Preliminary validation of the health and social care professionals’ knowledge and attitudes towards later-life intimacy and sexuality (HSCP-KALLIS) scale

Abstract

Background

The Health and Social Care Professionals’ Knowledge and Attitudes towards Later-Life Intimacy and Sexuality (HSCP-KALLIS) is designed to assess health and social care professionals’ knowledge and attitudes toward later-life intimacy and sexuality. Additional care considerations are included for older adults with dementia and those from diverse gender backgrounds. This study aimed to evaluate the reliability and validity of the HSCP-KALLIS scale.

Methods

This methodological study was a subsequent phase of the HSCP-KALLIS scale development undertaken between 2022 and 2023, using an online survey approach with participants who were health and social care professionals. Internal consistency was assessed using McDonald’s Omega and Cronbach’s alpha, while the underlying factor structure of the scale was examined through exploratory factor analysis.

Results

A total of 98 participants were recruited for the study. Participants primarily were females, registered nurses, worked in aged care, and demonstrated high levels of knowledge and positive attitudes towards later-life intimacy and sexuality. The final HSCP-KALLIS Scale consists of 30 knowledge items across two factors and 25 attitude items across three factors, with satisfactory internal consistency demonstrated.

Conclusions

This study provides preliminary evidence that the HSCP-KALLIS scale is a reliable tool for measuring health and social care professionals’ knowledge and attitudes towards later-life intimacy and sexuality. This scale shows potential for identifying staff training needs, evaluating training effectiveness, and informing policy and guidelines development. The primary study limitations include methodological constraints and a small sample size. Future research should involve a larger sample size to enable confirmatory factor analysis.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-026-07489-5.

Introduction

The significance of fulfilling intimacy and sexual expression in older adults has emerged as an increasingly crucial area of physical and psychological well-being, garnering attention in a range of contexts including human rights [1], media coverage [2], research focus [3–5], and education needs [6–8]. The baby boomer generation (those born between 1946 and 1966) is experiencing greater sexual liberation in their private lives [9]. This shift has been attributed to: (1) the gradual, yet significant social and cultural changes toward sexual expression for all ages in Western countries [10]; and (2) the implementation of human rights policies and guidelines, whereby older adults are protected from discrimination and prejudice in their sexual orientation, gender, and race [11]. Notably, despite these changes and improvements in a private context, intimate and sexual needs, as well as sexual expression in older adults, remain relatively undervalued and less discussed in healthcare settings [3].

Addressing older adults’ intimate and sexual needs does not appear to fit into clinical care contexts, as managing chronic physical conditions is typically a priority. Inadequate knowledge, lack of confidence in navigating discussions, or potential benevolence stigma (the belief that older adults need to be protected from harm) around such topics are highlighted in the literature [12–14]. These challenges lead many Health and Social Care Professionals (HSCPs) to hesitate in initiating discussions with older individuals about their intimate and sexual needs. To genuinely support older adults’ sexual expression, it is imperative that HSCPs have a strong understanding of sexual health, in addition to physical and psychological changes associated with older age [15].

Additionally, unique care needs for older adults with dementia and those identifying as Lesbian, Gay, Bisexual, Transgender, Intersex and Queer/Questioning (LGBTIQ+) must be considered. To address the challenges above, it is crucial to identify the levels of knowledge and attitudes held by HSCPs. However, existing instruments such as the Aging Sexual Knowledge and Attitudes Scale, ASKAS [16] may not reflect contemporary knowledge of later-life sexuality [17, 18]. As a result, the scale of Health and Social Care Professionals’ Knowledge and Attitudes Towards Later-Life Intimacy and Sexuality (HSCP-KALLIS) was developed [19] and comprises a Knowledge Scale and an Attitude Scale.

This study aimed to assess the reliability and validity of the developed HSCP-KALLIS Scale, with a particular focus on exploring its factor structure. It also examined participants’ knowledge and attitudes towards later-life intimacy and sexuality.

Methods

Study design

This methodological study was undertaken as part of the broader scale development process [19] and was conducted between March and December 2023 via a Qualtrics online survey [20]. Ethical approval was granted by Bond University Human Research Ethics Committee (#YC00016). Demographic information including age, gender, job position, highest education level, and professional specialty was collected for the purpose of describing the sample.

