Development and Psychometric Evaluation of a Chinese Instrument of Knowledge,Attitude and Preventive Practice on Dementia Care in Macao

Abstract

Background

Very few instruments to integrate knowledge, attitude and practice into dementia care as a holistic perspective were available to the Chinese.

Method

This article documented the development of a 30-item self-administered Chinese instrument of knowledge, attitude and preventive practice on dementia care and reported the results of psychometric testing among 1500 Chinese in Macao Special Administrative Region (SAR), including 234 primary health professionals, 272 staff working at day-care centers and nursing homes, 586 high school students and 408 community-dwelling older people. The Chinese instrument was developed through literature review and committee review. The psychometric methods were used to evaluate the reliability and validity of the Chinese instrument as measures of knowledge, attitude and preventive practice on dementia care for the Chinese.

Results

The preliminary results indicated that the Content Validity Index of the Chinese instrument was .973 and Cronbach’s alpha coefficient of the Chinese instrument was .842, among which Knowledge subscale, Attitude subscale and Preventive Practice subscale were .749, .633 and .845 respectively. The means and standard deviation were 65.13 ± 24.56 for Knowledge subscale, 74.76 ± 8.37 for Attitude subscale, 73.22 ± 14.05 for Preventative Practice subscale, and 70.99 ± 11.27 for the Chinese instrument.

Conclusion

The 30-item self-administered Chinese instrument of knowledge, attitude and preventive practice on dementia care had satisfied the psychometric evaluation well enough to warrant further use, and could also have particular implications for other Chinese populations all over the world.

Keywords

dementia Chinese instrument psychometric evaluation knowledge attitude preventive practice

Introduction

Dementia is a common neurodegenerative disease which involves progressive impairments to memory, thinking and behavior that affect everyday activities of older people, and at least 55 million people were believed to have been affected by dementia in 2019.¹ Although many measures of knowledge, attitude and preventive practice on dementia care have been developed throughout the last decades in Western countries, most of the Western measures covered either knowledge without the published reliability and validity² or knowledge and attitude themselves,³ and very few measures are applicable to the Chinese to integrate knowledge, attitude and practice into dementia care as a holistic perspective. Moreover, there were studies to demonstrate that the key obstacle is the cultural patterning and language difference between the Chinese and Western countries.^4,5 Eighty-nine percent of the population of Macao Special Administrative Region (SAR) China is Chinese, whose written language is Chinese, with the daily spoken language being Cantonese, and only 23% of the population in Macao SAR can speak English.⁶ Even though having been conducted similar studies on dementia care in Mainland China previously, either it was that knowledge and attitude were covered in the measures⁷ or that the measures were self-developed without the published reliability and validity in the studies.^8,9 There is an increasing demand for measurement tools to assess the knowledge, attitude and preventive practice as a holistic perspective on dementia care, where it stands in a pivotal position to evaluate their clinical effectiveness on dementia care. Particularly, Macao had a long history of domination by Portuguese, and was handed over back to China as a special administrative region on 20th December 1999. There had been the Chinese and the Western cultural coalescence for more than 400 years in Macao.¹⁰ Testing for a Chinese instrument as measures of knowledge, attitude and preventive practice as a holistic perspective on dementia care in Macao SAR is necessary prior to the Chinese instrument being applied to all the Chinese people in Macao SAR and various Chinese communities all over the world. Therefore, the objectives of this study were to document the development of a 30-item self-administered Chinese instrument of knowledge, attitude and preventive practice on dementia care and to evaluate the reliability and validity of the Chinese instrument as measures to integrate knowledge, attitude and preventive practice into dementia care as a holistic perspective for the Chinese.

Method

A three-stage method for testing the 30-item self-administered Chinese instrument of knowledge, attitude and preventive practice on dementia care had been developed.¹¹ The first stage was the development of the items of the Chinese instrument. The second stage was formal psychometric tests of item scoring and construction of multi-item instrument, which would ensure the scoring algorithms could be applied to the population concerned. The third stage was the validation and norming studies that provided a basis for interpretation. The first 2 stages were prerequisites to the third and were essential before the population concerned could use the Chinese instrument.

