Psychometric properties of the Chinese version of the aging transformation scale for older adults with dementia

With the changes in China’s social economy, population structure, and other factors, the aging process is accelerating. With such a background, Chinese scholars have included several adaptations to the living environment of older adults, the aging of the houses, and the aging of the settlements. Theoretical research and practice of aging construction and transformation design have achieved relatively fruitful results. Li Xiaoyun conducted research on urban older adults community-friendly planning strategies for older adults, and proposed an older adults friendly community social service planning strategy including housing, health and safety, old age culture, old age service system, age integration, and other planning contents such as, the living unit, friendly open spaces, friendly traffic environment, older adults service facilities, the old community suitable for aging design, and other planning content of older adults friendly community material environment planning strategy [26]. Zhou Yanqi and others analyzed the causes and performances of the current residential areas in terms of suitable aging design from different subjects such as developers, designers, and buyers. In combination with the needs of outdoor activities, the design principles for an outdoor environment suitable for older adults were proposed. The design points for different types of activity spaces, outdoor facilities and garden elements in the outdoor environment have also been addressed [27]. Yang Shenmao and others proceeded from the design concept of residential fitness and discussed the “dwelling residential design” in the United States, the “House Design Guide for Longevity Society” in Japan, and the “Residential Design for the older adults” in China. The difference between the design criteria of the three design guidelines has been previously addressed [28]. Domestic scholars have carried out most of the theoretical research and have been involved in the practice of aging construction and renovation design. There is currently no assessment of the correlation between aging and the home environment, therefore this kind of assessment is necessary in China.

In summary, because of the great differences in China’s home environment, living habits and lifestyle, and because China’s environmental and pension service professional capabilities are extremely scarce, the feasibility of directly introducing and localizing foreign assessment scales is extremely low. It is necessary to understand the status of the aging environment in China, investigate the living habits of the demented older adults in China and understand the requirements of the home environment, and compile a suitable aging assessment scale for older adults. Today, with the continuous development of community and home care services, medical staff are no longer merely continuing the basic health service functions of the community. With the deepening of the aging process, the functions of community medical staff are increasingly expanding towards compound professional skills. Medical staff should learn and use the Home Environment Assessment Scale to help design and implement a safer home environment, which will help to improve the quality of community care services.

The purpose of this study was to evaluate the psychometric properties of the aging transformation needs scale. Using this scale, we will be able to assess the perceptions of the aging transformation needs for older adults with dementia in China.

The aging transformation needs scale was independently created by a research team. The scale comprises 55 statements each with a five-point rating scale. Five alternative answers are given: 1 = “none,” 2 = “a little,” 3 = “some,” 4 = “many,” and 5 = “a lot.” The aging transformation needs scale consists of the following nine factors: entrance (12 items), indoor activities (6 items), toilet (3 items), bath (5 items), decoration (3 items), rest (5 items), preparation/meal (6 items), laundry (4 items), and supporting environment (11 items). The aging transformation needs scale has demonstrated good validity and reliability, and the Cronbach’s alpha coefficients ranged from 0.944 to 0.984.

Two hundred sampling frames were provided by the older adults with dementia identified from 10 communities in five districts of Ningbo in China between August 2018 and February 2019. The sample from each district comprised 40 older adults with dementia selected using convenience sampling. A total of 200 questionnaires were distributed to older adults with dementia, and 175 questionnaires with valid responses were finally included. The inclusion criteria were as follows: a. individuals older than 60 years of age from local households; b. those who met the diagnostic criteria for dementia as per the American Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and were diagnosed by relevant specialists; and c. those who were mainly at home for care. Exclusion criteria were severe cognitive dysfunction, unconsciousness, and difficulties in communicating and understanding.

The questionnaire was returned by 188 participants (response rate: 94.0%). Thirteen questionnaires were left blank and were, therefore, excluded. The final number of analyzed questionnaires was 175.

The Ningbo College of Health Sciences Ethics Committee approved this study (NBWY-031). Before the research was performed, all the candidates were invited to a scheduled meeting arranged by the community service center managers and were briefly informed about their right to withdraw from the study at any time. Next, a questionnaire was distributed to each patient with dementia who consented to or was authorized to participate in this study. To ensure confidentiality, each copy of the completed questionnaire was placed in an envelope with a code number for anonymity.

