| Objectives(1)To describe the status of dysphagia among the elderly in nursing homes in Hunan Provinces and analyze related factors,in order to provide reference basis for dysphagia intervention for the elderly in nursing homes.(2)To develop the Knowledge,Attitude,and Practice(KAP)scale of safety eating for the elderly with dysphagia and conduct reliability and validity tests,and describe the status of KAP of safety eating among the elderly with dysphagia in nursing homes and analyze related factors,in order to provide basis for the development of safety eating behavior intervention model for the elderly with dysphagia in nursing homes.(3)To develop a safety eating behavior intervention model for the elderly with dysphagia in nursing homes and evaluate the intervention effect,in order to provide new methods and ideas for the prevention and control of complications among the elderly with dysphagia in nursing homes.Methods(1)A multi-stage stratified cluster random sampling method was used to select older adults from 56 nursing homes in 14 cities in Hunan Province.The 30 ml water swallowing test and Eating Assessment Tool10 items(EAT-10)were used to screening dysphagia among the elderly in nursing homes.A series of questionnaires was used to assess lifestyle behaviors,health-related conditions,activities of daily living(ADL),cognition function and psychosocial factors.The Chi-square test was used to compare the difference of prevalence between different characteristics of older adults,and a multi-level logistic regression model was used to conduct multivariate analysis for dysphagia among the elderly in nursing homes.(2)Based on the KAP theory,we use literature review,qualitative interviews,focus group discussions and Delphi method to construct the initial version of KAP scale of safety eating for the elderly with dysphagia.A cluster random sample of 348 older adults with dysphagia in nursing homes in Hunan Province were choose to conduct a questionnaire survey for analyzed reliability and validity,then the final version of KAP scale of safety eating for the elderly with dysphagia was finalized.(3)A self-designed KAP scale of safety eating for the elderly with dysphagia was used to assess KAP of safety eating among the elderly with dysphagia in 56 nursing homes in Hunan Province.A series of questionnaires was used to assess lifestyle behaviors,ADL,cognition function and social support.The Mann-Whitney U,Kruskal-Wallis H non-parametric test and multiple linear regression model were used to analyze related factors for KAP of safety eating for the elderly with dysphagia in nursing homes.(4)The safety eating behavior intervention model was developed through literature research,semi structured interview and focus group discussion.Using a cluster randomized controlled trial design,the control group have implemented regular health education in nursing homes and the intervention group have implemented a 6-months safety eating behavior intervention model based on the control group.The baseline data of the intervention and the control group were collected.In order to analyze the intervention effect of this model,after 3 and 6 months of follow-up,standardized swallowing assessment(SSA)scale score,incidence of cough,swallowing quality of life(SWAL-QoL)scale score,KAP scale score of safety eating for the elderly with dysphagia and mininutritional assessment short form(MNA-SF)score were collected between the intervention group and the control group.Based on the intention to treat(ITT)data analysis principle,linear mixed effects model or multi-level logistic model was used to analyze the intervention effect.Results(1)A total of 5539 older adults in nursing homes were participant in dysphagia screening.The mean age was 78.52±9.18 years and 49.8%of participants were male.The prevalence of dysphagia was 31.0%(95%CI:28.9%～33.4%)among the elderly in nursing homes in Hunan Province.The zero model of two-level logistic regression showed that the Intraclass Correlation Coefficient(ICC)was 0.067(95%CI:0.041～0.106).Twolevel logistic regression model showed that individual-level related factors with dysphagia among the elderly in nursing homes were poor sleep quality(OR=1.472,95%CI:1.227～1.765);suffering from≥3 kinds of chronic diseases(OR=1.606,95%CI:1.294～1.993);history