.g., highly dependent or palliative patients, patients with significant cognitive decline, \u0026hellip;) because they believe it is their role to empower FHOP to maintain independence for as long as possible. Nurses indicated that taking over oral hygiene tasks for FHOP would create an internal conflict if they had not requested help and were still able to manage it themselves.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Nurse 14 \u0026ndash; Independent nurse: In palliative care, we pay more attention to oral health, because it\u0026rsquo;s really important for them to have a fresh mouth.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 3: It is also our role to encourage self-care. Everything they can still do for themselves is really important as well. It really lifts them up to think: \u0026ldquo;Oh, that\u0026rsquo;s something I can still manage on my own\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e HCWs\u0026rsquo; perception to have insufficient knowledge about oral health was identified not only as an overall barrier for engagement in FHOPs oral health but also repeatedly cited by participants as a specific obstacle to assisting and advising on oral health. Cleaning aides reported receiving no education on this topic. Recently qualified nurses and care aides have received training in oral health during their education, whereas their more experienced colleagues indicated that this topic was only touched upon very briefly in their training. The majority of participating nurses, care aides, and cleaning aides indicated that their lack of knowledge left them feeling uncertain about giving advice or assisting with daily oral hygiene.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 3: In my training 24 years ago, I certainly didn\u0026rsquo;t see anything about oral health\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Consequently, nearly all participants indicated that additional training in oral health would improve their confidence in this context. They expressed particular interest in learning more about denture maintenance, supporting toothbrushing, using adhesive denture paste and mouthwash, and understanding the costs and reimbursement of dental treatments. They noted that improved knowledge would enable them to provide more consistent and confident oral health guidance and would likely increase the credibility FHOP attributed to them regarding oral health.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 7: I think all nurses would welcome additional training on this matter. It would also bring a bit of uniformity in our approach and enable us to properly inform patients when they have questions.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e Care aide 13: Additional training would be beneficial, however, then it also has to be communicated to clients during intake that we can assist with oral care\u0026hellip;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e Cleaning aide 4: It would be great to receive more information on helping clients with oral health when we see they\u0026rsquo;re struggling. It would make it easier for us to respond to their questions and they would appreciate it if we can give tips.\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eResistance from FHOP\u003c/h3\u003e\n\u003cp\u003e Additionally, participants from all professional groups reported that they often encountered resistance from FHOP when providing assistance with or advice on oral hygiene. They highlighted that FHOP generally preferred to manage their own oral health and adhered to their established routines, and they often perceived that FHOP lacked trust in the methods suggested by HCWs.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Nurse 7: Oral hygiene is very personal. Much like washing their face, people prefer to do it themselves if they can.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 6: Many FHOP maintain their dentures incorrectly. But when you give advice, they say: \u0026lsquo;we\u0026rsquo;ve been doing it this way our whole lives. Who are you to come and tell me how to do it..\u0026rsquo; So yeah, that\u0026rsquo;s where it ends\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Furthermore, most nurses and care aides were convinced that it must be very uncomfortable and strange for FHOP to have someone else brushing their teeth. Care aides indicated that brushing FHOPs\u0026rsquo; dentures during night shifts was easier, since FHOP remove their dentures at night, thereby avoiding the embarrassment of requesting them to remove their teeth. Participants also noted that the dynamic and resistance differs from a residential setting; they are in the clients\u0026rsquo; homes, which is their territory, and FHOP prefer to maintain control over their care.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 11: It\u0026rsquo;s not like in a hospital where you say: \u0026lsquo;now this needs to happen, and now that needs to happen.\u0026rsquo; There\u0026rsquo;s a different hierarchy when you\u0026rsquo;re in their home, you\u0026rsquo;re on their territory.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, care aides and cleaning aides indicated that this was also dependent on the personalities of FHOP; and as they visited more regularly and built trust, they became more open to accepting HCWs\u0026rsquo; help and advice.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 15: The longer you visit FHOP and the more they trust you, the more they allow you to do.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Furthermore, especially cleaning aides and some care aides felt that FHOP also showed resistance because they were unaware that these professionals could play a role in their oral health. They believed FHOP did not see oral health as part of their job.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 15: You don\u0026rsquo;t really ask that as a cleaning aide, do you? \u0026ldquo;Have you cleaned your teeth?\u0026rdquo; I mean... For some people we\u0026rsquo;re \u0026lsquo;just\u0026rsquo; the cleaning aides\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e To reduce resistance from FHOP, most participants suggested that the intake process for new clients \u0026ndash; typically conducted by supervisors of HCWs \u0026ndash; should include oral hygiene, accompanied by a leaflet on daily oral care that could also be discussed with current clients by HCWs. They believed this would clarify that HCWs can support clients in this area, potentially leading to greater acceptance of oral health advice and encouraging clients to seek assistance more promptly when necessary. However, care aides expressed concerns about addressing oral health during intake, highlighting that it takes time to establish trust with FHOP.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 4: We really need a leaflet with information. Without it, convincing FHOP will be tough. If they\u0026rsquo;ve used toothpaste on their dentures for years, they may not believe us when we suggest to do it with soap.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e Care aide 5: Some clients don\u0026rsquo;t realise we want to help with oral hygiene. If they would know this from the beginning, it would make a difference\u0026hellip;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Subtheme 5: Bridging observation and conversation on suspected oral health problems\u003c/p\u003e \u003cp\u003e Although oral health is seldom discussed by those responsible for intake during the initial assessment, most HCWs frequently observed signs of poor oral health when visiting FHOP (e.g., non-use of dentures, unused or worn toothbrushes, dirty storage containers, bad breath, avoidance of hard foods). However, most HCWs rarely initiated conversations about FHOPs\u0026rsquo; oral health, finding it very challenging since oral health remains a highly sensitive topic for them.