The world is aging rapidly¹⁾. According to the United Nations, the number of people aged 65 is growing rapidly and will make up 16% of the world’s population by 2050²⁾. In response, the World Health Organization has selected the slogan “Decade of Healthy Aging” as a key issue for the next decade to promote healthy aging³⁾. While many countries are actively promoting policies and research to help older people realize healthy aging, a high proportion of them report that their health is “poor” and that they are functionally dependent due to at least one limitation in activities of daily living⁴⁾. In addition, they often live an unhealthy life due to geriatric disease conditions such as dementia and severe stroke⁵⁾.

In response to this trend, the Korean government has implemented a long-term care insurance system for elderly. Day and night care center provide various conveniences for elderly who cannot be cared for by their families for unavoidable reasons⁶⁾. The elderly in these facilities often suffer from mild cognitive impairment and mild dementia, which means that their memory and language skills are somewhat impaired^7,8), and they are more vulnerable to health problems^9,10). Their cognitive instability increases the need for basic care. Therefore, in the area of oral care, the focus is often on maintaining the status quo, rather than interventions that improve oral function^11,12). This leads to a rapid deterioration of the oral condition and a decline in oral functions such as mastication and swallowing^13,14).

Many recent studies have reported a link between dementia and oral health. Older people with fewer teeth were 81% more likely to develop vascular dementia¹⁵⁾. Conversely, mastication exercises have been shown to increase blood flow to the brain, helping to absorb oxygen, which can affect memory and concentration^16-18). In Japan, the importance of oral function in elderly has been recognized, and various programs have been developed and applied^19,20). However, in most facilities outside of Japan, most programs are related to physical function and muscle strength^21-23). In addition, practitioners who deliver these programs are overworked and lack relevant training, making it difficult for them to deliver programs that improve oral function^24,25).

Therefore, the demand and need for information and communication technology (ICT) - based programs that can be practiced by individuals with minimal training is gradually increasing^26-28). In the fields of rehabilitation medicine and occupational therapy, these programs are already being actively used in facilities and homes²⁹⁾. Similarly, in the field of dentistry, there is a need to develop an ICT-based oral function rehabilitation exercise (ICT-based OFRE) program to rehabilitate the declining oral function of the elderly.

OFRE program is an exercise to improve mastication, swallowing, articulation, and salivary function in the elderly, and its effectiveness has been confirmed in various recent studies^30-32). So, ICT-based OFRE will be an effective alternative in the era of digital care, especially since it is not limited by space and can be easily followed by the elderly in facilities.

Therefore, this study aims to identify the applicability of ICT-based OFRE programs by identifying the demand of facility workers, who will be the main providers of such programs, as well as the basic data and development directions for these programs.

1. Study subjects

The subjects of this study were workers at domestic day and night care facilities. In order to conduct the research smoothly, participants were recruited by sending an official letter to the Korean Dementia Society and the Korean Day and Night Care Center. A total of 235 people agreed to participate and responded to the questionnaire, and 222 of them who worked at day and night care facilities and answered all questions without omission were included in the final analysis subjects (Table 1). The participants’ age ranged from 26 to 70 years (mean 49.85±9.213 years). In terms of region, 67.1% of the participants lived in a province. With regard to occupation, care workers accounted for the majority (39.2%), followed by social workers (35.6%). For career tenure, 1-3 years was the highest at 34.7%, and the average number of seniors in the facility was 41.01 people. Finally, the average number of seniors in charge during working time was 22.24 people.