The HSCP-KALLIS scale development

The HSCP-KALLIS scale, which includes both Knowledge and Attitude Scales, was developed using a modified Delphi approach [19]. The Knowledge Scale comprises 46 items with response options of ‘Yes’, ‘No’, and ‘Do not know’. The inclusion of the option ‘Do not know’ was intended to minimise guessing. Knowledge items answered correctly received a score of one, while items incorrectly answered and ‘Do not know’ responses were given zero points [21]. The maximum score for the Knowledge Scale was 46 including eighteen reverse-scored items, with higher scores indicating greater knowledge [22]. The Attitude Scale consisted of 40 items scored including fifteen reverse-scored items on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree), with higher scores indicating stronger positive attitudes [23].

As part of the scale development process, the penultimate version of the HSCP-KALLIS was pilot tested with 26 HSCPs with expertise in ageing and sexuality to assess the clarity of the instructions, item wording, and overall flow. Feedback was collected via open-ended text boxes and analysed using content analysis [24]. No specific qualitative comments were made regarding the clarity of the instructions, items, or flow; therefore, no further refinements were made. In this small pre-testing sample, preliminary internal consistency was acceptable, with Cronbach’s alpha coefficients of 0.83 for the 46-item Knowledge Scale and 0.88 for the 40-item Attitude Scale.

The validation of the HSCP-KALLIS scale

Participant recruitment and procedure

The HSCP-KALLIS scale is intended to assess HSCPs’ knowledge and attitudes towards later-life intimacy and sexuality. Therefore, HSCPs working in healthcare settings or health-related educators with expertise in teaching about ageing and sexuality were invited to participate. Participants were purposively recruited from this target population through the research team’s healthcare professional networks via social media platforms (e.g., Twitter and Facebook), as well as via four Australian healthcare professional organisations: the Australian Nurse and Midwife Federation (Victorian Branch), the Australian Association of Gerontology (AAG), the Australian and New Zealand Association for Health Professional Educators (ANZAHPE), and Dementia Australia. The hyperlink and QR code for the online survey (administrated via Qualtrics) were included in the study flyer. After reading the explanatory statement and providing consent, participants completed demographic questions and two subscales of the HSCP-KALLIS Scale. The initial recruitment target of 385 was derived using a conventional sample size formular for unknown populations (95% confidence interval, 5% margin of error). Recruitment efforts yielded fewer responses than expected, despite the use of multiple strategies. As a result, the sample size target was adjusted to 100, which is regarded as adequate for the statistical analyses planned for the study [25].

Data analytic plan

Exploratory Factor Analysis (EFA) was performed to explore the underlying factor structure of the HSCP-KALLIS scale and identify the most psychometrically robust items. Principal Axis Factoring (PFA) extraction with Direct Oblimin rotation was chosen for the Knowledge Scale as it was coded dichotomously (0–1), while Maximum Likelihood Estimation (MLE) extraction with Direct Oblimin rotation was applied for the Attitude Scale which was coded on a Likert Scale (1–5). Parallel Analysis was used to determine the optimal number of factors to retain for each scale.

Item refinement was guided by multiple statistical criteria including the examination of inter-item and item-total statistics to assess each item’s contribution and its fit within the scale. We reported both McDonald’s Omega (ω) and Cronbach’s alpha (α) as measures of internal consistency, with values above 0.70 considered acceptable [26, 27]. Due to the limitations of Cronbach’s alpha (α), which can be influenced by the number of items and the assumption of tau-equivalence, we also reported McDonald’s Omega (ω) as it provides a more accurate estimate of internal consistency [28, 29].

While commonly accepted EFA factor loading cutoffs are typically around 0.40 [30], this study adopted a more conservative threshold of 0.55 due to the limited sample size, following recommendations from previous researchers [31].

Sample size justification

A total number of 156 survey responses were received, of which 58 were deemed invalid because respondents only completed the demographic items. The final analytic sample consisted of 98 responses, including nine that were partially completed. Missing data for those nine partially complete responses were determined to be completely missing at random. Although the recommended sample size for EFA ranges from 100 to 1000 samples, the literature indicates that EFA can still produce reliable factor solutions with samples smaller than 50 when certain conditions are met such as high factor loadings, a small number of factors, and strong communalities [32]. Furthermore, previous research has demonstrated acceptable use of small sample sizes in EFA applications [33]. Sample selection procedures are summarised in Fig. 1.

