{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T23:47:16Z","timestamp":1781048836221,"version":"3.54.1"},"reference-count":39,"publisher":"MDPI AG","issue":"20","license":[{"start":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T00:00:00Z","timestamp":1760486400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004663","name":"National Science and Technology Council, Taiwan","doi-asserted-by":"publisher","award":["NSTC 113-2410-H-255-011"],"award-info":[{"award-number":["NSTC 113-2410-H-255-011"]}],"id":[{"id":"10.13039\/501100004663","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background: Swallowing difficulties (dysphagia) are highly prevalent among older adults and significantly contribute to malnutrition, dehydration, and poor health outcomes. Healthcare aides (HCAs), as frontline caregivers in long-term care, play a pivotal role in supporting residents\u2019 nutritional intake. However, validated tools to evaluate their competencies in nutrition-related eating support are lacking. Methods: A cross-sectional study was conducted to develop and validate a competency-based questionnaire assessing healthcare aides\u2019 knowledge, attitudes, and behaviors toward nutrition-focused eating support. Core domains, including oral function care, safe feeding practices, food texture modification, and nutrition safety, were identified through a systematic literature review and refined using a two-round modified Delphi process involving 26 experts. A 47-item questionnaire was then administered to 202 HCAs in Taiwan. Psychometric testing included item analysis, KR-20, Cronbach\u2019s \u03b1, confirmatory factor analysis (CFA), composite reliability (CR), and average variance extracted (AVE). Results: The final instrument demonstrated strong content validity. The knowledge domain achieved acceptable reliability (KR-20 = 0.61), while the attitude and behavior domains showed excellent internal consistency (Cronbach\u2019s \u03b1 = 0.98). CFA confirmed good structural validity (\u03c72\/df = 3.86, CFI = 0.93). CR and AVE values further supported construct validity. Conclusions: This nutrition-centered questionnaire is a valid and reliable tool to assess HCAs\u2019 competencies in providing eating support. It offers a foundation for identifying training needs and designing educational programs aimed at preventing malnutrition and enhancing person-centered mealtime care in long-term care facilities.<\/jats:p>","DOI":"10.3390\/nu17203235","type":"journal-article","created":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T11:57:42Z","timestamp":1760529462000},"page":"3235","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Development and Validation of the Eating Support for Healthcare Aides (ESHA) Questionnaire in Long-Term Care"],"prefix":"10.3390","volume":"17","author":[{"given":"Chia-Hui","family":"Lin","sequence":"first","affiliation":[{"name":"Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi 61363, Taiwan"},{"name":"Center for Smart Healthcare Education, Chiayi Campus, Chiayi 61363, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1421-6289","authenticated-orcid":false,"given":"Ming-Yi","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Senior Welfare and Services, Southern Taiwan University of Science and Technology, Tainan City 71005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1055\/s-0039-1688837","article-title":"Presbyphagia to dysphagia: Multiple perspectives and strategies for quality care of older adults","volume":"40","author":"Riquelme","year":"2019","journal-title":"Semin. Speech Lang."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1403","DOI":"10.2147\/CIA.S107750","article-title":"European Society for Swallowing Disorders\u2013European Union Geriatric Medicine Society white paper: Oropharyngeal dysphagia as a geriatric syndrome","volume":"11","author":"Baijens","year":"2016","journal-title":"Clin. Interv. Aging"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Carri\u00f3n, S., Costa, A., Ortega, O., Verin, E., Clav\u00e9, P., and Laviano, A. (2018). Complications of oropharyngeal dysphagia: Malnutrition and aspiration pneumonia. Dysphagia: Diagnosis and Treatment, Springer.","DOI":"10.1007\/174_2017_168"},{"key":"ref_4","first-page":"103","article-title":"Dysphagia management in Europe: Whether knowledge and skills are sufficient?","volume":"20","author":"Bradauskiene","year":"2023","journal-title":"Darn. Aplink. Vystym."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1016\/j.jamda.2008.03.005","article-title":"Nutritional Issues in Long-Term Care","volume":"9","author":"Sloane","year":"2008","journal-title":"J. Am. Med. Dir. Assoc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1111\/j.1468-3148.2005.00250.x","article-title":"Barriers to caregiver compliance with eating and drinking recommendations for adults with intellectual disabilities and dysphagia","volume":"19","author":"Chadwick","year":"2006","journal-title":"J. Appl. Res. Intellect. Disabil."