Table 1 . Demographic characteristics of the sample

	Female	Male	Total
Participants (N)	174	48	222
Mean age (years)	50.82	46.31	49.85
Age SD	8.5	10.8	9.2
Age range	26-70	26-66	26-70
Region
Metropolitan (%)	28.2	50.0	32.9
Province (%)	71.8	50.0	67.1
Occupation
Care worker (%)	43.1	25.0	39.2
Social worker (%)	31.6	50.0	35.6
Nurse (%)	4.0	-	3.2
Nursing assistant (%)	12.1	2.1	9.9
Physical therapist (%)	1.1	2.1	1.4
Occupational therapist (%)	-	4.2	0.9
Etc. (%)	8.0	16.7	9.9
Career
Less than 1 year (%)	21.8	16.7	20.7
1-3 (%)	37.9	22.9	34.7
4-6 (%)	16.7	27.1	18.9
7-9 (%)	12.6	12.5	12.6
Over 10 year (%)	10.9	20.8	13.1
Average number of seniors in facility	40.41	43.21	41.01
Average number of seniors in charge during working hours	21.12	26.27	22.24

The number of participants in this study met the minimum sample size of 197, which was calculated using the G*Power 3.1 analysis program with a significance level of .05, an effect size of .25, and a power of 95%. This study was approved by the Research Ethics Review Committee of Sunmoon University (Review Number SM-202207-033-1).

2. Study methods

2.1. Developing a questionnaire

This questionnaire was developed by revising and supplementing it three times. The first questionnaire was developed by three researchers with relevant research experience based on previous studies on dementia and oral-related awareness, the definition of oral functional rehabilitation exercise, and awareness of the utilization of oral functional rehabilitation exercise programs³³⁾. Subsequently, content validity was conducted by forming a committee of seven experts to ensure that the survey questions were appropriately structured. For validation, the expert committee members were asked to review the validity of each item on a 5-point Likert scale (1=not at all appropriate, 2=not appropriate, 3=somewhat appropriate, 4=appropriate, 5=very appropriate) after the purpose of the study was explained. The participants were encouraged to provide additional details and general comments in a narrative format. Content validity was measured using the content validity index (CVI)³⁴⁾. The cutoff was set at .75, and items that fell below this cutoff were deemed to be less valid. The second version of the questionnaire, which was validated, was preliminarily tested on 10 day and night care center workers, and the development of the questionnaire was completed after a final review of the questions.

2.2. Organization of the questionnaire

The questionnaire used in the study consisted of 34 questions, including 7 questions on general characteristics, 6 questions on dementia and oral-related awareness, 11 questions on the need for oral functional rehabilitation exercises, and 10 questions on the use of ICT-based oral functional rehabilitation exercise programs. Except for dichotomous questions, each question was constructed using a Likert scale ranging from 1 to 5. The reliability analysis for each question to evaluate the internal consistency of the questionnaire content showed that the standardized Cronbach’s a values were 0.810, 0.907, and 0.741, respectively, which were evaluated as good.

2.3. Conducting surveys and statistical analysis

This survey was conducted for approximately one month from September 2022 using an online self-administered survey method using Google forms. As a result of the survey, responses that were excessively short or insincere were excluded, and cases where there was a high concentration of specific options were reviewed to ensure the reliability and validity of the responses. Accordingly, a total of 222 questionnaires were ultimately analyzed. The collected data were analyzed using SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.). Frequency analysis was conducted to identify the general information, type and organization of work, awareness of dementia and oral health, need for the OFRE program, and need for the ICT-based OFRE program. The chi-square test was conducted to identify the differences according to the characteristics of the study subjects. Finally, a logistic regression analysis was conducted to identify the needs of ICT-based oral rehabilitation exercise programs according to the degree of oral functional rehabilitation exercise needs. All statistical significance was set at P<0.05.

1. Need for OFRE based on the presence of oral health activities in the center

OFRE needs according to whether the center conducted oral-related activities are shown in Table 2. Of the 221 participants, 75.1% reported conducting oral-related activities and 24.9% reported not conducting oral-related activities. The overall need for OFRE among those who reported having oral health activities in their center was 8.65 on average, which was 0.46 points higher than those who reported not having oral health activities (P<0.05). Participants who reported having oral health activities in their center had higher needs on average for all performance items on the OFRE, especially those related to mastication (P<0.05).