Development of the Chinese Instrument of Knowledge, Attitude and Preventive Practice on Dementia Care

The 30-item self-administered Chinese instrument to integrate knowledge, attitude and preventive practice into dementia care as a holistic perspective was generated from a literature review, based on the relevant open-published and freely items-cited questionnaires without copyrights from Chinese communities.^7-9 The Chinese instrument investigated the knowledge, attitude and preventive practice on dementia care, among which the participants were provided with options to choose true/false for each question under the 10-item Knowledge subscale, strong agree/agree/no comment/disagree/strong disagree for each question under the 10-item Attitude subscale and all of the time/most of the time/some of the time/a little of the time/none of the time for each question under the 10-item Preventive Practice subscale (Table 1). The single subscale score of Knowledge, Attitude and Preventive Practice ranged from 0 to 100 respectively, with higher scores indicating more knowledge, more positive attitude and more preventive practice on dementia care.

Table 1.

Items of the Chinese Instrument of Knowledge, Attitude and Preventive Practice on Dementia Care.

Subscales and Items	Response
Knowledge subscale	True/False
K1	Dementia is not a natural part of ageing
K2	Alzheimer’s disease is the most common type of dementia
K3	No cure for dementia currently
K4	Hypertension and diabetes mellitus are not risk factors of dementia
K5	Memory difficulty is the only symptom of dementia
K6	People living with dementia suffer from unstable temper
K7	People living with dementia suffer from disorientation
K8	Changing environment frequently is helpful for people living with dementia
K9	People with late stage dementia need others to take care their activities of daily living
K10	Mental exercise, physical activity, healthy diet and social interaction can prevent dementia
Attitude subscale	Strong agree/Agree/No comment/Disagree/Strong disagree
A1	Meaningless life if suffering from dementia
A2	I like to make friend with people living with dementia
A3	I like to take care family member living with dementia
A4	To arouse the public awareness of dementia in community is important
A5	Should encourage people living with dementia to join community activities
A6	Family members should make all the decisions for people living with dementia
A7	I am embarrassed if family member suffering from dementia
A8	Better to send people living with early stage dementia to day-care center
A9	Better to send people living with late stage dementia to nursing home
A10	Macao SAR Government should build dementia friendly community actively
Preventive practice subscale	All the time/Most of time/Some of time/A little of time/None of time
P1	More mental exercise
P2	More old and new interesting habits
P3	Physical activities regularly and body weight control
P4	Healthy diet
P5	More social interactions
P6	Body check regularly
P7	More attendance of lecture on dementia
P8	Acceptance and inclusiveness of people living with dementia
P9	Home adaptation to make family member with dementia live well at home
P10	Communication with people living with dementia by simple and direct way

The Chinese instrument was subsequently validated, prior to being sent to the participants, by 5 native speakers of Chinese panel in Macao SAR who were proficient in Chinese knowledge and with multi-disciplinary backgrounds, consisting of an experienced specialist in geriatric medicine, an experienced specialist in public health, a senior nurse in geriatric ward, a senior geriatric scholar and a senior social worker in geriatric field. Content validity is the degree to which an instrument has an appropriate sample of items for the construct being measured and is an important procedure in instrument development and the Content Validity Index (CVI) is the most widely used index in quantitative evaluation.¹² A cover letter and the Chinese instrument were included with the content validity survey explaining why panel were invited to participate, along with clear and concise instructions on how to rate each item. To evaluate whether items were relevant, panel were given a critical appraisal sheet with the relevance of each item in the instrument (how important the item is). For the relevancy scale, a 4-point Likert scale was used, and responses include: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, and 4 = very relevant.