Fig. 1.

Sample selection flowchart

Results

The data were analysed using SPSS Version 28 and JASP Version 0.19.0. An alpha level of 0.05 was utilised to determine the statistical significance of all results, unless stated otherwise. The completion rate was 91% for the Knowledge Scale and 90% for the Attitude Scale among those who participated. Due to the low participation rate, data with partial missing responses were included in the data analysis. The issue of missing data was addressed and managed by implementing pairwise deletion to allow the retention of as much information as possible and to maximise the use of data.

Participant demographics

As shown in Table 1, a total of 98 participants took part in the study. The majority were female (82%) with mean age of 44.6 years (SD = 12.1). Approximately half of the participants were aged care nurses who reported working clinically. Regarding professional experiences, about a quarter of the participants reported having over 20 years of experience.

Table 1.

Demographic characteristic of participants for the validation of the HSCP-KALLIS scale

Characteristic	n = 98 (%)
Gender
Male	13(13.3)
Female	82(83.7)
Non-binary/third gender/prefer not to say	3(3.0)
Job title
Registered nurse & Nurse practitioner	76(77.6)
Physicians	7(7.1)
Allied health professionalsa	12(12.0)
Other job titlesb	3 (3.0)
Professional specialty
Aged care/ageing care	43(43.9)
Acute care (Medical/Surgical settings)	35(35.7)
Community care settings (including general practitioner clinic)	9(9.2)
Other professionalsc	11 (11.2)
Years of working
Less than 20 years	79(80.6)
21 years and above	19(19.4)
Previous received intimacy and sexuality training
No, not had training	68(69.4)
Yes, had training	30(30.6)

^aReflects Allied health professionals included physiotherapist, occupational therapist, social worker, sexologist & speech pathology

^bReflects other job titles included advocacy, activity officer & researcher

^cReflects other professionals included academic, mental health, midwifery, health promotion

Knowledge and attitude scale total scores

The overall knowledge scores ranged from zero to 46 (M = 39.5, SD = 7.5), indicating generally high levels of knowledge among participants. Although most items were answered correctly, there were six items (K17, K32, K33, K34, K39 and K42) for which less than 75% participants responded correctly as shown in Table 2. Notably, items relating to understanding sexuality diversity among older people showed higher average correct response rates compared to the pre-testing sample, but the correct response rate for Item K42, addressing older adults’ right to intimacy and sexuality, was much lower than in the pre-testing sample (82.8%).

Table 2.

Participants’ knowledge scale results

Knowledge scale items with less than 75% correct responses	Percentage of correct responses (%)
K17 Maintenance of physical appearance is a form of sexual expression.	68.8
K32(R) Care practices of all aged care organisations are LGBTIQ+ inclusive.	52.7
K33 In healthcare systems, sexual rights of older LGBTIQ+ adults are at times ignored because of homophobia and heterosexism. (Heterosexism: The assumption and treatment of all older people as heterosexual)	69.9
K34(R) Aged care staff are well trained in the care issues relevant to the older LGBTIQ+ population.	74.2
K39(R) Nursing homes do not have an obligation to support later life sexuality.	69.9
K42(R) Aged care providers need to abide by the family’s decision when it comes to older people’s intimate and sexual behaviours.	43.3

Items marked with (R) are reverse-scored items. Bold figures represent items less than 75% correct responses

The overall attitude scores ranged from 115 to 191 (M = 157.6, SD = 19.3), reflecting neutral attitudes among most participants. Six reverse-scored attitude items (A7, A9, A15, A18, A21 and A22) were found that most participants agreed and strongly agreed, indicating potential negative attitudes. For example, 66.7% of participants agreed with Item A7 “Frequent requests by a male resident for unnecessary perineal care from female staff should be considered problematic sexual behaviour”, while 76.6% of participants agreed to Item A21 “Public masturbation in an older person living with dementia would be considered inappropriate sexual behaviour”. Just under half of the sample (40%) responded neutrally to Item A18, indicating uncertainty about item statement. See Table 3 for further details.

Table 3.

