Introduction
According to the World Population Prospects 2022, the global population over 65 years old in 2050 will be over 16%, up from one in 10 in 2022 (10%; United Nations, 2022). The higher medical care demand of the older adult population poses challenges to health systems, and the way medical services are provided affects national health-related expenditures (Williams et al., 2019).
After retirement, individuals without adequate postretirement plans often experience a loss of self-worth. Thus, postretirement planning has become a topic of importance. Active social engagement by middle-aged and older adults is crucial to address the challenges brought about by population aging. Engaging in community activities allows middle-aged and older adult retirees to develop new roles and expand their social circle to promote happiness and extend healthy life expectancy (Ho et al., 2016; Tomioka et al., 2018). By volunteering in healthcare services, middle-aged and older individuals can facilitate health promotion and illness prevention, serving as important human resources in community healthcare and promoting community empowerment.
A recent survey conducted in Taiwan revealed that middle-aged and older volunteers accounted for 13.5% of all volunteer service providers, whereas those aged above 65 years constituted 9.3% (Ministry of Health and Welfare, Taiwan, ROC, 2018a). Since the Older Volunteering Initiative was launched by the Ministry of Health and Welfare in 2016, a steady upward trend has been observed in these figures. Furthermore, county and municipal governments have taken active steps to recruit middle-aged and older volunteers for an extensive range of volunteer services, including reading at libraries, volunteering at hospitals, working at police stations or Mass Rapid Transit stations, cleaning streets, and providing labor welfare-related consultations (Liu, 2018).
Although middle-aged and older adults have shown ever-growing enthusiasm for participating in volunteer services, a large proportion of these lack sufficient experience. The strategies currently in place for promoting middle-aged and older volunteering are also subject to flaws such as insufficient volunteer service options suited to middle-aged and older volunteers, lack of an incentive management mechanism, and rigid curriculum designs for volunteer training that are ill suited to the physical and mental traits and social contexts of middle-aged and older adults (You, 2015).
A systematic literature review on the benefits of volunteering in older adults by Anderson et al. (2014) revealed volunteering to be associated with reduced symptoms of depression, better self-reported health, fewer functional limitations, and lower mortality. The sense of satisfaction and accomplishment derived from volunteering is a significant determinant that influences participation in volunteer initiatives (Shih, 2017). Multiple studies have shown that older volunteers exhibit better functional performance, better cognitive aging, and lower symptoms of depression than their older, nonvolunteer peers (Guiney & Machado, 2018; Jiang et al., 2021; Marti & Choi, 2022) and that volunteering increases positive emotions and reduces negative emotions (Tse, 2020). Volunteering acts as a buffer for older adults that may reduce the negative effects of low self-esteem on sense of belonging and life satisfaction (Russell et al., 2019). Therefore, an effective way to promote successful or active aging is to encourage volunteering among older adults to stimulate social engagement.
Education and training are crucial to improving the quality of service and personal capabilities of volunteers, boosting their self-esteem and self-efficacy, and potentially, helping them achieve a state of self-actualization (Chinman & Wandersman, 1999; Dionigi et al., 2020). The volunteer training provided to middle-aged and older adults in Taiwan has been primarily religious in nature and has focused on phone greetings, home visits, social education, and disaster relief (Chang, 2011). With the extensive efforts put into promoting middle-aged and older volunteering in recent years, adjustments have been made to volunteer training programs. The 6 hours of mandatory basic training now focuses on the essence and ethics of volunteer service, applicable legislation and regulations, and volunteer experience sharing. Additional training beyond the basic training program is referred to as special training and focuses on social welfare and related social resources and volunteer services. Special training, in conjunction with a short-term practicum, lasts for 6 hours in total. Online teaching has also been implemented to overcome the constraints of geographic distance and environment (Ministry of Health and Welfare, Taiwan, ROC, 2018b). However, the existing curriculum has not incorporated training components centered on healthcare services and, importantly, has failed to reflect the desire of middle-aged and older volunteers to gain professional knowledge through the learning and training process (Lin et al., 2009). If the training and support needs of volunteers cannot be met, they may become dissatisfied and stop volunteering (Hurst et al., 2019).