Study Sample

The target sample of the Chinese instrument is all Chinese people and 4 sample groups of 1500 Chinese people were used in order to include subjects from a wide range of age, educational and social groups. The first sample group was 234 primary health professionals who were consisted of doctors and nurses (response rate of 62.4%), being selected conveniently from all the 375 primary health professionals working at all the Health Centers throughout Macao SAR in October 2018. The second sample group consisted of 586 high school students who came from Form 4 to Form 6 levels in 10 high schools (20.4%), being randomly selected from all 49 high schools throughout Macao SAR in November 2018. The third sample group comprised 408 community-dwelling older people aged 65 years and above out of 10 day centers (41.7%), being randomly selected from all 24 day centers throughout Macao SAR and 4 community rehabilitation wards in Macao SAR during September to October in 2019. The fourth sample group comprised 272 staff who included health care assistants, administrators, social workers and health professionals working at 25 day-care centers or nursing homes (67.6%), being randomly selected from all 37 day-care centers and nursing homes throughout Macao SAR during September to October in 2019. The Chinese instrument of knowledge, attitude and preventive practice on dementia care was self-administered by each subject, who then indicated whether he or she understood each question, found it difficult to answer, thought it was relevant to him or her, or minded answering the question. Information on age, gender, educational level, and occupation of the respondents was also obtained.

Data Analysis

For the relevancy instrument, ratings of 1 not relevant and 2 somewhat relevant were considered content invalid while ratings of 3 quite relevant and 4 very relevant were considered content valid. The CVI was computed as the number of panel giving a rating of 3 quite relevant or 4 very relevant for each item divided by the total number of panel.¹³

The Multi-trait Analysis Program-Revised (MAP-R) was used for multi-trait scaling analysis to evaluate hypothesized item groupings and assumptions underlying Liker’s methods of summated ratings.^14,15 Multi-trait scaling analysis involved examining the completeness of data in terms of item and subscale-level missing data, item frequencies, item and subscale descriptive statistics, internal consistency reliability, item-subscale correlations (corrected for overlap), and correlations among subscales. For the test of internal consistency reliability (Cronbach’s alpha), the standard for group comparisons was followed and considered reliability to be acceptable when an alpha coefficient was ≥.70, with higher alpha coefficient value indicating better reliability. In addition, a scaling success was counted whenever the correlation between an item and its hypothesized subscale ≥.40.¹⁶ Moreover, the subscale means and the relative relationship of Knowledge, Attitude and Preventive Practice subscale were compared with those of primary health professionals, high school students, community-dwelling older people and the staff working at day-care centers and nursing homes, and the construct validity was used to test whether and how the Chinese instrument discriminated among various groups. Items within a subscale measuring similar levels of function were put into 1 subscale, and those measuring different levels of function were put into different subscales. The relative order of the item-subscale means should follow the hypothesized order by the levels of function they measure. Items within the same subscale should have similar means and no ordering was hypothesized.¹¹

The scores of the Chinese instrument of knowledge, attitude and preventive practice on dementia care were constructed using the method of summated ratings, based on 5 assumptions:^11,15,17 (1) items measuring the same concept should have approximately equal variances (standard deviations), to avoid the need for standardization. This is a test of equal item variance; (2) an item should be substantially linearly related to the underlying concept being measured (item-subscale correlation should be .4 or above). This is a test of internal consistency; (3) item in a given subscale should contain about the same proportion of information about a concept, therefore, there should be roughly equal item-subscale correlation within a subscale (equivalent item-subscale correlation); (4) an item should correlate higher with its hypothesized subscale than with subscales measuring other concepts (item discriminant validity); and (5) subscale scores should be reproducible (reliability) and interpretable (inter-subscale correlation). Internal reliability of subscale scores was measured by the Cronbach’s alpha coefficient. Nunnally and Bernstein¹⁶ had suggested .7 as the minimum reliability coefficient for group comparison. Correlation between subscales should be less than their internal reliability coefficients (Cronbach’s alpha) if each subscale measures a unique concept.