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1186\/s12877-021-02366-9","article-title":"Interventions to prevent aspiration in older adults with dysphagia living in nursing homes: A scoping review","volume":"21","author":"Chen","year":"2021","journal-title":"BMC Geriatr."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1007\/s00455-021-10275-7","article-title":"Management of dysphagia in nursing homes: A national survey","volume":"37","author":"Engh","year":"2022","journal-title":"Dysphagia"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2319","DOI":"10.1002\/lary.30043","article-title":"Discriminant ability of the Eating Assessment Tool-10 to detect swallowing safety and efficiency impairments","volume":"132","author":"Donohue","year":"2022","journal-title":"Laryngoscope"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1478","DOI":"10.1111\/1460-6984.13015","article-title":"Supporting Safe Swallowing of Care Home Residents with Dysphagia: How Does the Care Delivered Compare with Guidance from Speech and Language Therapists?","volume":"59","author":"Griffin","year":"2024","journal-title":"Int. J. Lang. Commun. Disord."},{"key":"ref_11","unstructured":"National Association of Professional Cooks (2025, October 04). Kaigo Shokushi (Care Food Specialist) Qualification Overview. Available online: https:\/\/www.kaigosyokushi.jp\/qualifications\/kaigosyokushi\/."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1300\/J084v10n01_07","article-title":"Neglect and abuse associated with undernutrition in long-term care in North America: Causes and solutions","volume":"10","author":"Aziz","year":"1999","journal-title":"J. Elder Abus. Negl."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1053\/gn.1999.v20.97011","article-title":"Dysphagia among nursing home residents","volume":"20","author":"Pengilly","year":"1999","journal-title":"Geriatr. Nurs."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1111\/scd.12861","article-title":"Knowledge, attitudes, and behaviors of dysphagia clinicians regarding oral health\u2014An international study","volume":"44","author":"Arslan","year":"2024","journal-title":"Spec. Care Dent."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s12877-023-03762-z","article-title":"Nursing assistants\u2019 knowledge, attitudes, and training needs regarding urinary incontinence in nursing homes: A mixed-methods study","volume":"23","author":"Liao","year":"2023","journal-title":"BMC Geriatr."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Saunders, G.H., Dann, S.M., Griest, S.E., and Frederick, M.T. (2014). Knowledge, Attitudes, and Behaviors Questionnaire (KAB) [Database Record], APA PsycTests.","DOI":"10.1037\/t45348-000"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Guin\u00e9, R.P.F., Floren\u00e7a, S.G., Apar\u00edcio, G., Cardoso, A.P., and Ferreira, M. (2022). Food Literacy Scale: Validation through Exploratory and Confirmatory Factor Analysis in a Sample of Portuguese University Students. Nutrients, 15.","DOI":"10.3390\/nu15010166"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Drancourt, N., El Osta, N., Decerle, N., and Hennequin, M. (2022). Relationship between Oral Health Status and Oropharyngeal Dysphagia in Older People: A Systematic Review. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph192013618"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1174","DOI":"10.1038\/ejcn.2016.87","article-title":"Reliability and validity of a revised version of the General Nutrition Knowledge Questionnaire (GNKQ-R)","volume":"70","author":"Kliemann","year":"2016","journal-title":"Eur. J. Clin. Nutr."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1608","DOI":"10.1017\/S1368980019005135","article-title":"Validation of a revised General Nutrition Knowledge Questionnaire for Australia (AUS-R NKQ)","volume":"24","author":"Thompson","year":"2021","journal-title":"Public Health Nutr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1008971","DOI":"10.3389\/fnut.2023.1008971","article-title":"Development and validation of a short nutrition literacy scale for young adults","volume":"10","author":"Vrinten","year":"2023","journal-title":"Front. Nutr."},{"key":"ref_22","unstructured":"Klein, R. (2016). Principles and Practice of Structural Equation Modelling, Guilford Press. [4th ed.]."