Table 2 . The need for OFRE according to the progress of oral-related activities in the center

	Oral-related activities (N=221)
	No (n=55)			Yes (n=166)		t (P)
	Mean	SD		Mean	SD
OFRE	8.09	1.578		8.65	1.361	―2.537*
Mastication in OFRE	4.04	0.744		4.31	0.656	―2.549*
Strengthening of the oral muscles	4.07	0.813		4.26	0.621	―1.766
Swallowing exercise	4.04	0.881		4.25	0.690	―1.815
Oral exercise	4.00	0.793		4.19	0.667	―1.760
Tongue strengthening exercise	4.02	0.850		4.13	0.690	―0.997
Intra-oral massage	3.98	0.850		4.05	0.738	―0.604

*P<.05.

2. Demand for ICT-based OFRE programs based on experience with ICT-based rehabilitation programs

ICT-based OFRE program needs according to the experience of using ICT-based rehabilitation programs are shown in Table 3. Of the 222 respondents, 52.3% had used ICT-based rehabilitation programs and 47.7% had not. The mean score of ICT-based OFRE program needs for those with experience was 4.41, which was 0.48 points higher than those without experience (P<0.001). Respondents with experience were also more likely than those without experience to have attended training on the use of ICT-based OFRE programs (P<0.01) and to have actually applied ICT-based OFRE programs to older adults in their centers (P<0.05).

Table 3 . Demand for ICT-based OFRE program according to ICT-based rehabilitation program use experience

	Experience in using ICT-based rehabilitation programs (N=222)
	No (n=106)			Yes (n=116)		t (P)
	Mean	SD		Mean	SD
Necessity of ICT-based OFRE programs	3.93	0.979		4.41	0.781	―4.054***
Intention to use the ICT-based OFRE program	4.07	0.876		4.41	0.802	―3.012**
Intention to attend ICT-based OFRE program education	4.01	0.822		4.36	0.806	―3.224**
Applicability of ICT-based OFRE programs to seniors in the facility	3.60	1.021		3.92	0.970	―2.384*

*P<.05, **P<.01, ***P<0.001.

3. Considerations for developing and implementing an ICT-based OFRE program

Considerations for developing and applying ICT-based OFREs are shown in Table 4. First, when developing the program, convenience of use was the highest at 50.9%, followed by simplicity of content at 23.9%, effectiveness of use at 18.0%, and accumulation of information at 7.2%. In terms of program implementation, 24.8% of the respondents said focused on training on how to use the program, 24.3% focused on raising awareness to engage patients and patient guardians, 18.5% on providing educational materials on how to use the program, 13.1% on providing oral aids to participate in the program, 9.5% on providing ICT devices, 7.7% on developing work guidelines for program operation, and 2.3% on providing a place to facilitate program use.

Table 4 . Considerations when developing and applying ICT-based OFRE programs

	Total (N=222)
	N	%
Considerations when developing an ICT-based OFRE program
Convenience of use (easy and convenient operation)	113	50.9
Simplicity of content (uncomplicated content and organization)	53	23.9
Effectiveness of use (improvement of oral function)	40	18.0
Accumulation of information (provision of continuous exercise information)	16	7.2
Considerations when applying the ICT-based OFRE program	55	24.8
Training on how to use the program
Raising awareness for participation of patients and patient guardian	54	24.3
Provision of educational materials on how to use the program	41	18.5
Provision of oral care products for participation in the program	29	13.1
Provision of ICT devices	21	9.5
Development of work guidelines for program operation	17	7.7
Provision of a place for smooth program progress	5	2.3

4. Preferred forms of training and reasons for applying ICT-based OFRE programs

The preferred form of training and reasons for applying ICT-based OFRE programs are shown in Table 5. Of the 222 total participants, 73.4% preferred group training and 26.6% preferred individual training, with group training being more than twice as likely to be preferred. Among those who preferred group training, the following reasons were cited: lack of staff and time to deliver the training (22.7%), ease of communication and consensus building (22.1%), high participation (12.3%), characteristics of the organization providing the training (11.0%), convenience of the training (9.2%), and the possibility of repeating the training (3.1%). For those who preferred individualized training, the following reasons were cited: the ability to reflect individual characteristics in training (47.5%), improved focus (25.4%), and improved quality (18.6%).