In response to population aging and the shortage of caregivers, the global community has developed innovative service strategies. Age UK introduced well-trained volunteers as coordinators for integrated services, which has drastically improved the health conditions and user satisfaction of older adults in the United Kingdom. After piloting the project in the Cornwall region in 2014, the rate of emergency admissions among older adults in that region had fallen to one third after just 1 year (Age UK, 2018). On the basis of this example and the diverse needs of healthy and subhealthy older adults, who constitute 83.5% of Taiwan's older adult population, it is evident that current generic volunteer training is inadequate. Thus, establishing multilevel caregiver training based on disability-prevention and disability-delaying healthcare is of the utmost importance. However, most volunteers are middle-aged and older adults. Scholars have urged that greater attention be given to the characteristics of older adult learners, who are generally more averse to excessively stressful learning and have lower levels confidence. Therefore, learning content should be elder centric and practice oriented (Boulton-Lewis, 2010). Learning motivation is crucial in older adult education. By drawing on the attention, relevance, confidence, and satisfaction (ARCS) model of learning motivation (Keller, 1983), this study takes into account the characteristics of the middle-aged and older-adult population as learners. The ARCS model has been used to guide and develop related research into learning (Li & Keller, 2018; Xiong et al., 2019). In this study, the modified Delphi method was adopted to establish consensus among programs, thus allowing the development of a set of multilevel volunteer training programs for neighborhood care. The developed programs are expected to provide a reference for the training of volunteer neighborhood caregivers and to offer strategic recommendations for the government to ameliorate the long-term shortage of caregivers.
In this study, "volunteer neighborhood caregivers" is used to refer to individuals who reside in a particular geographical region and are willing to interact with and serve their community through engagements within their neighborhood. Volunteer neighborhood caregivers have completed the three-level training program and participated in nonspecialized altruistic or egoistic healthcare services. The responsibility of these caregivers is to facilitate the provision of healthcare services for subhealthy older adults in their neighborhood under the supervision of healthcare professionals. These services include ongoing health assessments, health education and guidance, guided health promotion activities, and follow-up care.
Methods
This study was conducted in northern Taiwan in two phases. In Phase 1, data collected from April to August 2018 were used to develop the training course using the modified Delphi method. In Phase 2, preliminary preparation and formal training were conducted between September 2018 and June 2019 (Figure 1).
Study Design
Phase 1: Development of neighborhood care volunteer training programs
The modified Delphi method (Murry & Hammons, 1995) was adopted in Phase 1 to establish the content and methods used in the multilevel volunteer training programs for neighborhood caregivers. To simplify the complex process involved in iterated questionnaires, the first-round questionnaire was replaced by a literature review. This approach allowed the experts to focus on the research topic, avoided speculation arising from open-ended questionnaires, and improved the response rate. The Delphi consensus process queries a panel of experts' opinions regarding a specific topic using a series of continuous, intensive questionnaires completed anonymously by experts and followed by controlled feedback to achieve consensus. After each questionnaire survey, the analytical results are distributed to the panel members, along with the new questionnaire, as a reference for reconsidering or adjusting their previous opinions. This process is repeated at least once until a consistent and specific consensus is achieved with minimal differences in opinions (Chan & Chung, 2009; Sung, 2001).
Phase 2: Implementation and evaluation training programs
Phase 2 consisted of two stages. The first stage was the preparatory period (before conducting the course) and included confirming the teaching staff and sites required for the course, recruiting participants, and performing other relevant precourse preparations and liaison work. The second stage was course implementation, during which the participants underwent a three-level training course lasting 69 hours. Subsequently, a course satisfaction survey and analysis were conducted using the program satisfaction scale that covered the following dimensions: program contents, program effectiveness, and self-evaluation.
Ethics Statement
This study received ethical approval from the Chang Gung Medical Foundation institutional review board (IRB number: 201701094B1). All of the participants provided informed consent.
Setting and Participants
The targets were Delphi experts in Phase 1 and volunteers in Phase 2. The former consisted of a panel of 17 academic and practical experts involved in long-term geriatric care. The latter were those who met the following training program eligibility criteria: community residents > 40 years old, completed at least a primary school education, and living in northern Taiwan.