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Care aide 13: I find that really difficult\u0026hellip; I once visited an older lady whose breath smelled very unpleasant. I had to turn my head away while she spoke, but it\u0026rsquo;s so difficult to address that. I even find it easier to mention a urine smell\u0026hellip; You really have to visit them a while before you dare to say something about their oral health.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSome HCWs occasionally engaged in such conversations, but their confidence in doing so largely depended on their relationship with FHOP and FHOPs\u0026rsquo; personalities.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 6: It really depends on the person\u0026hellip; I have a client who is very proud; I don\u0026rsquo;t think I could say anything to her.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 1: When you spend more time with a client, you become a trusted figure, making them more likely to accept your input.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Some participating care aides and most cleaning aides expressed fear of potentially offending clients by initiating this conversation and creating an impression of intrusiveness. Because they believed FHOP do not expect action from them in this area, cleaning aides and care aides regarded it as primarily the role of family caregivers and nurses to initiate this discussion.\u003c/p\u003e \u003cp\u003e\u003cem\u003eCleaning aide 1: I don\u0026rsquo;t think that\u0026rsquo;s our primary role to address that, and we don\u0026rsquo;t want to offend them, you know\u0026hellip;If we notice something\u0026rsquo;s wrong, it\u0026rsquo;s our job to tell it to our supervisors. But to be honest, that almost never involves oral health\u0026hellip;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Most participants reiterated the potential benefits of providing a leaflet that would promote discussions about oral health, and advocated for including oral health within the intake process to inform clients that, alongside nurses, care aides and cleaning aides can offer support in this area.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 15: With a little leaflet, you have a starting point to have that conversation\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipating nurses, care aides and cleaning aides did report suspected health problems to their supervisors. Nevertheless, most participants indicated that this rarely pertained to oral health.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 15: We are also quite important, as we sometimes spend four hours there, and therefore we might notice more quickly if they\u0026rsquo;re showing signs of dementia or start to wobble, just to give an example. Our supervisors expect that we communicate that. I do think we can do that. And then our supervisor passes that on to the home care team and they pay more attention to that.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSubtheme 6: Overcoming access barriers and low outcome expectations\u003c/p\u003e \u003cp\u003e When FHOP did approach HCWs with oral health concerns, most participants reported referring them to a dentist or GP, though they reiterated that enhanced oral health knowledge is needed to facilitate smoother referrals. Nurses and care aides also expressed a preference for referring FHOP to general practitioners, citing (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the limited availability of oral health professionals \u0026ndash; especially for FHOP who often lack a regular dentist - and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) greater FHOP familiarity with their GP.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 13: \"Dentists are so hard to reach these days, and getting FHOP there is challenging. Honestly, I\u0026rsquo;ve never called a dentist in twelve years. I\u0026rsquo;d rather buy them some mouthwash and in the worst case, I\u0026rsquo;d contact the GP.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, most HCWs reported low outcome expectations regarding FHOP visiting a dentist after referral, even when dental appointments would be more accessible. Beyond the broader lack of prioritisation of oral health in this patient group, they cited many reasons why FHOP would not attend dental visits, including: unfamiliarity with dental care from their upbringing, the belief that seeking oral healthcare is no longer worthwhile at their age, mobility issues, cost concerns, fear of pain associated with dental treatments, and the prosect of navigating a lengthy, burdensome process.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 15 \u0026ndash; Independent nurse: \"These patients only visit the dentist when they have problems; they don\u0026rsquo;t see the need otherwise. Regular check-ups make sense to us because it was ingrained in our upbringing, but not to them\u0026mdash;they act only when in pain.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e Cleaning aide 7: I just think they\u0026rsquo;re not thinking about their oral health. If there is a problem with their teeth, they just mash their potatoes and they can still eat, so they don\u0026rsquo;t see the problem.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Despite these doubts, participants described several strategies to engage FHOP in the oral health circuit. First, they suggested that conducting preventive oral health screenings at home or in local service centres could be beneficial. Some participants argued that these could be performed by dental hygienists, noting that preventive tasks should be delegated to this professional group to allow dentists to devote more time to dental treatments.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 3: Home visits for preventive check-ups would be excellent. If hairdressers and doctors can come to their house, why not dentists?\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSecond, they suggested low-cost initiatives similar to bowel cancer screenings and mammograms, with invitations sent to FHOP. Participating HCWs saw a role for them in encouraging FHOPs attendance.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 4: They would come to us with these invitation letters. If we could explain it to them and motivate them a bit, they\u0026rsquo;ll be more likely to do it.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Finally, some participants suggested raising awareness among FHOP about the importance of oral health and oral health screenings; however, most believed that FHOP are very hard to reach with preventive measures.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 16 \u0026ndash; Independent nurse: \"Prevention? These people aren\u0026rsquo;t thinking about that; they\u0026rsquo;re focused on dying, not on going to the dentist.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSubtheme 7: Practical barriers and family-induced obstacles\u003c/p\u003e \u003cp\u003e Concerning support for FHOP in arranging dental appointments, care aides and cleaning aides occasionally assisted in scheduling these appointments or communicated with their superiors for this purpose. In contrast, nurses typically delegated this responsibility to family caregivers, citing a lack of time, whereas family caregivers\u0026rsquo; greater availability and better insight into suitable appointments were noted.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 6: \"Sometimes we make an appointment for them. They don\u0026rsquo;t want to ask their children because they already have so much to do.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 15 \u0026ndash; Independent nurse : \"There are FHOP who ask to make an appointment, but I usually refer them to their family. We can\u0026rsquo;t take that on us.