of stroke(OR=1.662,95%CI:1.352～2.043);unhealthy oral health(OR=1.824,95%CI:1.478～2.251);number of teeth ≤10(OR=1.323,95%CI:1.057～1.656);frailty(OR=1.530,95%CI:1.259～1.860);sarcopenia(OR=1.252,95%CI:1.032～1.521);moderate ADL impairment(OR=1.353,95%CI:1.114～1.642);severe ADL impairment(OR=1.438,95%CI:1.164～1.779);mild cognitive impairment(OR=1.255,95%CI:1.050～1.500);depression symptoms(OR=1.216,95%CI:1.013～1.460)and anxiety symptoms(OR=1.213,95%CI:1.004～1.465).Nursing homes level related factors were living in the medical institution within nursing home(OR=1.484,95%CI:1.113～1.979)and living in a nursing home within the medical institution(OR=2.418,95%CI:1.658～3.528).(2)The KAP scale of safety eating for the elderly with dysphagia have 40 items,which including the knowledge subscale(13 items),the attitude subscale(11 items)and the practice subscale(16 items).The Cronbach ’s α coefficient of the KAP scale of safety eating for the elderly with dysphagia was 0.849,and the Cronbach’s α coefficient of the knowledge,attitude and practice subscale were 0.726,0.885 and 0.821,respectively.The split-half reliability of the KAP scale of safety eating for the elderly with dysphagia was 0.758,and the split-half reliability of the knowledge,attitude,and practice subscale were 0.763,0.817,and 0.738,respectively.The test-retest reliability of the KAP scale of safety eating for the elderly with dysphagia was 0.878,and the test-retest reliability of the knowledge,attitude,and practice subscale were 0.804,0.889,and 0.817,respectively.The Item Content Validity Index(I-CVI)of the KAP scale of safety eating for the elderly with dysphagia range from 0.93 to 1.00,the Scale Content Validity Index(S-CVI)was 0.912.The Comparative Fit Index(CFI)of the knowledge subscale of safety eating for the elderly with dysphagia was 0.999,the Tucker-Lewis Index(TLI)was 0.999 and the Root Mean Square Error of Approximation(RMSEA)was 0.005;the CFI of the attitude subscale of safety eating for the elderly with dysphagia was 0.995,the TLI was 0.992 and the RMSEA was 0.028;the CFI of the practice subscale of safety eating for the elderly with dysphagia was 0.996,the TLI was 0.990 and the RMSEA was 0.024.(3)The median score of safety eating knowledge subscale among the elderly with dysphagia was 3.00 points(total score was 13 points),the awareness rate ranges from 12.7%to 33.3%.Three items with a low awareness rate were "choosing the right consistency of food can prevent dysphagia and its complications"(12.7%),"taking the next swallow after the previous swallow can prevent dysphagia and its complications"(13.7%)and "choosing the right eating tool can prevent dysphagia and its complications"(15.2%),respectively.Related factors of safety eating knowledge score among the elderly in nursing homes were education,residence duration,personal monthly income and cognition function.The median score of safety eating attitude subscale among the elderly with dysphagia was 5.25 points(total score was 11 points),the positive attitude rate ranges from 43.1%to 74.0%.Three items with low positive attitude holding rate are "I think my swallowing problem makes me loss weight at present"(43.1%),"I think early screening of swallowing problems can reduce the occurrence of complications of dysphagia"(45.5%)and "I think learning safe eating skills can help improve swallowing problems"(46.1%),respectively.Related factors of safety eating attitude score among the elderly in nursing homes were education,residence duration,visiting frequency and social support.The median score of safety eating practice subscale among the elderly with dysphagia was 6.50 points(total score was 16 points),the positive behavior rate ranges from 22.6%to 61.8%.Three items with a low positive behavior holding rate were "actively learning about swallowing and safe eating"(22.6%),"actively consulting doctors about swallowing and safe eating"(24.3%),and "choosing an appropriate amount of food to avoid too much or too little"(25.2%),respectively.Related factors of safety eating behavior among the elderly in nursing homes were education,cognition function and ADL.