Results

Characteristics of Sample

Four sample groups of 1500 Chinese people in Macao SAR were surveyed, including 234 primary health professionals, 586 high school students, 408 community-dwelling older people and 272 staff working at day-care centers and nursing homes. The age of the subjects ranged from 14 to 99 years old (40.6 ± 25.4 years). The age of the 234 primary health professionals ranged from 24 to 64 years old (41.0 ± 10.0 years). Most of the primary health professionals were female (79.7%, n = 185), over half of them (53.0%, n = 122) were nurses and 46.5% were doctors (n = 107). The age of the 586 high school students ranged from 14 to 20 years old (16.5 ± 1.2 years), over half of them (58.9%, n = 345) were male students and 41.1% were female students (n = 241). The age of the 408 community-dwelling older people ranged from 65 to 99 years old (76.0 ± 7.9 years), and most of them were female (n = 326, 79.9%), education levels of primary school or below (n = 279, 69.2%) and the retired (n = 346, 95.6%). The age of the 272 staff working at day-care centers and nursing homes ranged from 19 to 80 years old (38.1 ± 12.7 years), and most of them were female (n = 228, 85.1%), health care assistants (n = 105, 39.8%) and health professionals (n = 63, 23.9%).

Psychometric Testing Results

The preliminary results showed all the 30 items of the Chinese instrument of knowledge, attitude and preventive practice on dementia care were responded at score 4 or score 3 by the 5 native speakers of Chinese panel in Macao SAR who were proficient in Chinese knowledge and with multi-disciplinary backgrounds, and the CVIof the Chinese instrument was .973, which indicated all items were considered quite relevant and there was no item changed, dropped or added. The psychometric testing results indicated that most items for each subscale generally exceed the standard (.40) for item-internal consistency (Table 2). However, there were some exceptions to the above observation, among which the correlation coefficient between item A6 being “Family members should make all decisions for the people living with dementia” (.143) and A8 being “Better to send the people living with early stage dementia to day-care center” (.284), as well as the hypothesized Attitude subscale were slightly below .40.

Table 2.

Pearson Correlations^a between KAP Items and Hypothesized Subscales, Total Sample (n = 1500).

Item	Mean	Standard deviation	Knowledge	Attitude	Preventive practice
Knowledge subscale
K1	5.20	5.00	.447*	.070*	.102*
K2	6.10	4.88	.622*	.125*	.158*
K3	6.10	4.89	.606*	.115*	.079*
K4	4.80	5.00	.521*	.037*	.147*
K5	5.30	4.99	.528*	.054	−.023
K6	7.40	4.40	.560*	.136*	.143*
K7	8.60	3.47	.603*	.131*	.093*
K8	4.90	5.00	.551*	.105*	.124*
K9	8.60	3.47	.551*	.176*	.061
K10	8.50	3.59	.514*	.180*	.192*
Attitude subscale
A1	7.80	2.06	.236*	.389*	.106*
A2	7.28	1.71	.229*	.505*	.241*
A3	8.26	1.61	.159*	.513*	.141*
A4	8.56	1.39	.256*	.530*	.224*
A5	8.60	1.40	.260*	.524*	.246*
A6	5.86	2.32	.185*	.143*	−.080*
A7	7.50	1.98	.183*	.403*	.130*
A8	6.84	2.08	−.064	.284*	.122*
A9	6.90	2.09	.076*	.344*	.139*
A10	8.60	1.44	.241*	.500*	.228*
Preventive practice subscale
P1	8.08	1.64	.155*	.186*	.560*
P2	7.90	1.77	.135*	.151*	.613*
P3	7.54	2.01	.067*	.103*	.736*
P4	7.84	1.78	.075*	.154*	.729*
P5	7.48	1.99	.150*	.209*	.769*
P6	6.68	2.31	.112*	.150*	.757*
P7	5.82	2.59	.233*	.164*	.667*
P8	7.94	2.05	.238*	.298*	.323*
P9	7.92	2.00	.177*	.244*	.410*
P10	8.10	1.76	.280*	.382*	.475*

^aPearson correlation coefficient.

*Correlation is significant at the .01 level (2-tailed).