\"\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Care aides reported occasionally accompanying clients to dental appointments, recognising that this support is valued by clients and helped FHOP feel more at ease with the dentist.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 9: They appreciate it if we can join them to the dentist. Because they know their GP, but they might not have seen a dentist for years, so they don\u0026rsquo;t know what to expect and then they really appreciate our company.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, they also faced a range of practical and organisational challenges, frequently requiring them to adjust their own working hours to accompany clients. Additionally, they often encountered resistance from family caregivers who judged a dental visit unnecessary for FHOP or who were reluctant to provide financial resources.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Care aide 15: You can\u0026rsquo;t just bypass the family and say \u0026lsquo;I\u0026rsquo;m taking you to the dentist.\u0026rsquo; Some FHOP don\u0026rsquo;t have any money at home; everything has to go through the family\u0026hellip; Sometimes you have more trouble with the family than with FHOP themselves.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. \u003cem\u003eCausal loop diagram illustrating the interactions among factors that facilitate or hinder HCWs\u0026rsquo; engagement in the oral health of FHOP. Positive arrows indicate facilitating relationships, while negative arrows indicate inhibiting ones. Solid arrows represent relationships identified in the focus groups; dashed arrows indicate additional links anticipated by the research team. The section above the title shows overarching facilitators and barriers to HCW engagement, whereas the section below lists specific factors cited by participants, corresponding to particular behaviours shown in bold.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eTheme 2: Needs and barriers for interprofessional collaboration on oral health\u003c/p\u003e \u003cp\u003eSubtheme 1: Unclear oral health responsibilities among home care workers\u003c/p\u003e \u003cp\u003eFrom the focus groups, it became clear that oral health responsibilities \u0026ndash; and their distribution among HCWs \u0026ndash; were perceived as unclear by participating HCWs, a situation they attributed to several factors.\u003c/p\u003e\n\u003ch3\u003eAwareness of oral health needs and the potential need for assistance\u003c/h3\u003e\n\u003cp\u003e Some nurses and care aides noted that awareness of FHOPs\u0026rsquo; oral health needs must be established before collaboration can commence. While all participating HCWs agreed that monitoring oral health primarily falls to the individual responsible for daily hygiene, most nurses and care aides reported that oral health was rarely addressed at intake. As previously indicated, the necessary follow-up in this already vulnerable patient group was generally lacking when oral health was addressed at intake. This resulted in limited awareness of (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) FHOPs\u0026rsquo; oral health status, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) whether FHOP could manage their oral health independently, and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e3\u003c/span\u003e) whether oral health assistance was already provided by others (e.g. family caregivers or other supportive HCWs of the client).\u003c/p\u003e \u003cp\u003eFurthermore, most participants noted uncertainty regarding the activities of other HCWs when visiting FHOP.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 17 \u0026ndash; Independent nurse: What care aides do when they visit our patients, we don\u0026rsquo;t really know. They\u0026rsquo;re mainly there for household tasks. I know some who struggle with just putting in eye drops. I don\u0026rsquo;t think there\u0026rsquo;s much actual care work going on there\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e However, regarding oral health, most participants were convinced that it was not addressed by other HCWs.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 9: Usually we\u0026rsquo;re already there when the nurse arrives, and patients already have their dentures in, but I never noticed nurses checking their dentures\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCare aide 5: I don\u0026rsquo;t think nurses pay attention to their teeth\u0026hellip; I believe it often gets neglected, because when we arrive at the start with a new client, you can really see that those teeth are often quite dirty.\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFormal and informal communication and coordination among HCWs\u003c/h2\u003e \u003cp\u003eFurthermore, participants indicated that the above lack of awareness about FHOPs\u0026rsquo; oral health needs and the potential need for assistance led to minimal (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) communication concerning oral health and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) coordination regarding oral health tasks. This occurred both among colleagues within the same discipline and between HCWs of different disciplines. For instance, nurses, care aides, and cleaning aides visiting the same FHOP often held internal meetings, yet oral health was rarely addressed during these discussions.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Nurse 16 \u0026ndash; Independent nurse: I think that we only communicate this to the teams in palliative care, if they have a really dry mouth. I think that otherwise, oral health hardly comes up in briefings.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Care aides and nurses indicated that efforts to coordinate task division between the two professional groups \u0026ndash; aiming at enabling nurses to focus on medical responsibilities \u0026ndash; had some success with individual clients. However, outcomes were highly dependent on individual care aides and families of FHOP, who did not always consent due to financial reasons (see next theme).\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 8: It somewhat depends on who the care aide is and what the patient allows\u0026hellip; Some patients prefer that we do it instead of having to pay care aides to do it, even if it means we\u0026rsquo;re spending our 15 minutes on it \u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome care aides mentioned initiatives at the organisational level to redistribute tasks between themselves and nurses but noted that these were halted by the nursing management because the proposed redistribution of tasks would have affected nurses\u0026rsquo; salaries.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Care aide 11: We had a meeting with nurses to take on more tasks from them, so they could focus on medical tasks, and we would take over the intimate care. In the Netherlands, that\u0026rsquo;s the norm. But here in Belgium, it doesn\u0026rsquo;t work like that. It\u0026rsquo;s all about the money after all. Every little task is also income for them.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e In addition to formal agreements, participants reported that making informal agreements with other HCWs was also challenging. Firstly, opportunities for spontaneous interaction are scarce, as FHOP and their families schedule HCWs\u0026rsquo; visits to prevent overlaps. Secondly, although communication notebooks are often used, cleaning aides and care aides expressed hesitation to write in them, due to negative reactions where their input was dismissed as interference by other HCWs, FHOP, or their family caregivers. Additionally, cleaning aides indicated that they preferred to inform their supervisor rather than directly report issues to other HCWs, due to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) not perceiving themselves as healthcare professionals, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) experiencing a lack of respect from nurses, care aides and family caregivers, and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e3\u003c/span\u003e) concerns about offending their clients or breaching their privacy.