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e006682","DOI":"10.1136\/bmjopen-2014-006682","article-title":"Standardised method for reporting exercise programmes: Protocol for a modified Delphi study","volume":"4","author":"Slade","year":"2014","journal-title":"BMJ Open"},{"key":"ref_24","first-page":"20","article-title":"A preliminary study on the competency development of feeding support caregivers","volume":"28","author":"Lin","year":"2025","journal-title":"J. Long-Term Care"},{"key":"ref_25","first-page":"152","article-title":"Content validity index in scale development","volume":"37","author":"Shi","year":"2012","journal-title":"Zhong Nan Da Xue Xue Bao Yi Xue Ban"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"18","DOI":"10.34293\/education.v11i3.6081","article-title":"Estimating the psychometric properties of test items using the Kuder-Richardson approach (KR-20)","volume":"11","author":"Ntumi","year":"2023","journal-title":"Shanlax Int. J. Educ."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2860","DOI":"10.3390\/ijerph20042860","article-title":"The study adapted instruments based on confirmatory factor analysis (CFA) to validate measurement models of latent constructs","volume":"20","author":"Baharum","year":"2023","journal-title":"Int. J. Environ. Res. Public Health"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1177\/002224378101800104","article-title":"Evaluating structural equation models with unobservable variables and measurement error","volume":"18","author":"Fornell","year":"1981","journal-title":"J. Mark. Res."},{"key":"ref_29","first-page":"378","article-title":"Assessing the reliability and validity of the attitude construct using partial least squares structural equation modeling","volume":"12","author":"Yusuff","year":"2022","journal-title":"Int. J. Acad. Res. Bus. Soc. Sci."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies","volume":"370","author":"Altman","year":"2007","journal-title":"Lancet"},{"key":"ref_31","first-page":"101","article-title":"Misuses of KR-20 and Cronbach\u2019s alpha reliability coefficients","volume":"34","author":"Tan","year":"2009","journal-title":"Educ. Sci."},{"key":"ref_32","first-page":"104","article-title":"Psychometric Validation and KR-20 Reliability of a Knowledge Tool for Semi-Intensive Pig Production","volume":"61","author":"Roy","year":"2025","journal-title":"Indian J. Ext. Educ."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"53","DOI":"10.5116\/ijme.4dfb.8dfd","article-title":"Making sense of Cronbach\u2019s alpha","volume":"2","author":"Tavakol","year":"2011","journal-title":"Int. J. Med. Educ."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1101","DOI":"10.1016\/j.jval.2011.06.003","article-title":"Response burden and questionnaire length: Is shorter better? A review and meta-analysis","volume":"14","author":"Rolstad","year":"2011","journal-title":"Value Health"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e0284657","DOI":"10.1371\/journal.pone.0284657","article-title":"Status of knowledge, attitude, and practice of post-stroke dysphagia in neurological nurses in China: A cross-sectional study","volume":"18","author":"Wang","year":"2023","journal-title":"PLoS ONE"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"16","DOI":"10.21037\/apm-21-3672","article-title":"A multicenter cross-sectional survey of the knowledge, attitudes, and practices of geriatric nurses regarding dysphagia care","volume":"11.1","author":"Luo","year":"2022","journal-title":"Ann. Palliat. Med."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"O\u2019Leary, M., Mooney, E., and McCloat, A. (2025). The Relationship Between Nutrition Knowledge and Dietary Intake of University Students: A Scoping Review. Dietetics, 4.","DOI":"10.3390\/dietetics4020016"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1515\/ijamh-2020-0192","article-title":"Nutrition knowledge and its relation with dietary behaviour in children and adolescents: A systematic review","volume":"34","author":"Thakur","year":"2022","journal-title":"Int. J. Adolesc. Med. Health"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1097\/01.ASW.0000350838.11854.0a","article-title":"The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper","volume":"22","author":"Dorner","year":"2009","journal-title":"Adv. Ski. Wound Care"}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/17\/20\/3235\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,15]],"date-time":"2025-10-15T12:05:12Z","timestamp":1760529912000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/17\/20\/3235"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,15]]},"references-count":39,"journal-issue":{"issue":"20","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["nu17203235"],"URL":"https:\/\/doi.org\/10.3390\/nu17203235","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,15]]}}}