Table 3 listed the mean scores and standard deviations of the 30 items grouped under their subscales in the four various sample groups, being hypothesized item-cluster order. The items within each subscale had similar standard deviations (scaling assumption 1 on equal item variances) in the 4 various sample groups.

Table 3.

Distribution of Mean (Standard deviation) Item Scores in the Hypothesized Item-cluster.

Mean Item Score (Standard deviation)
KAP Items	Health professional	Nursing home staff	High school student	Older people
Clustered in order	(n = 234)	(n = 272)	(n = 586)	(n = 408)
Knowledge subscale
K1	6.60 (4.75)	5.50 (4.98)	4.30 (4.95)	5.40 (4.99)
K2	9.30 (2.61)	8.10 (3.91)	5.50 (4.98)	3.70 (4.83)
K3	8.80 (3.23)	7.30 (4.43)	4.90 (5.00)	5.30 (5.00)
K4	7.70 (4.24)	5.40 (4.99)	3.40 (4.72)	4.80 (5.00)
K5	8.40 (3.67)	6.20 (4.86)	6.00 (4.91)	1.90 (3.96)
K6	9.40 (2.39)	8.50 (3.54)	6.10 (4.89)	7.30 (4.44)
K7	9.90 (1.13)	9.10 (2.87)	8.10 (3.94)	8.30 (3.78)
K8	7.70 (4.24)	7.30 (4.45)	3.10 (4.65)	4.10 (4.93)
K9	9.70 (1.59)	9.30 (2.52)	7.80 (4.17)	8.70 (3.38)
K10	9.60 (1.94)	9.40 (2.31)	7.40 (4.40)	8.80 (3.25)
Attitude subscale
A1	8.44 (1.44)	8.30 (2.00)	8.04 (1.96)	6.72 (2.16)
A2	7.50 (1.44)	7.86 (1.77)	6.98 (1.72)	7.18 (1.70)
A3	8.36 (1.30)	8.46 (1.71)	8.42 (1.62)	7.82 (1.60)
A4	9.00 (1.12)	8.82 (1.47)	8.32 (1.45)	8.50 (1.31)
A5	9.10 (1.11)	8.74 (1.70)	8.42 (1.39)	8.46 (1.26)
A6	6.24 (2.32)	6.38 (2.65)	5.90 (2.15)	5.26 (2.18)
A7	7.82 (1.75)	8.16 (2.00)	7.32 (1.93)	7.14 (2.04)
A8	6.32 (2.15)	7.14 (2.02)	6.26 (1.99)	7.72 (1.83)
A9	6.84 (1.85)	7.38 (2.22)	6.06 (1.94)	7.78 (1.86)
A10	8.94 (1.38)	8.84 (1.54)	8.38 (1.45)	8.58 (1.35)
Preventive practice subscale
P1	8.32 (1.35)	7.94 (1.85)	8.28 (1.64)	7.76 (1.58)
P2	8.20 (1.46)	7.68 (1.87)	8.20 (1.74)	7.46 (1.78)
P3	7.76 (1.76)	7.52 (2.11)	7.30 (2.16)	7.78 (1.81)
P4	8.02 (1.55)	8.12 (1.84)	7.42 (1.93)	8.20 (1.49)
P5	7.90 (1.61)	7.56 (2.09)	7.12 (2.15)	7.70 (1.78)
P6	7.42 (1.86)	7.22 (2.09)	5.40 (2.33)	7.78 (1.68)
P7	6.92 (1.92)	6.88 (2.33)	4.30 (2.30)	6.64 (2.44)
P8	8.48 (1.46)	8.80 (1.97)	7.70 (1.94)	7.42 (2.29)
P9	8.46 (1.51)	8.54 (1.90)	7.64 (2.13)	7.62 (1.98)
P10	8.48 (1.25)	9.04 (1.31)	7.64 (1.96)	7.90 (4.66)