\u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 6: You don\u0026rsquo;t have much time to communicate with them [other HCWs] to be honest, because they\u0026rsquo;re always quickly back outside. \u0026ndash; Cleaning aide 3: And if the client is there, you can\u0026rsquo;t start talking about them either\u0026hellip; So, it\u0026rsquo;s quite difficult.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCleaning aide 10: If you write something in these notebooks, they [other HCWs] feel attacked quite easily. After a while, you don\u0026rsquo;t dare to say anything anymore, you just hold back. Once, they wrote as an answer: You are just a cleaning aide\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGuidelines and organisational focus\u003c/h3\u003e\n\u003cp\u003e Furthermore, especially nurses and care aides, noted that their organisation offered very limited guidelines on oral health and rarely emphasised its importance, both towards FHOP (e.g., during intake) and them as HCWs (e.g., during team meetings). Some participants suggested that increased organisational focus could enhance their attention to oral health with clients and reduce resistance to assistance in FHOP. Additionally, some participants indicated that a few individual dentists provided FHOP with checklists with concise oral-care instructions for HCWs, which motivated care aides and nurses to dedicate more attention to their patients\u0026rsquo; oral health.\u003c/p\u003e \u003cp\u003eSubtheme 2: Financial structures hindering interprofessional collaboration\u003c/p\u003e \u003cp\u003eAnother subtheme identified during analysis was how current financial structures appear to hinder (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) HCW engagement in oral health of FHOP and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) interprofessional collaboration between HCWs. Regarding the first point, nurses noted the lack of reimbursement codes for daily oral hygiene activities, which diminished organisational incentives to prioritise oral health and consequently affects the attention nurses allocated to it within FHOP.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 3: What will the organisation get out of it if we suddenly start paying attention to oral health? We don\u0026rsquo;t receive money for that from RIZIV. If it means I have to work longer tomorrow to observe their oral health, my bosses have to pay me for it, but they wouldn\u0026rsquo;t like doing that\u0026hellip; If you help someone putting on their compression socks, you get an extra penny for that, but that\u0026rsquo;s not the case for brushing teeth or cleaning dentures\u0026hellip;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFurthermore, both care aides and nurses indicated that financial structures hindered interprofessional collaboration. Both professional groups believed that supporting daily oral hygiene should primarily fall to care aides, indicating that they typically spend more time with clients, often had stronger trust relationships with FHOP, and could assist with purchasing suitable oral hygiene products. However, as previously mentioned, FHOPs and their families did not always agree with this division. They tended to prefer nurses to handle daily oral care, since no co-payment is required for the services of nurses employed by an organisation, unlike the services of care aides. Some nurses added that making these services free is not advisable, as it results in family caregivers delegating tasks they would otherwise perform themselves.\u003c/p\u003e \u003cp\u003e\u003cem\u003e Nurse 7: Quite often, when you try to make arrangements with care aides, FHOP say: \u0026ldquo;You shouldn\u0026rsquo;t ask them, because we have to pay for them, and you do it for free.\u0026rdquo; It\u0026rsquo;s like that for washing their feet, cleaning their dentures, \u0026hellip; We try to pass that on to care aides because they have more time, but patients quickly say: \u0026lsquo;oh no, I have to pay for them\u0026rsquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e Cleaning aide 5: I have a feeling that care aides are much more focused on hygiene now, also on daily oral hygiene\u0026hellip; But they [FHOP] rather let the nurse do it, because it\u0026rsquo;s for free\u0026hellip; That plays a role for older people\u0026hellip;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eNurse 4: If I were to tell her daughter \u0026lsquo;It\u0026rsquo;s 2 euros to clean her teeth, she would quickly start cleaning her mother\u0026rsquo;s teeth herself. If they have to pay for it, suddenly they can do it themselves. Sometimes it\u0026rsquo;s not a good thing that it\u0026rsquo;s free; people have really gotten used to that\u0026hellip;\u003c/em\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e This study identified multiple barriers, facilitators and needs experienced by HCWs regarding (a) engagement in oral health for FHOP (Theme 1) and (b) interprofessional collaboration on oral health for this patient group (Theme 2).\u003c/p\u003e \u003cp\u003eAlthough research exists on HCWs\u0026rsquo; engagement in oral health in residential care settings, this study is among the first to explore the perspectives and opinions of nurses and care aides within home care contexts. To our knowledge, it is also the first study to examine the potential roles and viewpoints of cleaning aides in the oral health of this population. The study primarily provides novel insights at the micro level and in relation to normative integration, enhancing understanding of the factors that impede HCWs\u0026rsquo; engagement in the oral health of FHOP. It adopts a broader perspective on HCWs\u0026rsquo; oral health-related behaviours than existing literature in residential settings, extending beyond the provision of daily oral hygiene assistance.\u003c/p\u003e \u003cp\u003eComparison with existing literature\u003c/p\u003e \u003cp\u003eTo facilitate the comparison with the existing literature, we summarised the findings in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e in accordance with the Rainbow Model for Integrated Care (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e55\u003c/span\u003e). In the remainder of the discussion, the focus will be primarily on novel insights.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAt the micro level, most nurses and care aides involved in our study expressed a sense of responsibility for assisting in oral health, recognising it as an integral component of basic hygiene, as noted in prior work (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e56\u003c/span\u003e). They demonstrated a willingness to engage in oral care, primarily because they believe a fresh mouth supports FHOPs\u0026rsquo; wellbeing and because they would like similar care for themselves as they age, in line with earlier research (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Care aides in our study appeared to engage more actively in FHOPs\u0026rsquo; daily oral hygiene than nurses and demonstrated a more positive attitude towards providing such assistance. This observation is consistent with a quantitative study in nursing homes, which also found that home care aides showed greater involvement in residents\u0026rsquo; daily oral hygiene and exhibited more positive attitudes than nurses, who showed lower involvement but possessed greater knowledge of oral health (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Previous research has also indicated that knowledge alone is insufficient to establish behavioural change (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e58\u003c/span\u003e). However, interventions aimed at enhancing knowledge and skills may strengthen not only care professionals\u0026rsquo; knowledge, but also their beliefs about their capabilities and the consequences of their actions, both of which have been shown to predict behaviour (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Similarly, increased involvement in daily oral hygiene may provide HCWs with opportunities for experiential learning, potentially enhancing their confidence and promoting more positive attitudes and behaviours towards assisting with oral care. Participants in our study also indicated that performing oral health tasks more frequently might reduce their reluctance to provide support and facilitate habit formation.