Participants’ attitude scale results

Attitude scale items with most participants responding ‘neutral’ or ‘agreed’	Percentage of participants (%)
	Neither agreed nor disagreed	Agreed and strongly agreed
A7(R) Frequent requests by a male resident for unnecessary perineal care from female staff should be considered problematic sexual behaviour.	23.3	66.7
A9(R) A resident living in a nursing home in my care who is having a sexual relationship with another resident should be reported to the care manager.	24.4	47.8
A15(R) I do not raise the topic of intimacy and sexuality with older people under my care unless they begin the conversation.	24.4	50.0
A18(R) Older people living with dementia in a nursing home who have a spouse living in the community should not develop a sexual and/or intimate relationship with another resident.	40.0	26.7
A21(R) Public masturbation in an older person living with dementia would be considered Inappropriate Sexual Behaviour (ISB).	14.4	76.6
A22 (R) It is inappropriate for residents living with dementia to have intimate and/or sexual relationships with more than one resident and they should be stopped.	35.0	27.0

Items marked with (R) are reverse-scored items. Bold figures represent items with 50% of participants responding ‘neutral’ or ‘agreed’

Exploratory Factor Analysis (EFA)

The suitability of EFA for both Knowledge and Attitude Scales was assessed prior to analysis and confirmed through the inspection of the correlation matrix, overall and individual Kaiser-Meyer-Olkin values, Bartlett’s Test of Sphericity, and communalities.

Parallel Analysis suggested the retention of a four-factor solution for both the Knowledge and Attitudes Scales. However, inspection of the factor loadings revealed that the reverse-scored items were loading onto a single factor in both scales, indicating the presence of a method factor. This suggested the shared variance of the reverse-scored items may have been attributed to the scoring method rather than the intended content of the constructs. To address the method factor issue, the EFAs for both scales were re-run without the reverse-scored items, consistent with recommendations by Solís Salazar [34]. Parallel Analysis then suggested retaining a two-factor solution for both scales. Additional manual extractions for one, three and four-factor solutions were explored and considered. All factor solutions were based on item loadings, cross-loadings, cumulative variance explained, theoretical coherence and meaningfulness as well as scree plot examination. The final factor solution for each scale was determined through consensus by the research team.

For the Knowledge Scale, a two-factor solution was identified, with eight items (K1, K2, K6, K8, K12, K19, K20 and K46) removed due to low and/or cross-loadings as shown in Table 4. Factor One was labelled ‘Knowledge of Intimacy and Sexuality Rights and Expressions for Older Adults’, and Factor Two was labelled ‘Knowledge of Changes in Intimacy and Sexual Expression with Ageing’. In total, these factors accounted for 63.3% of the variance in the Knowledge Scale.

Table 4.

Rotated factor structure of the HSCP-KALLIS knowledge scale items without reverse-scored items