In this study, the statistical analyses of the data were performed using the Statistical Package for Social Sciences software (version 22.0, SPSS Inc., Chicago, IL, USA). A p-value < 0.05 was considered statistically significant. Missing values were processed following the mean imputation method developed by Polit and Beck (2004). Five experts were selected to assess the aging transformation needs scale. The five experts were selected based on the following criteria: (a) having 5 years or more experience of caring for older adults with dementia; (b) working in nursing homes or community service centers; and (c) having a title of deputy senior or above. Each of the five experts selected in this study were subordinate to five community service centers located in five cities in China. Before implementation, the method proposed by Lawshe (1975) was used by an expert panel to assess the content validity of the questionnaire. A content validity ratio (CVR) was introduced in this study for quantitative assessment. In the formula, \( \mathrm{CVR}=\frac{ne-N/2}{N/2} \), ne and N represent the number of panelists who indicated “fairly relevant” or “very relevant” in response to a specific question in the questionnaire and the total number of panelists, respectively. The relevance of the whole questionnaire was assessed by each of the five selected experts. One of the following four possible answers were selected: do not need it at all, do not need it, need it somewhat, or need it totally. The exploratory factor analysis and principal component analysis were performed with varimax rotation as the method of extraction to determine the construct validity of the questionnaire and derive an independent sub-questionnaire out of the total 55-item questionnaire, respectively. Four factors were chosen to evaluate the constructed sub-questionnaire when a loading level of 0.50 was used as a threshold for including items. The internal consistency of the instrument was tested by calculating the Cronbach’s alpha coefficients of the entire questionnaire and each of the sub-questionnaires (Polit & Beck, 2004). The potential correlation between items was assessed by performing an item-total correlation analysis at an accepted threshold of correlation coefficient = 0.40 (Spector, 1992).

Table 1 shows that the number of entries that were “very relevant” and “relevant, but needed to be changed” (269/275), and the “one-point irrelevant” entry was 0. This result indicated that the home environment was suitable. Therefore, the aging transformation demand scale has a good surface validity. The CVR of the Home Environment Adaptation Requirement Scale was 0.965, which meets the requirements of CVR ≥ 0.80. These results proved that the self-made items of this scale basically met the requirements for suitable aging transformation needs; however, there was also a “must be modified to be relevant” item with a proportion of 2.18% (6/275). This result prompted us to further analyze the data and pay attention to the individual differences of the patients themselves.

Table 2 shows that the care needs of the respondents were focused on resting and the presence of a supporting environment and indoor activity space. In most cases, people with mild dementia could eat, wear, and wash, among others. These patients were able to take care of themselves in their daily life and reduce their dependence on others. Therefore, there is a high demand for transforming the supporting environment and indoor activity space, with the hope to create larger and safer spaces for activities. Older adults often request for lights near the bed as the indoor lighting allows them to see their surroundings. Additionally, phone and doorbell sounds should be loud and the flooring should be anti-skid to prevent falls among older adults. This is consistent with the research results of An Haoyuan [5]. A large number of studies conducted in China and abroad [29, 30] found that the home environment of older adults is important to improve their quality of life. In addition, the aging transformation of the home environment can help prevent falls, delay functional decline, and save manpower costs. Therefore, it is necessary for home care services to give importance to the needs of environmentally-friendly aging transformations. Demand assessment is the basis for this transformation, and we hope that the government and relevant personnel will pay close attention to these needs and provide the required support.

Table 3 shows that there was a significant correlation between the aging transformation needs scale and the nine constituent factors. The nine constituent factors of the scale also had a good correlation. The results of this study indicate that if relevant departments actively explore the needs of the aging population, this will greatly improve the living environment of the older adults with dementia and consequently, their survival. Quality promotes the rapid development of China’s pension unemployment.

The questionnaire had a good reliability. Reliability is defined as the degree of reliability and stability of a scale, expressed in terms of reliability coefficients. Reliability is a prerequisite for questionnaire design [31]. The Cronbach’s alpha is an important indicator of reliability in a questionnaire, and is used to assess the internal consistency of the sub-sections in the full scale and their respective reliabilities [32]. The scale designed here was deemed reliable and valid, and the items in the scale were relevant to the aging transformation needs of older adults with dementia. In addition, an item-to-total correlation analysis was performed to validate the scale’s reliability [33]. The high item-total and test-retest correlation coefficients further showed the reliability of the scale. Repeatability was not assessed on this scale because it requires two measurements of the same object using the same scale in a short period of time. Considering the large sample size of this study and the special group analyzed, it was not appropriate to complete two measurements of the patients in a short period of time.

The scale had a good validity. Validity is defined as the extent to which a measurement tool can measure the event it is measuring. CVRs ranging from 0.8 to 1.0 were obtained from the expert panelists. All five experts agreed that the full scale was relevant. The items loaded on the nine factors were in line with each sub-scale. The high factor loadings of items on each factor were consistent with Waltz et al.’s recommendation of at least 0.4 for factor loadings [34]. It is acceptable that individual factors could explain 3.2 to 64.6% of the variance. The explanation of 95.2% of the variance by the nine factors was consistent with the recognized standard that an ideal factor analysis explains 40 to 60% of the variance. Our factor analysis results were consistent with the original nine-factor model. This evaluation further shows that the questionnaire is valid, reliable, and suitable for the use as an aging transformation needs measurement for older adults with dementia.

The psychometric testing was limited by the use of a convenience sample and the fact that the data gathering sites were located in ten communities in one city in China. In the future, a test–retest procedure could be used to further establish the reliability of the long-term care needs questionnaire. As a result of the large sample, it was not feasible to examine the test–retest reliability. Therefore, further research is required to verify the relationships between the aging transformation needs and aging transformation needs outcomes such as life quality and cognitive status in the same way researchers have studied these relationships in Western countries. Further studies with older adults with dementia in China are also needed to evaluate the utility of the aging transformation needs scale.