\u003c/p\u003e \u003cp\u003e Furthermore, nurses in our study indicated that empowering FHOP is a key aspect of their role, rather than merely taking over (oral) care. Previous research also suggests that older adults wish to remain independent in their oral health as long as possible (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e60\u003c/span\u003e), and that HCWs must balance the promotion of patient autonomy with the provision of necessary care (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e61\u003c/span\u003e). However, our findings raise the question of whether some nurses may be invoking the concept of autonomy as a justification for the limited attention currently given to oral health, as true empowerment would require systematic assessment of their oral health status and daily hygiene routines at intake, along with regular follow-up throughout the care pathway. A potentially more effective approach would be to involve HCWs in integrating daily oral hygiene into the prominence-gaining care concept of \u0026lsquo;reablement\u0026rsquo;. In this approach, FHOP receive intensive, short-term support based on a comprehensive assessment by a multidisciplinary team, with the aim of maximising their independence and achieving sustained improvements in both activity performance and satisfaction with the performance over the long term (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e62\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the Vision Report 2030 suggests that non-health professionals, such as cleaning aides, could play a significant role in the oral health of this group (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e26\u003c/span\u003e), to our knowledge this study is the first to explore the potential willingness of cleaning aides to take on such a role. Our findings indicate that some cleaning aides already perceive it as their responsibility to signal suspected (oral) health problems to their supervisors. Furthermore, with appropriate support \u0026ndash; including oral health training, organisational backing, and respect and support from other primary care professionals, family caregivers and FHOP themselves \u0026ndash; some cleaning aides would be willing to provide oral health advice, facilitate appointments with oral health professionals, and some would be willing to assist with daily oral hygiene when FHOP lack other support. It is noteworthy that, whereas current Belgian legislation (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e47\u003c/span\u003e) prescribes that cleaning aides should perform only cleaning tasks and no care tasks, none of the participating cleaning aides mentioned this during the focus groups. Perhaps signalling suspected problems, giving advice and facilitating appointments do not fall under care tasks in their view. Additionally, some of the participating cleaning aides indicated that they would be happy to learn more about oral health and play a role in this area. This could be in line with the Job Characteristics Model, which suggests that giving mentally challenging work can increase job satisfaction, although this also depends on an individual\u0026rsquo;s desire for personal development at work (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Given the high workload faced by primary care professionals and the possibility that involving cleaning aides in oral health could enhance job satisfaction for some, policymakers could consider whether there could be a signal function for cleaning aides in case of suspected (oral) health problems.\u003c/p\u003e \u003cp\u003e It was also notable that, towards the end of each focus group, participants expressed the view that oral health warranted greater attention and the intention to be more mindful of it in their future practice. This may reflect a combination of evolving understanding developed through discussion and a degree of social desirability bias among colleagues. This raises the question whether the inclusion of oral health topics in continuing professional education sessions might already enhance oral health awareness among HCWs.\u003c/p\u003e \u003cp\u003eEven though most participants were willing to play a role in the oral health of FHOP, participants in our study acknowledged that they often don\u0026rsquo;t pay attention to their oral health needs, which is consistent with existing literature (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Several functional barriers to overall engagement in oral health identified by our participants align with existing literature (often in residential settings), with insufficient knowledge and training and time constraints occurring particularly frequently (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e56\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition, several normative barriers \u0026ndash; such as the low prioritisation of oral health within FHOP (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e), FHOPs\u0026rsquo; resistance when assistance with daily oral hygiene is offered (particularly early on in the professional care relationship when trust has not yet been established (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e), and the perception of oral care assistance as an unpleasant and even repulsive task relative to other nursing activities (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e) \u0026ndash; also correspond with previous findings.\u003c/p\u003e \u003cp\u003eCare aides and nurses in our study also emphasised that assisting with denture cleaning is considerably easier than assisting with brushing natural teeth, in line with earlier research in residential settings (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Our participants indicated that they perceived brushing someone else\u0026rsquo;s teeth as more intimate than performing personal hygiene and toileting. Given that FHOP aim to stay at home longer and are increasingly retaining their natural teeth (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e65\u003c/span\u003e), it is essential to address both the barriers faced by FHOP in accepting assistance, as well as the challenges faced by HCWs in providing support. Furthermore, care aides in our study noted that denture cleaning is easier in the evening, when many FHOP remove their dentures, which can help overcome barriers such as embarrassment and resistance that arise when explicitly asking FHOP to hand over their dentures. Henni et al. (2023) also reported that timing matters when assisting in daily oral hygiene (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e), and Ek et al. (2018) found that some older people were reluctant to receive oral health assistance in the mornings due to nausea or other personal factors (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e38\u003c/span\u003e). From these findings, it follows that timing should be considered in task allocation discussions among HCWs.