Knowledge item description	Factor loading
	1	2
Factor 1: Knowledge of Intimacy and Sexuality Rights and Expressions for Older Adults
K40 Aged care facilities can support interpersonal relationships by providing privacy, appropriate furnishings (i.e., a double bed or “Do Not Disturb” signs) and facilitating overnight stays.	0.916
K35 Older adults do not always feel safe disclosing their sexuality.	0.831
K38 The person-centred care model considers older people’s personal values and preferences including forming relationships and expressing intimate and sexual needs as a priority.	0.813
K37 An older person is entitled to masturbate in private.	0.796
K41 Policies to guide professional response to behaviours of intimacy and sexuality are needed in healthcare settings, including long-term care facilities.	0.790
K36 Older LGBTIQ+ adults face challenges in finding an aged care service where they feel safe.	0.763
K33 In healthcare systems, sexual rights of older LGBTIQ+ adults are at times ignored because of homophobia and heterosexism. (*Heterosexism: The assumption and treatment of all older people as heterosexual).	0.756
K4 Sexuality reflects how people feel, perceive, identify, behave, and express themselves as individuals.	0.734
K44 Sexual rights are part of human rights.	0.694
K45 There is a need to address sexual health, including the risks of Sexually Transmitted Infections (STIs) with older people in policy and clinical practice guidelines for care provision.	0.633
K43 It is important for health and social care professionals to assess sexual intimate needs as part of aged care.	0.612
K17 Maintenance of physical appearance is a form of sexual expression.	0.601
K19 Older adults and their partners can experience difficulties in discussing their intimacy and sexuality needs if health and social care professionals have limited understanding.	0.547
K20 Older adults and their partners can experience difficulties in discussing their intimacy and sexuality needs if health and social care professionals have poor attitudes.	0.498	0.570
K1 Intimacy refers to the closeness between people in relationships, driven by the need to connect with another person for companionship, care and affection.	0.487	0.500
K12 Reading or watching pornography (magazines or movies) is a form of sexual expression.	0.447
K8 Maintaining a healthy and active sex life can be of benefit to older people because it is a way to fulfil their psychosocial needs.	0.438
Factor 2: Knowledge of Changes in Intimacy and Sexual Expression with Ageing
K23 For older people, physical changes (i.e., menopause, changes in hormone levels) can change the way intimacy and sexuality are expressed.		1.001
K24 A common sexual difficulty for older women (including transgender) is vaginal dryness.		0.863
K25 Older men can experience decreased erectile function and difficulty achieving orgasm despite adequate stimulation.		0.801
K22 Multiple physical disabilities and chronic diseases in older people can negatively affect their sexual function and reduce wellbeing.		0.708
K18 Issues in long-term care facilities such as lack of privacy, unsupportive organisational culture and values, fear of gossip and negative views of staff, family and other residents can adversely impact sexual and intimate activities for older people.		0.636
K29 Older people living with dementia still express sexuality and engage in sexual activities.		0.619
K14 Older people living with or without dementia may cease or have reduced interest in sexual activities. Instead, they may engage in intimate or affectionate behaviours such as holding hands or kissing.		0.579
K11 Holding hands, stroking touch, hugging, and kissing are ways of expressing intimacy and sexuality for older people.		0.559
K46 Older people who are transgender, gender diverse or intersex may have additional personal care, medical or health needs.		0.509
K6 Expression of sexuality is an integral part of being human and a life-long process.		0.461
K2 Intimacy can be associated with family relationship and friendship that is non-sexual in nature.		0.414

Factor Loadings ≥ 0.55 are in boldface. Applied rotation method is oblimin

For the Attitude Scale, a three-factor solution was identified, with nine items (A2, A10, A14, A19, A23 A24, A26, A28 and A29) removed due to low and/or cross-loadings. Factor One was labelled ‘Attitudes on Supporting Intimacy and Emotional Connection for Older Adults in Care’. Factor Two was labelled ‘Attitudes on Education and Training for Sexual Expression and Intimacy in Later-Life’ and Factor Three was labelled ‘Attitudes on Sex Worker Services in Aged Care’. In total, these factors accounted for around 55% of the variance in the Attitude Scale. Table 5 provides an overview of Rotated Factor Structure of the Attitude Scale without reverse-scored items.

Table 5.

Rotated factor structure of the HSCP-KALLIS attitude scale items without reverse-scored items