Table 4 presented item means and standard deviations of the transformed subscales for the total sample as well as for the 4 various groups. The scores of primary health professionals spread over the full range, except those of the Attitude subscale. For the total sample, the means and standard deviations were 65.13 ± 24.56 for Knowledge subscale, 74.76 ± 8.37 for Attitude subscale, 73.22 ± 14.05 for Preventative Practice subscale, and 70.99 ± 11.27 for the Chinese instrument. Most measures met the minimum reliability standard (i.e., the internal consistency coefficients were above .70), with .749 for Knowledge subscale, .633 for Attitude subscale, .845 for Preventative Practice subscale, and .842 for the Chinese instrument to integrate knowledge, attitude and preventive practice into dementia care as a holistic perspective.

Table 4.

Knowledge, Attitude and Practice Instrument Psychometric Results, Total and by Sample Groups.

KAP instrument	Mean	Standard deviation	Reliability (Cronbach’s alpha)
Total (n = 1500)	70.99	11.27	.842
Knowledge subscale	65.13	24.56	.749
Attitude subscale	74.76	8.37	.633
Preventive practice subscale	73.22	14.05	.845
Health professional (n = 234)	78.06	7.09	.811
Knowledge subscale	87.02	14.01	.588
Attitude subscale	69.52	5.83	.615
Preventive practice subscale	77.88	13.18	.911
Nursing home staff (n = 272)	77.46	9.88	.801
Knowledge subscale	76.23	19.62	.664
Attitude subscale	80.05	8.92	.642
Preventive practice subscale	75.59	13.88	.823
High school student (n = 586)	66.22	11.04	.818
Knowledge subscale	56.27	24.90	.730
Attitude subscale	73.97	7.72	.595
Preventive practice subscale	68.34	14.05	.845
Older people (n = 408)	69.69	10.31	.815
Knowledge subscale	58.15	20.95	.637
Attitude subscale	75.34	7.99	.646
Preventive practice subscale	76.10	12.48	.836

As hypothesized, significant positive correlations were found between all 3 pairs of subscales. The inter-subscale correlations were less than the subscale internal reliability coefficient for all the subscales, showing that each subscale measured a unique concept, relative to other subscales (Table 5).

Table 5.

Internal Reliability Coefficients and Inter-subscale Correlations.a

KAP subscale	Knowledge	Attitude	Preventive practice
Knowledge	1
Attitude	.195*	1
Preventive practice	.196*	.228*	1

^aPearson correlation coefficient.

*Correlation is significant at the .01 level (2-tailed).

Discussion

The 30-item self-administered Chinese instrument to integrate knowledge, attitude and preventive practice into dementia care as a holistic perspective was generated from a literature review based on the relevant questionnaires from Chinese communities, and the study used 4 sampling groups of 1500 Chinese people, including 234 primary health professionals, 586 high school students, 408 community-dwelling older people and 272 staff working at day-care centers and nursing homes. The wide range of sample groups of subjects represented variety of ages, social classes and educational levels in the testing of the Chinese instrument. The psychometric testing of the Chinese instrument yielded results that satisfied conventional psychometric criteria, with the reliability Cronbach’s alpha of .842 for the Chinese instrument. Among the 3 subscales of the Chinese instrument, reliabilities were above the norm (.70) for 2 subscales, with .749 for Knowledge subscale and .845 for Preventative Practice subscale. Pertaining to the results for the acceptability, construct validity and psychometric properties of the Chinese instrument could be applicable to other Chinese people because the sample consisted of subjects with a wide range of demographic characteristics.

Because of cultural patterning and language barriers, Chinese were largely under-studied in health services research which related to the integration of knowledge, attitude and preventive practice into dementia care as holistic perspectives. The study could fill a gap in the literature of health services research related to knowledge, attitude and preventive practice as a holistic perspective on dementia care among Chinese in the field. Despite concerns about the differences existing in different populations,^18-20 there seemed to be few difficulties in applying the Chinese instrument of knowledge, attitude and preventive practice as a holistic perspective on dementia care to the 4 various groups. The Chinese instrument discriminated relatively well among different populations. These results were encouraging, suggesting the Chinese instrument might be appropriate in general population surveys as well as clinical practice or research.

