This study utilized the modified Delphi method to develop the Chinese version of the Scale for Assessment of LTCRL. After one expert meeting, three rounds of Delphi process, and a pilot assessment on the performance of home care workers in LTCRL in Taiwan, the scale was found to be feasible and reliable in the pilot test. The higher the educational levels of home care workers in Taiwan, the better the performance of LTCRL, especially in the Process/Appraise and Apply/Use categories.
In the Chinese version of the Scale for Assessment of LTCRL, we incorporated both the concept of health literacy and reablement literatures [10, 18] and then modified the scenario-based questionnaires to fit the common situation of reablement in Taiwan. The scale was completed through a three-round Delphi process by 10 respondents from five different professional fields. R Latif, A Dahlan, Z Abdul Mulud and M Nor [19] had stated that a good result of Delphi process can be achieved even with small panels of 10 individuals in the healthcare study. We invited a panel of experts, who have profound experiences in reablement, and most of them work as supervisors for reablement in both private and public healthcare settings; thus, the scale in the study had met face/content validity. Regarding reliability, the coefficient of K-R-20 was 0.53, which is acceptable (> 0.5) for clinical practices [21]. The reason for low reliability might be that the proportion of the response to the items is highly correct. The average score of the scale is 25.19, and the full mark is 29 in the study. The dichotomy of the response answer designed for the scale might be the other potential reason for the low reliability. Nevertheless, after a structured expert consensus was obtained throughout the modified Delphi method and a pilot assessment, the Chinese version of the Scale for Assessment of LTCRL seems to be feasible for testing the LTCRL among home care workers in Taiwan.
One of the roles of home care workers is being a personal trainer for older people who are enrolled in reablement [22]. Herein, the ability to absorb knowledge, as well as applying it to the clinical setting, is essential. We found that the Taiwanese home care workers were good at categories of Access/Obtain and Understand but not in the later skillful and advanced competencies of Process/Appraise and Apply/Use categories. Furthermore, the educational levels were related to the Process/Appraise and Apply/Use categories, consistent with previous studies in which people with higher education performed better scores on health-related literacy [11, 12, 14]. In addition, our finding shed light on the existing educational program for home care workers in Taiwan. The teaching strategies for the current in-service education in Taiwan were mostly lectures and case reports [23], more likely linking to the basic literacy (Access/Obtain and Understand). We recommend that the educational programs should further emphasize on a scenario-based exercise related to advanced competencies of literacy. Thus, the home care workers enrolling reablement would have better skills in evaluating the caring problems and in selecting the optimal decisions to help older adults relearn or regain their ability to perform ADLs independently.
According to this study, the roles of education and self-rated general Chinese proficiency were important to LTCRL. Clearly, people with higher educational attainment would perform better readiness and can better utilize knowledge to practical use than those who had lower educational attainment. This finding is consistent with past literature that showed a positive effect of education on health-related literacy [11, 12, 14]. Surprisingly, the working experience of being a home care worker was insignificantly associated with literacy in this study, possibly because we measured the variable by the year of working experience and not the status of employment (full-time, part-time, and unemployed) as other studies [13]. Although the statistically insignificant in the current study, the gradient decrease in the scores of LTCRL was notable. One qualitative study mentioned that LTC professionals with abound experience of conventional home care services faced more challenges to this new approach of caring older adults [24]. Hence, we recommend that in-service education for home care workers in Taiwan should be more addressed on reablement in the future.
Meanwhile, several limitations were noted in the study. First, the pilot assessment for the scale recruited participants with purposive sampling. Although we had recruited participants from the north, middle, and southern Taiwan, it cannot be represented the overall home care workers in Taiwan. Second, each category has an unbalanced number of questionnaire items. One of the expert panel members suggested the merging of the categories of Access/Obtain (5 items) and Understand (4 items), resulting in a relatively equal number of items to the categories of Process/Appraise (11 items) and Apply/Use (9 items). However, considering the original conceptual framework for the literacy definition [10], we decided to maintain four categories in the study. Third, the Delphi method was used to obtain data from expert consensus, and it considered a validation process. However, given the dichotomy response design for the scale and a highly correct response rate found in the pilot test, the indicators of construct validity were not as good as the criterion used in testing construct validity through confirmatory factor analysis. We recommend that in future studies, developing an assessment scale through Delphi method should also include testing the enhanced validity such as construct validity.