Attitude item description	Factor loading
	1	2	3
Factor 1: Attitudes on Supporting Intimacy and Emotional Connection for Older Adults in Care
A11 Married couples with one living in the community and one living in a nursing home should be supported to maintain their sexual needs and intimacy in a private place within the facility.	0.855
A12 Health and social care professionals should provide older adults the opportunity to discuss their needs and concerns about intimacy and sexuality.	0.793
A1 Feelings of belonging, and being loved, needed and valued in any type of relationship are important for older people.	0.723
A8 Nursing homes need to support later life intimacy and sexuality.	0.677
A6 Older people should feel supported in expressing their sexuality, including those living with dementia in residential care.	0.668
A25 Married couples both living with dementia in a nursing home should be supported to have sexual intimacy in their room as long as their sexual activity is consensual.	0.589
A29 Older LGBTIQ+ adults should have their sexual and intimate needs recognised and supported equally as older heterosexual adults.	0.499
A26 A resident living in a nursing home in my care who is having a same-sex relationship with another resident should be supported.	0.466
A28 Older Lesbian, Gay, Bisexual, Transgender, Intersex or Queer/Questioning (LGBTIQ+) adults should be supported and receive the same standard quality of care as older heterosexual adults.	0.464	0.487
A24 Married couples with one living in the community and one with dementia in a nursing home should be supported to have sexual intimacy in a private place within the facility.	0.443	0.485
A14 I am comfortable discussing the topic of intimacy and sexuality with older people who are under my care.	0.438
Factor 2: Attitudes on Education and Training for Sexual Expression and Intimacy in Later-Life
A34 Organisations should provide training for staff to become skilled and knowledgeable about supporting older people’s individual gender and sexuality including specific information to support LGBTQI+ individuals who access their services.		0.927
A35 Health and social care providers should address concerns and support older adults who wish to be sexually active as part of care provision.		0.816
A33 Health and social care professionals who work in aged care settings should receive later life sexuality training as part of orientation and professional development.		0.798
A36 Aged care facilities or healthcare settings should have an expert for patient advocacy in complex sexual expression situations that involve family and consent issues.		0.672
A37 Older people living in the community or in long-term care should receive information/education (with their family) about later life sexuality and intimacy.		0.659
A32 I would like to know more about how to appropriately respond to requests to support a person’s sexual expression.		0.572
A31 I would like to know more about how to appropriately respond to intimate and sexual expression in older people with/without dementia.		0.567
Factor 3: Attitudes on Sex Worker Services in Aged Care
A38 Organisations should include policies and guidelines for sex worker services in healthcare settings.			0.925
A40 I would feel comfortable if my patient/resident asked for information about sex worker services.			0.725
A39 Residents in long-term care facilities should be able to request the services of a sex worker.			0.645
A23 Inappropriate sexual behaviours can indicate unmet needs for older people living with dementia.			0.413
A2 Many older couples enjoy emotional intimacy rather than sexual activity as they age.
A10 A resident living in a nursing home in my care who is having a romantic relationship (non-sexual) with another resident should be supported.
A19 Staff have the right to intervene in a relationship when a resident living with dementia appears upset during private interactions with his/her spouse/partner who is cognitively intact.

Factor Loadings ≥ 0.55 are in boldface. Applied rotation method is oblimin

After the factor structure for the Knowledge Scale and Attitude Scale was identified without influence of a method factor, the research team examined whether any of the reverse - scored items could be appropriately re-assigned to the relevant factors. Three team members (YHC, AB and CJ) independently reviewed and reassigned to the reverse-scored items to the suitable factors. For an item to be considered for re-assignment, it needed to capture a distinct aspect of the factor under consideration and have an Item-Content Validity Index (I-CVI) greater than 0.70, as established during the development of the HSCP-KALLIS scale (see [19]). This process ensures earlier validity work supporting reverse-scored item retention decision. For eligible reverse-scored items, the research team then reviewed the allocations and reached a consensus on the appropriate factor for each item. Any disagreement was resolved through consultation with a fourth team member (MH).

For the Knowledge Scale, 18 reverse-scored items were reviewed. Eight reverse-scored items were removed (K5, K7, K26, K27, K28, K31, K32 and K34), while ten reverse-scored items (K3, K9, K10, K13, K15, K16, K21, K30, K39 and K42) were retained and re-assigned to the most appropriate factor within the Knowledge Scale. For the Attitude Scale, 15 reverse-scored items were evaluated. Six reverse-scored items (A3, A4, A5, A7, A27 and A30) were removed, while nine reverse-scored items (A9, A13, A15, A16, A17, A18, A20, A21 and A22) were retained and re-assigned to the most appropriate Attitude Scale.

Internal consistency estimates were calculated for each factor in the relevant scales, both with and without the reverse-scored items, to assess the impact of re-allocating the eligible reverse-scored items. As shown in Table 6, internal consistency estimates were acceptable for the individual factors and overall total for both the Knowledge and Attitude Scales, albeit with a slight reduction with the reverse-scored items included. An inspection of item-total statistics for each factor with the reverse-scored items included indicated that removing any of these items would not substantially improve the internal consistency estimates. Therefore, the re-allocated reverse-scored items were retained due to their theoretical meaningfulness and for exploration in further research.

Table 6.