\u003c/p\u003e \u003cp\u003eWhile earlier literature has mainly examined barriers to assisting with daily oral hygiene itself (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e), our study also identified barriers related to other oral-health promoting behaviours of HCWs. For example, our participants identified barriers to initiating oral health conversations with FHOP. Nurses, care aides and cleaning aides all perceive oral health as a highly sensitive topic to approach. This has been previously documented among GPs and pharmacists (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Participating home care aides, and especially cleaning aides in our study feared being seen as intrusive, believing older adults are unaware that they can offer support and advice, and thus do not expect them to initiate such discussions. Many HCWs assume FHOP would not appreciate conversations about their oral hygiene. However, a study by Blasi (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e60\u003c/span\u003e) indicates that, although older adults prefer to manage their oral care independently for as long as possible, they do expect HCWs to support them once they can no longer do so themselves. A recent interview study with Flemish FHOP also revealed that older adults themselves were reluctant to seek help with oral health, in part because they recognise that HCWs face time constraints and do not wish to impose additional burdens, and partly because they consider oral care to be an intimate matter and believe HCWs would be reluctant to perform this task (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e66\u003c/span\u003e). To address oral health in FHOP, concerted efforts are required to move oral health out of the taboo sphere, as both parties currently seem reluctant to start the conversation.\u003c/p\u003e \u003cp\u003eFurthermore, our participants also identified several barriers when attempting to support FHOP in accessing dental care. First, many HCWs express low expectations of positive outcomes from their efforts to refer FHOP to the dentist, primarily due to the limited availability of dentists and the numerous barriers this target group faces in accessing dental care, which have been previously documented in literature (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e67\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSecond, while care aides sometimes attempt to accompany FHOP to the dentist, they express a desire for greater autonomy to do so without consulting family caregivers, often facing resistance \u0026ndash; particularly over financial resources. However, earlier studies exploring family caregivers\u0026rsquo; perspectives show they highly value the support of HCWs (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e68\u003c/span\u003e), while also wishing to be involved in care planning and decision-making (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e69\u003c/span\u003e). Other studies further emphasised that families can serve as both facilitators and barriers (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e69\u003c/span\u003e), underscoring the importance of relationship-building, role negotiation, and knowledge-sharing between family and professional caregivers to foster effective collaboration and improve care quality for FHOP (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Given that participants in our study reported limited opportunities for interaction with family caregivers, it prompts the question of whether improved communication could enhance collaboration between HCWs and family caregivers.\u003c/p\u003e \u003cp\u003eAt the meso level, in terms of normative integration, many HCWs in this study reported that oral health was given low priority within their organisations, aligning with previous findings (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e70\u003c/span\u003e). This limited prioritisation was evident in the absence of oral health topics during FHOP intake procedures and the lack of oral health guidelines for HCWs. Consequently, HCWs perceived not only a lack of expectations from older adults but also an absence of organisational expectations to act on oral health. However, research on diabetes care has shown that healthcare professionals\u0026rsquo; perceptions of expectations to perform certain behaviours were strongly linked to their intentions, which subsequently predicted their professional behaviour (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e71\u003c/span\u003e). Similar perceptions of expectations may also influence HCWs\u0026rsquo; oral health\u0026ndash;related behaviours. Furthermore, evidence from residential settings indicated that organisational context factors - such as leadership and culture - influenced care aides\u0026rsquo; adherence to best practices, suggesting that targeting these factors may be a powerful approach when developing interventions (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e72\u003c/span\u003e). Future research could examine whether establishing clear organisational expectations on oral health might likewise enhance HCWs\u0026rsquo; engagement in supporting FHOPs\u0026rsquo; oral health.\u003c/p\u003e \u003cp\u003eFurthermore, our participants experienced uncertainty about their role in oral healthcare for FHOP, aligning with earlier findings (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e). HCWs highlighted the need for clearer role definitions, task delegation among HCWs and improved interprofessional communication and collaboration. However, cleaning aides and care aides reported reluctance to communicate on FHOP\u0026rsquo;s health with other HCWs due to previous negative experiences, citing feelings of disrespect and negative reactions from HCWs, family caregivers or FHOP.\u003c/p\u003e \u003cp\u003eIn contrast with findings from other countries, where HCWs appear to seek greater collaboration with oral health professionals (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e40\u003c/span\u003e), our participants did not report this trend. Nurses perceived their role primarily as advising the target group to consult a dentist, while care aides and cleaning aides were satisfied with the current process, which involves reporting suspected problems to a supervisor who then contacts the GP or dentist as needed. A first possible explanation for this difference compared with other countries is the structural separation between home-care services and dental professionals in our country. By contrast, in Norway, public dental service units and home-care services jointly determine how collaboration is organised to ensure that older adults receive the oral health support to which they are entitled by law (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Although Henni et al. note that improved collaboration is necessary, it remains plausible that policy-driven expectations, together with enabling conditions, could empower home-care professionals to engage more actively with oral health professionals. Another potential explanation is the pronounced hierarchy within our home-care services, which may deter HCWs from contacting dentists. A third possibility is that HCWs have attempted to contact dentists but ceased doing so after negative experiences, linked to the shortage of dentists in our country and the tendency for this patient group not to have a regular dentist.