# Development and Validation of the Eating Support for Healthcare Aides (ESHA) Questionnaire in Long-Term Care

## TL;DR

This study created a reliable questionnaire to assess healthcare aides' skills in supporting nutrition for elderly residents with swallowing issues.

## Contribution

The novel contribution is the development and validation of the ESHA questionnaire for evaluating healthcare aides' eating support competencies.

## Key findings

- The ESHA questionnaire showed strong content validity and acceptable reliability for assessing healthcare aides' competencies.
- Confirmatory factor analysis confirmed good structural validity of the questionnaire.
- The tool can help identify training needs to improve mealtime care in long-term care settings.

## Abstract

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’ 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’ 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’s α, 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’s α = 0.98). CFA confirmed good structural validity (χ2/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’ 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.