Table 5 . Education type preference and reasons for applying ICT-based OFRE program

Form of education	Reason for selection	n	%
Group education	Lack of staff and time to deliver the training	37	22.7
	Ease of communication and consensus building	36	22.1
	High participation	20	12.3
	Characteristics of institutions providing the training	18	11.0
	Convenience of the training	15	9.2
	Possibility of repeating the training	5	3.1
	Etc.	32	19.6
	Total	163	73.4
Individual education	Reflection of individual characteristics	28	47.5
	Improvement of concentration in the training	15	25.4
	Improvement in quality of the training	11	18.6
	Etc.	5	8.5
	Total	59	26.6

5. How OFRE program needs affect ICT-based program needs

The impact of OFRE program needs on ICT-based program needs is shown in Table 6. Higher perceived OFRE program needs were associated with significantly higher ICT-based program needs (OR=1.902, 95% CI=1.479-2.446). When all variables were adjusted for, ICT-based program needs were still significantly higher (OR=1.930, 95% CI=1.493-2.495).

Table 6 . Impact of OFRE program needs on ICT-based program needs: logistic regression analysis

The need of OFRE program	OR (95% CI)†	P
Model 1: crude
Yes	1.902 (1.479-2.446)	<0.001
No	-
Model 2*: adjusted
Yes	1.930 (1.493-2.495)	<0.001
No	-

*Model 2 was adjusted for age, area, career, oral health activity in facility.

^†OR, odds ratio; CI, confidence interval.

The recent global aging of the population has led to growing interest in geriatric health. ICT-based digital technologies are increasingly used to run rehabilitation programs in elderly facilities because they can assist workers in caring for elderly people and improve the quality of services provided³⁵⁾. However, there are very few ICT-based oral rehabilitation programs, and these programs are underutilized. Therefore, this study aims to identify the perceptions of center workers who will be the main providers of ICT-based OFRE programs, identify considerations for development, and serve as a basis for effective program development.

First, the perceived need for OFRE is higher when oral health activities are conducted within the center. This may be because oral-related activities in most senior centers are often one-time and unstructured activities, which increases the need for activities with a structured process and the perceived need for OFRE³⁶⁾.

Second, the need for masticatory exercises among performance items is statistically significant. For center seniors, diet is a direct determinant of overall health³⁷⁾, and significant improvements in diet and blood flow have been reported in nursing home seniors when performing exercises to improve oral function³⁸⁾. Mastication is a very important indicator of the health of the elderly in facilities. When mastication exercise was performed on elderly people over 65 years old living in the community, occlusal power and the thickness of the masseter muscle improved³⁹⁾. When masticatory muscle strengthening exercise was performed using a mouthpiece, occlusal power, the thickness of the masseter muscle, and the echo intensity of the masseter muscle also improved⁴⁰⁾. Such a decline in the important masticatory function not only leads to incomplete diet, which causes malnutrition⁴¹⁾, but also leads to a decline in digestive function, which can cause rapid deterioration of health⁴²⁾. Conversely, exercise interventions to improve mastication in institutionalized seniors have been shown to improve overall oral function⁴³⁾. It is likely that center workers, who are closest to elderly individuals, are aware of the importance of mastication because they directly observe physical changes in the oral health of elderly individuals.

Third, participants with experience using ICT-based rehabilitation programs had more positive perceptions of the feasibility of applying new ICT-based rehabilitation programs. Flexible acceptance of the program by the actual program providers may be an important factor in the adoption of new programs. When ICT-based mobile application programs were applied to elderly people with actual care needs, it was found that their care burden was reduced and their job satisfaction increased^44,45). These experiences are believed to have had a positive impact on their perceptions of ICT-based programs. In addition, the recent proliferation of smart devices in society and their increased accessibility and ease of use may have influenced the responses. Previous studies have shown that caregivers in elderly care facilities are highly receptive to smart technology and expect it to ease their workload²⁶⁾.