\u003c/p\u003e \u003cp\u003e At the macro level, participants in our study primarily indicated that current financial structures hinder engagement in oral health and collaboration among various HCWs. A systematic review by Flodgren et al. (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e73\u003c/span\u003e) suggests that \u0026ndash; although evidence is limited - financial incentives are generally effective in improving care processes, including referrals and admissions. Additionally, Gilles et al. emphasise that addressing financial barriers is important but must be undertaken alongside organisational improvements to effectively facilitate interprofessional collaboration within integrated care initiatives (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e74\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eAdopting a qualitative approach with a multidisciplinary team experienced in qualitative research enabled in-depth discussions and thorough analyses of this complex topic. While the lack of member checks may restrict the credibility of the results, researcher triangulation was utilised to address this issue. Recruitment was limited to two primary care zones in Belgium, with only 16 or 17 participants from each professional group, which may have influenced the richness of the data and the transferability of the findings. Although the homogeneous composition of the focus groups aimed to promote open and in-depth discussions on interprofessional collaboration, the presence of colleagues may have increased the risk of socially desirable responses. Despite these limitations, the findings align with existing literature, indicating a reasonable level of transferability.\u003c/p\u003e \u003cp\u003eRecommendations for practice\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOperational level\u003c/h2\u003e \u003cp\u003e Although assisting with daily oral hygiene primarily falls within the scope of nurses and care aides, consideration should be given to the potential role of cleaning aides and the delineation of responsibilities among all HCWs in activities such as providing oral health advice, initiating conversations about oral health, making referrals to oral health professionals, GPs or pharmacists, and alerting supervisors in case of oral health problems. Oral health should be systematically documented by HCWs or their supervisors during initial assessments, with regular follow-up and recording in the patient\u0026rsquo;s file, as the (oral) health of this population can decline rapidly. Home care organisations should place greater emphasis on the importance of oral health, establish clear guidelines and communicate to FHOP that nurses, home care aides and cleaning aides can play a role in maintaining and improving oral health. This could help older adults seek help earlier or accept assistance more readily. Additionally, concise oral-care instructions for HCWs provided by dentists could motivate care aides and nurses to dedicate more attention to patients\u0026rsquo; oral health. Furthermore, HCWs should be encouraged to communicate more actively and collaborate effectively regarding the (oral) health of individual patients. Additionally, strategies should be developed to optimise collaboration with the family caregivers of FHOP.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEducation\u003c/h2\u003e \u003cp\u003e Providing (additional) oral health training for nurses, home care aides and cleaning aides would increase their confidence in giving oral health advice and assisting in daily oral care. Given the sensitivity of the topic, they should be equipped with tools to facilitate conversations about oral health. Especially care aides and cleaning aides would appreciate having a leaflet they can discuss with clients, to inform older people that they are trained and qualified to provide support in this area. Practical tips to assist in daily oral hygiene are particularly needed to help FHOP with natural teeth, as FHOP increasingly retain their natural dentition, and both HCWs and FHOP themselves often experience reluctance to assist with daily oral hygiene, accept help or initiate a conversation regarding assistance with oral hygiene. Additionally, it would be valuable to organise joint (oral health) trainings for local home nurses and home care aides, which could give them the opportunity to understand each other\u0026rsquo;s perspectives more fully and potentially enhance interprofessional collaboration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePolicy\u003c/h2\u003e \u003cp\u003e Policymakers should consider establishing clear guidelines to enhance the responsibility of home care organisations for oral health and to clarify the division of tasks among different HCWs. It may also be worth reconsidering whether the strict prohibition on cleaning aides performing care-related tasks is necessary. Reorganizing financing systems to enhance collaboration between HCWs is also essential, and cooperation among HCWs should be actively encouraged. Creating awareness campaigns highlighting that HCWs can provide support and advice on oral health might reduce the resistance of FHOP. Raising public awareness about the importance of oral health may also encourage individuals to prioritise maintaining good oral hygiene.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eIntervention development\u003c/h2\u003e \u003cp\u003eThis study confirms that interventions targeting functional aspects alone are insufficient; strategies at the normative level are also essential when developing effective interventions to enhance the integration of oral health care into primary care (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e76\u003c/span\u003e). Our findings also confirm the interconnectedness of barriers and needs across different levels, consistent with the Rainbow Model of Integrated Care (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e55\u003c/span\u003e). For example, the absence of oral health guidelines within organisations (meso level- functional integration) appears linked to HCWs\u0026rsquo; low oral health engagement at the micro level (normative integration). Consequently, interventions at one level can substantially influence other levels, underscoring the need for a thorough examination of the dynamic interplay between different levels of integration to develop an effective intervention strategy.\u003c/p\u003e \u003cp\u003eDirections for future research\u003c/p\u003e \u003cp\u003eBased on the discussion in this paper, several directions for future research can be suggested. First, further investigation and quantification of the extent to which identified needs and barriers influence engagement and interprofessional collaboration regarding oral health are needed to inform targeted interventions. In addition, given that care aides and cleaning aides in our study reported not collaborating directly with oral health professionals or GPs on oral health, but instead relaying information through their supervisors, it may be valuable to explore the experiences and the needs and barriers these supervisors encounter in this collaboration.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThere is a need for coordinated efforts across micro-, meso-, and macrolevels to enable HCWs to (a) engage in and (b) collaborate on the oral health of FHOP, with the aim of achieving functional and normative integration of oral health into primary care. Although HCWs are willing to engage in the oral health of FHOP, they currently face numerous barriers across various levels. Enhanced financial structures at the macro level and higher oral health prioritisation and clear guidelines at both macro and meso levels could strengthen their capacity and confidence to take an active role in the oral health of FHOP and facilitate effective collaboration on oral health with other HCWs.