Internal consistency of the knowledge and attitude scales with and without reversed-scored items

		Number of items		Internal consistency
		Reversed-scored items not included	Reversed-sored items included	McDonald’s ω	Cronbach’s α
Knowledge scale
	Factor 1	12		0.86	0.85
	Factor 2	8		0.83	0.83
	Factor 1		8	0.84	0.85
	Factor 2		2	0.79	0.79
Total		30		0.89	0.89
Attitude scale
	Factor 1	6		0.89	0.89
	Factor 2	7		0.92	0.91
	Factor 3	3		0.88	0.88
	Factor 1		8	0.78	0.78
	Factor 2		1	0.87	0.86
	Factor 3		0	0.88	0.88
Total		25		0.89	0.89

McDonald’s ω = McDonald’s omega; Cronbach’s α = Cronbach’s alpha. Reverse-scored items are included as specified

The final HSCP-KALLIS Scale, as demonstrated in Supplementary Appendix 1, consists of 55 items, with 30 items in the Knowledge Scale and 25 items in the Attitude Scale. The scoring range for the Knowledge Scale is from zero to 30, with scores greater than 24 indicating a high-level of knowledge, while scores less than 18 indicating a low-level of knowledge. For the Attitude Scale, total scores range between 25 and 125, with scores greater than 100 indicating strong positive attitudes and, scores less than 75 indicating more negative attitudes. These classification thresholds are based on modified Bloom's cut-off points [35].

Discussion

This study aimed to establish the reliability and validity of the HSCP-KALLIS scale, a newly developed instrument (see [19]) that assesses health and social care professionals’ knowledge and attitudes about later-life intimacy and sexuality. Using a methodological study approach, the final HSCP-KALLIS scale consists of 55 items with 30 knowledge items in two factors and 25 attitude items in three factors (see Supplementary Appendix 1. for a copy of the final HSCP-KALLIS Scale). These identified factors address key aspects of older adults’ intimate and sexual needs, which are essential for person-centred care. Preliminary results suggest that the final HSCP-KALLIS scale demonstrated good internal consistency across both knowledge and attitude scales, supporting its use for ongoing refinement and psychometric validation. It would be beneficial to compare factor solutions of the final HSCP-KALLIS Scale both with and without reverse-scored items, which would provide more comprehensive insights into the robustness of the factor structure across different modelling approaches in future research.

Certain limitations of this study should be acknowledged. First, the small sample size is a noted constraint. However, recommendations on sample size for EFA vary, with some suggesting a minimum of 250 participants, while others indicate reliable results can be obtained with as few as 20 [36]. Research also suggests that sample sizes below 50 can yield valid findings in behavioural research [32]. To account for the limited sample, this study adapted a more conservative factor loading threshold of 0.55, following recommendations from previous researchers [31]. Nonetheless, further validation of the HSCP-KALLIS scale with a larger sample is needed, particularly through confirmatory factor analysis, to ensure the robustness of the findings.

Second, the inclusion of multiple reverse-scored items introduced a method effect. That is, the shared variance of the reverse-scored items, may have been attributed to the scoring method rather than the intended content of the constructs. Reverse-scored items are often used to mitigate acquiescence bias (the tendency to agree with statements) and encourage more thoughtful responses [37]. However, reverse-scored items can also introduce confusion due to their opposite phrasing, potentially causing misinterpretation, cognitive fatigue, and response errors [38]. This can result in reverse-scored items measuring unintended constructs [39] and reducing internal consistency, as participants may process reverse-scored items differently than positively worded items [34]. There are various approaches to managing the presence of a method factor in EFA [40], including removal of all reverse-scored items [41, 42], utilisation of different factor rotation techniques [43], rewording all reverse-scored items [44], or a combination approach [38, 39]. At present, there is no commonly agreed recommended approach. As the HSCP-KALLIS scale is still in the early stages of validation, the present study employed EFA and we opted for a flexible approach that would acknowledge the method factor, while also exploring whether any of the reverse-scored items could be retained.

Whilst the level of participants’ knowledge and attitudes was not the primary focus of this study, our findings revealed gaps in participants’ understanding of LGBTIQ+ issues and potential mixed and neutral attitudes towards supporting the intimate and sexual needs of older adults with dementia or from gender diverse backgrounds. These findings are consistent with previous studies that have highlighted the varying levels and inadequacy of staff knowledge regarding later-life sexuality in HSCPs [18, 45, 46]. Addressing these gaps requires targeted education and training that focuses on the special considerations and needs when addressing later-life intimacy and sexuality, particularly for those identifying as LGBTIQ + and those living with dementia, to enhance HSCPs’ competency to ensure provision of competent care in clinical settings [47–49]. Furthermore, the development of policies and guidelines to support sexuality and sexual health for older adults is crucial, particularly ensuring inclusive care for LGBTIQ+ older individuals and special care needs for those living with dementia. More importantly, healthcare organisations must apply a holistic approach to ensure that sexuality and sexual health for older adults are adequately addressed. Utilising standardised resources and assessments, with the collaboration of the healthcare team, will ensure that diverse needs are met [9]. As indicated by the qualitative results from the pre-testing sample, providing education and training, along with policies and guidelines in place, are key strategies for improving care provision and supporting later-life intimacy and sexuality for older adults.