Fourth, ease of use and simplicity of content were highly rated as considerations for developing an ICT-based OFRE program. When applied, increased awareness for elderly people and patient guardians regarding the smooth participation and dissemination of educational materials on how to use the program was highly rated. The center’s elderly individuals, who are the actual users of the ICT-based OFRE program, often suffer from dementia or have early cognitive impairment, so they may have low literacy⁷⁾ as well as limited access to and fear of smart technology^46,47). Therefore, it is necessary to develop these areas, and systematic training is necessary to avoid a work burden on the providing organization.

Fifth, there was a strong preference for group delivery of ICT-based OFRE programs. This is similar to the majority of program offerings currently available in senior living facilities, which have been reported to be effective in delivering programs to older adults with reduced physical functioning in a group setting⁴⁸⁾. Group exercise has also been reported to improve compliance with physical activity, psychological factors, and social relationships⁴⁹⁾. However, individualized and tailored programs have been found to be more effective when targeting older adults with cognitive decline or dementia⁵⁰⁾. Factors that increase the participation of the elderly in facilities include communication with the staff providing the intervention and interest. Furthermore, the effectiveness of the program is greater when it is conducted in a small group^51,52). Of the respondents in this study who preferred the group format, 22.7% cited a lack of staff and time to deliver the program and 11% cited the nature of the delivery organization. These responses suggest that, conversely, if the program delivery environment were improved, people would prefer individualized training. In addition, the ICT-based OFRE program offers the possibility of individualized education due to its ease of use and the fact that it does not require additional personnel. Therefore, there is a need for further exploration to identify the factors that influenced the responses and for further discussion of the form of delivery of ICT-based OFRE programs.

Finally, the need for OFRE programs was found to have a significant effect on the need for ICT-based oral programs. This suggests the applicability of ICT-based oral rehabilitation programs, which can be an effective alternative for institutionalized elderly people who need continuous nursing care due to advantages such as repetitive performance, no space limitations, and no need for additional personnel^53,54). Previous studies have shown that applying an ICT-based language rehabilitation exercise program to elderly individuals with dementia improves attention, and applying an ICT-based game program to elderly individuals with mild cognitive impairment improves overall cognitive function⁵⁵⁾. Therefore, multifaceted efforts are needed to provide effective oral function rehabilitation programs in line with the rapidly approaching digital care era.

There are some limitations to this study. First, this study was conducted on a small number of institutions, so it is difficult to generalize the results. However, since it is data based on actual experience of directly mediating the elderly, it can be used as a practical reference when applying it to elderly facilities in the future. Therefore, it is necessary to confirm the generalizability of the research results through in-depth research that expands the number of institutions and participants in the future. Second, this study did not take into account various emotional factors and working environments that may affect day and night care center workers’ identification of oral-related awareness and the demand for oral functional rehabilitation exercise programs. Future studies should consider these issues. Nevertheless, this study identified the perceptions of OFRE programs among day and night care center workers at the point of entry into digital care-based elderly society and presented various considerations for developing ICT-based programs.

This study identified the awareness and needs of facility workers who will be the main providers of the ICT-based OFRE program for maintaining and improving oral function in the elderly admitted to facilities.

The results of this study are as follows.

1. The high demands and expectations of facility workers were confirmed, and the possibility of application to elderly facilities in the future was confirmed.

2. The high need for chewing exercise among the intervention areas was confirmed, and it was confirmed that it should be included as an essential part of the intervention area in the future.

3. The specific considerations related to this program were confirmed, and the parts necessary for actual application were confirmed.

Through the above results, the basic data for introducing the ICT-based OFRE program was identified, and it is expected that it can be used as major data in policy discussions for the application of this program.

This work was supported by the National Research Foundation of Korea in 2022 (2022R1F1A1063262).