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"LIST OF ABBREVIATONS","content":"\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eFHOP: frail home-dwelling older people\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHCWs: home care workers\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGP: general practitioner\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval for this study was obtained from the independent Committee for Medical Ethics of Ghent University Hospital (reference number ONZ-2022-0369). This study was conducted in accordance with Good Clinical Practice guidelines and the Declaration of Helsinki, established to safeguard participants in clinical studies. After receiving verbal and written information about the study, all participants gave written consent for participation and for recording the focus groups.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eThis is not applicable. Prior to the focus groups, all participants provided written informed consent. They agreed that their data would be pseudonymised for the study. The consent form included information about privacy and how the data would be stored.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during this study are not publicly available owing to the potential for participants to be identified. The pseudonymised transcripts are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was part of the Gerodent Plus project, funded by the Flemish Agency for Care and Health, and published with the support of the University Foundation of Belgium. LP was supported by a Research Foundation – Flanders (FWO) Postdoctoral Fellowship – junior (12ZF122N).\u003c/p\u003e\n\u003ch2\u003eAuthors’ contributions\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003eConceptualisation: FM, PP, BJ, NH\u003c/li\u003e\n \u003cli\u003eMethodology: EB, ADV, FM, LP, BJ, PP, NH\u003c/li\u003e\n \u003cli\u003eData collection: EB, ADV, FM, NH\u003c/li\u003e\n \u003cli\u003eSoftware: NH\u003c/li\u003e\n \u003cli\u003eFormal analysis: EB, ADV, FM, NH\u003c/li\u003e\n \u003cli\u003eWriting – original draft preparation: NH\u003c/li\u003e\n \u003cli\u003eWriting – review and editing: EB, ADV, FM, LP, BJ, PP, NH\u003c/li\u003e\n \u003cli\u003eVisualisation: NH\u003c/li\u003e\n \u003cli\u003eSupervision: FM, LP, BJ, PP\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe would like to express our gratitude to the participating HCWs and organisations for sharing their perspectives and experiences. We also wish to acknowledge our collaborating partners for their contributions to participant recruitment and the refinement of the interview guides.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. World report on ageing and health. Geneva. https://www.who.int/publications/i/item/9789241565042. Accessed 10 Sept 2025.\u003c/li\u003e\n\u003cli\u003eRoy N, Dub\u0026eacute; R, Despr\u0026eacute;s C, Freitas A, L\u0026eacute;gar\u0026eacute; F. Choosing between staying at home or moving: A systematic review of factors influencing housing decisions among frail older adults. PLoS ONE. 2018. https://doi.org/10.1371/e. 0189266.\u003c/li\u003e\n\u003cli\u003eChowdhury SR, Chandra Das D, Sunna TC, Beyene J, Hossain A. Global and regional prevalence of multimorbidity in the adult population in community settings: a systematic review and meta-analysis. 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Int J Care Coord. 2020;23(1):9-13.\u003c/li\u003e\n\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-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Older adults, frailty, oral health, interprofessional collaboration, primary care, home nurses, home care aides, cleaning aides, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8396075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8396075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOlder adults are at increased risk of deteriorating oral health, while dental attendance often declines over time among frail, home-dwelling older people (FHOP), leading to a substantial burden of untreated oral disease. Interprofessional collaboration is considered crucial in addressing oral health problems in ageing populations, with potential contributions from primary care professionals (e.g., home nurses, home care aides) and non-health professionals (e.g., cleaning aides). However, little is known about (a) the current engagement of these professionals in FHOPs\u0026rsquo; oral health and (b) the needs and barriers they encounter in interprofessional collaboration. Therefore, this study aims to (a) explore the current oral health engagement of home nurses, home care aides, and cleaning aides \u0026ndash; collectively referred to as home care workers (HCWs) - in FHOPs\u0026rsquo; oral health, and (b) identify perceived needs and barriers to interprofessional collaboration in this context.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween February and December 2023, seven focus groups were conducted in Flanders, Belgium: two with home nurses, two with home care aides, two with cleaning aides, and one mixed group, involving 50 participants in total. Discussions were analysed using a reflexive thematic approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eHCWs\u0026rsquo; engagement in FHOPs\u0026rsquo; oral health is limited. Most participants recognise their potential role, but multiple barriers exist, including limited knowledge, time constraints, low oral health awareness and prioritisation among FHOP and HCWs, oral health being a sensitive topic, intimacy of assisting with brushing, and FHOPs\u0026rsquo; resistance to accept help. Quality of relationships with FHOP was a facilitator. Participants recommended integrating oral health into intake procedures, providing informative leaflets, and offering additional training. Barriers to interprofessional collaboration included financial structures and unclear role responsibilities.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e This study provides novel insights into HCWs\u0026rsquo; engagement in and collaboration on FHOPs\u0026rsquo; oral health and underscores the need for coordinated action at multiple levels to enable HCWs to realise their potential role and to improve interprofessional collaboration: e.g., enhancing awareness and knowledge (micro level), increasing prioritisation and establishing guidelines (meso level), organising oral health campaigns and reorganising financial structures (macro level).\u003c/p\u003e","manuscriptTitle":"Interprofessional collaboration on oral health for frail home-dwelling older people: a focus group study exploring the perspectives of home nurses, home care aides and cleaning aides","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 13:37:18","doi":"10.21203/rs.3.rs-8396075/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-21T18:18:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T13:32:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265558363972655564605572481931212044546","date":"2026-01-23T13:28:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75952108738383018782401855386854215076","date":"2026-01-22T11:32:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64348377901726448524363091066314374674","date":"2026-01-21T08:52:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167404932032515776437049108873181934008","date":"2026-01-14T09:58:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T08:00:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-23T06:46:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-22T00:56:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-22T00:54:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-12-18T13:31:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d7badb5-f126-4c0b-82f4-c5cc34114f87","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T13:37:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 13:37:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8396075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8396075","identity":"rs-8396075","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}