The results of the study indicated that generally the development of the 30-item Chinese instrument of knowledge, attitude and preventive practice on dementia care was successful, though there were still a few areas requiring further examination. The study used 4 sampling groups of 1500 Chinese people in order to cover subjects from a wide range of age, educational and social groups. However, a much larger sample size would be needed if subjects were randomly selected from the general population, in order to include people from more educational and social groups.²¹ Due to the small sample size, the results based on group comparisons should be interpreted with caution. The psychometric testing results also indicated specific areas of the Chinese instrument of knowledge, attitude and preventive practice on dementia care, in which further work would be required. Among the 3 subscales of the Chinese instrument, Attitude subscale was the least satisfactory in term of reliability, as Cronbach’s alpha (.633) was slightly below the norm (.70). The 2 attitude items, being “Family members should make all decisions for the people living with dementia” and “Better to send the people living with early stage dementia to day-care center” were correlated more lowly with their hypothesized Attitude subscale. This finding seemingly pointed to the differences in the cultural interpretation of items. The Chinese family members usually took the deeply ingrained responsibility to care for the older persons living at home and took it for granted to do all the things for the older persons, especially for whom suffering from dementia. This represented the traditional Chinese culture of filial piety.²² This rigidly observed Confucian ideology of Chinese family’s filial piety might be not supportive for the older people living with dementia to live independently in community. Therefore, further study would be necessary to explore the attribution on the domineering status of Confucian ideology of Chinese family’s filial piety in the realm of dementia care under Chinese culture.

The results of this study would benefit others around Chinese communities who worked with the Chinese population. It is anticipated that the results of this work would encourage further research about establishing the reliability, validity, and clinical application of the Chinese instrument of knowledge, attitude and preventive practice on dementia care in larger groups of Chinese communities. The results of the study would also provide a valuable experience for developing measures of knowledge, attitude and preventive practice as a holistic perspective on dementia care in other underserved populations.

Limitations

As mentioned above, there were cultural patterning and language difference between the Chinese and Western countries, and the study strived to develop the Chinese instrument to integrate knowledge, attitude and preventive practice into dementia care as a holistic perspective for the Chinese population, therefore, the study did not conduct a review of international questionnaires as a base for generating items.

Conclusion

Because very few psychometrically-evaluated Chinese instruments to integrate knowledge, attitude and preventive practice into dementia care as holistic perspectives were available to the Chinese, the study filled a gap in the literature of dementia services research among the Chinese. The results of the study indicated that the 30-item Chinese instrument could serve as an instrument with satisfied reliability and validity for measuring the knowledge, attitude and preventative practice on dementia care among the Chinese. The Chinese instrument would not only be useful in assessing the effectiveness of dementia care in the underserved population, but also valuable in social science research of determinants of health practice among the Chinese. Also, the results of the work would benefit others around the world who worked with the Chinese populations. It was expected that the results of the study would inspire further research to establish the reliability, validity and clinical application of the Chinese instrument of knowledge, attitude and preventive practice on dementia care. The results of the study would also provide a valuable experience for developing dementia care measures in other underserved Chinese populations. It was essential to note that there were common characteristics of prototypically Chinese culture shared by all the Chinese. Keeping this in mind, it was anticipated that even though the study was conducted among the Chinese in Macao SAR, the 30-item Chinese instrument of knowledge, attitude and preventive practice on dementia care could also have particular implications for other Chinese populations all over the world.

Footnotes

Acknowledgments

The authors would like to thank all the people who participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and publication of this article: The research was funded by the Macao Health Bureau, the Government of Macao Special Administrative Region, China.

Ethical Approval

Ethical approval was obtained through the Medical Ethical Committee of the Centro Hospitalar Conde de São Januário, the Government of Macao Special Administrative Region, China.

ORCID iD

ZENG Wen

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