(4)Based on behavior change theories such as KAP,and the status of KAP of safety eating for the elderly with dysphagia in nursing homes,the safe eating behavior intervention model including health education on dysphagia and safe eating knowledge,guidance and demonstration of safe eating behavior for elderly with dysphagia,provision of safe eating behavior for the elderly with dysphagia,psychological support and telephone or SMS reminder.A total of 287 participants in the intervention group and 305 participants in the control group were included in this cluster randomized controlled trial,respectively.Results showed that after three months follow-up,the SSA score of the intervention group was lower 1.282 points(b=-1.282,95%CI:-2.136～-0.429)than the control group;the safety eating knowledge score of the intervention group was higher 3.209 points(b=3.209,95%CI:3.004～3.414)than the control group;the safety eating attitude score of the intervention group was higher 2.298 points(b=2.298,95%CI:2.111～2.484)than the control group;the safety eating behavior score of the intervention group was higher 2.124 points(b=2.124,95%CI:1.832～2.417)than the control group;the risk of cough of the intervention group was lower 52.0%(OR=0.480,95%CI:0.361～0.639)than the control group;the SWALQoL score of the intervention group was higher 19.545 points than the control group(b=19.545,95%CI:16.801～22.289);the MNA-SF score of the intervention group was higher 0.622 points than the control group(b=0.622,95%CI:0.436～0.808).After six months follow-up,the SSA score of the intervention group was lower 3.235 points(b=-3.235,95%CI:-4.088～-2.381)than the control group;the safety eating knowledge score of the intervention group was higher 4.232 points(b=4.232,95%CI:4.027～4.437)than the control group;the safety eating attitude score of the intervention group was higher 2.671 points than the control group(b=2.671,95%CI:2.484～2.858);the safety eating behavior score of the intervention group was higher 3.817 points(b=3.817,95%CI:3.524～4.109)than the control group;the risk of cough of the intervention group was lower 59.9%than the control group(OR=0.401,95%CI:0.291～0.551);the SWAL-QoL score of the intervention group was higher 46.690 points than the control group(b=46.690,95%CI:43.946～49.434);the MNA-SF score of the intervention group was higher 1.272 points than the control group(b=1.272,95%CI:1.086～1.457).Conclusions(1)The prevalence of dysphagia was 31.0%among the elderly in nursing homes in Hunan Province.There is aggregation of dysphagia among the elderly in nursing homes.Individual-level related factors with dysphagia among the elderly in nursing homes were sleep quality,ADL,number of chronic diseases,history of stroke,oral health,number of teeth,frailty,sarcopenia,cognition function,depression symptoms and anxiety symptoms.Nursing home-level related factor with dysphagia among the elderly was type of nursing homes.(2)The KAP scale of safety eating for the elderly with dysphagia has 40 items,including knowledge subscale(13 items),attitude subscale(11 items)and practice subscale(16 items).The construction of this scale conforms to the theoretical conception,and have good reliability and validity among the elderly with dysphagia in nursing homes.It can be used as an assessment tool for the safety eating knowledge,attitude and behavior among the elderly with dysphagia.(3)The elderly with dysphagia in nursing homes have low awareness about safety eating knowledge.Their attitude towards safety eating is relatively positive,and their safety eating behavior needs to be improved.Related factors with safety eating knowledge among the elderly with dysphagia were education,cognition function,residence duration,and personal monthly income.Related factors with safety eating attitude among the elderly with dysphagia were education,residence duration,visiting frequency and social support.Related factors with safety eating behavior among the elderly with dysphagia were education,cognition function and ADL.(4)The safety eating behavior intervention model can improve KAP of safety eating for the elderly with dysphagia in nursing homes.It can also decrease the risk of aspiration and cough,improve the quality of life among the elderly with dysphagia,and their nutrition status.The safety eating intervention model could as an effective intervention model for the elderly with dysphagia in nursing homes. |
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