Implications for clinical practice, education and research

The HSCP-KALLIS scale is designed to assess HSCPs’ knowledge and attitudes towards later-life intimacy and sexuality in clinical care contexts. The scale may assist clinical educators in identifying training needs and may inform the development of future professional development training packages addressing later-life intimacy and sexuality, including supporting LGBTIQ+ individuals and older adults with dementia, and sex worker services in long-term care. Given that intimacy and sexuality remain important throughout ageing and cognitive decline, including in dementia and from diverse gender backgrounds, person-centred care must acknowledge and support these evolving needs [50].

The HSCP-KALLIS scale has potential to be used for evaluating the effectiveness of educational interventions by comparing pre- and post-training scores. Each individual item may assist as prompts for facilitated discussion and reflection among clinical staff. Using the HSCP-KALLIS scale in a wide range of clinical environments could enhance HSCPs’ ability to provide better care and to support intimate needs and sexual expression of older adults. The findings offer valuable insights into the importance of later-life intimacy and sexuality, the impact on psychological and physical well-being of older adults and the implications for policy and practice guidelines development in this area of need. Further research should recruit HSCPs from various clinical settings to ensure broader applicability.

Conclusions

This study has provided preliminary validation evidence and establishes the reliability of the HSCP-KALLIS scale, a 55-item instrument designed to assess HSCPs’ knowledge and attitudes towards later-life intimacy and sexuality. Further research is required to robustly establish its psychometric properties and to examine its application in practice. It is hoped that the HSCP-KALLIS can be used by health services and organisations to identify and evaluate training for HSCPs in this area.

Abbreviations

ASKAS

The Aging Sexual Knowledge and Attitudes Scale

AAG

The Australian Association of Gerontology

ANZAHPE

The Australian and New Zealand Association for Health Professional Educators

EFA

Exploratory Factor Analysis

HSCPs

Health and Social Care Professionals

HSCP-KALLIS

Health and Social Care Professionals’ Knowledge and Attitudes towards Later-Life Intimacy and Sexuality Scale

I-CVI

Item-Content Validity Index

JASP

Jeffreys’s Amazing Statistics Program

LGBTIQ+

Lesbian, Gay, Bisexual, Transgender, Intersex and Queer/Questioning

M

Mean

MLE

Maximum Likelihood Estimation

PFA

Principal Axis Factoring

SPSS

Statistical Package for Social Sciences

SD

Standard Deviation

Authors' contributions

All authors reviewed and approved the final manuscript. Y-HC: Conceptualisation, Methodology, Investigation, Data Curation, Formal Analysis, Validation, Writing Original Draft, Writing, Review and Editing, Visualisation and Project Administration. AB and CJ: Conceptualisation, Methodology, Investigation, Data Curation, Formal Analysis, Validation, Writing, Review and Editing, Visualisation, Supervision and Project Administration. MH: Methodology, Investigation, Data Curation, Formal Analysis, Validation, Writing, Review and Editing, Visualisation, Supervision and Project Administration. MA: Formal Analysis, Validation, Writing, Review and Editing, Visualisation and Supervision.

Funding

This research was funded by the Australian Government Research Training Program and supported by Michael Dent Scholarship, The Australian Nurses Memorial Centre.

Data availability

Due to the nature of the questions asked in this study, participants were assured that raw data would remain confidential and would not be shared. Data that has been used is confidential and not available.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from Bond University Human Research Ethics Committee (#YC00016), Australia. The study did not collect any personal identifiable data and only assessed individual’s knowledge and attitude about later-life intimacy and sexuality. Prior to participation, a detailed study information including aim, procedures, and data usage was provided at the introductory page of the survey. Participants indicated their informed consent by selecting a checkbox at the beginning of the survey.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.