Data Collection and Analysis
Phase 1: Program development through the modified Delphi method
1. Round 1
The program content in Round 1 was synthesized from a literature review and discussed among our research team of geriatric care experts to develop a set of ARCS-based volunteer training programs for neighborhood caregivers. The program was devised using the ARCS model of motivation to learn proposed by Keller (1983). The ARCS model includes four major elements. Attention refers to the ability of the program to attract learners' interest and attention and spark their motivation to learn. In addition, the training programs in this study involved topics that were of general interest to older adults or were currently popular or interesting at the time. Relevance refers to the ability of the program to provide learners with content worthy of learning, thus spurring proactive interest in learning. The learning content revolved around existing or prospective health-related issues that closely relate to the middle-aged and older volunteers or their families. Confidence aspects are intended to build learner confidence through teaching strategies and convince them of their ability to complete the programs and to fully grasp the learning content. A progressive program design was adopted to transition from overview information to more in-depth topics across the three levels of basic, advanced, and instructor training. Satisfaction aspects focused on using hands-on practices and actual services to allow learners to actualize their abilities during the learning process in return for a sense of achievement. The ARCS model has been widely applied to investigate the effect of improving teaching strategies on motivation-promotion in learners (Huang et al., 2016; Lee & Hao, 2015; Li & Keller, 2018).
The volunteer training programs for neighborhood caregivers devised in Round 1 were divided into three levels. Level 1 (basic caregiver training) was organized to equip trainees with basic care competencies such as interpersonal communication skills, understanding of aging and diseases, leisure activities for older adults, basic concepts related to diet and nutrition, knowledge regarding dementia, and the importance of fall prevention. Seven tentative topics were outlined and covered in 16 hours of classes.
Level 2 (advanced caregiver training) was organized to develop the ability of trainees to carry out health assessments and develop problem-solving skills. Topics covered included handling common accidents and emergencies and conducting physical fitness examinations and assessments for older adults. Six tentative topics were outlined and covered in over 22 hours of classes.
Level 3 (volunteer caregiver instructor training) was organized to transform trainees into instructors who were familiar with case management concepts and capable of leading volunteer caregivers. Seventeen tentative topics, including practical work, discussions, and sharing sessions, were outlined and covered in 30.5 hours of classes.
2. Round 2
In Round 2, experts were sent email invitations, with 17 experts agreeing to participate in this study. The Likert scale was applied to the questionnaire design, and the experts were instructed to rate the importance and feasibility of each program topic between 5 (very important/feasible) and 1 (very unimportant/unfeasible). Their opinions regarding how to improve each program were used as the basis for revising the indicators. IBM SPSS Statistics Version 22.0 (IBM Inc., Armonk, NY, USA) was employed in data processing and analysis. The second-round questionnaire yielded a response rate of 100%.
3. Round 3
The central tendency (mean) and measures of spread (standard deviation and quartile deviation) for each item were calculated. Additions and revisions to questionnaire content were made based on the experts' feedback. After marking the revised and added parts, the measures of central tendency for each item and rating criteria in the previous questionnaire were provided to the experts in the third round. The response rate in Round 3 was 94%. After collecting responses, the mean values, quartile deviations, and standard deviations were analyzed and compared. The mean measures the centrality of data, which is an indicator of degree of expert agreement (Chan & Chung, 2009). Level of quartile deviation correlates positively with the degree of disparity present among expert opinions on a particular item, with quartile deviation levels < .6 indicating high consistency, between .6 and .9 indicating moderate consistency, and >= 1.0 indicating inconsistency (Faherty, 1979; Holden & Wedman, 1993).
Convergence was used to assess whether the experts had arrived at a consensus, determined based on changes in the standard deviation value of each item between the two questionnaires. A standard deviation value on the second questionnaire smaller than or equal to that on the first indicates that the experts' opinions are sufficiently consistent and have achieved convergence, meaning that the corresponding item may be retained. Lindeman (1975) and Salmond (1994) suggested that experts' opinions should be considered stable when 75% of the items achieve convergence, at which point the modified Delphi consensus process may be concluded.
Phase 2: Implementation and evaluation training programs
The training programs were held between March and June 2019 in the form of classroom teaching, group discussions, and practical exercises. A program evaluation form was used to measure the posttraining satisfaction of the trainees using a 5-point Likert scale ranging from 1 to 5, with higher scores indicating higher levels of agreement or satisfaction. Trainees were required to provide feedback regarding the program content (level of difficulty, relevance to themes, practicality, amount and quality of teaching materials, and distribution of program hours), program effectiveness (teaching new concepts and skills, improving trainees' ability to carry out healthcare services, applying healthcare services effectively, solving problems associated with healthcare services, and the training being relevant to healthcare services), and subjective evaluation (e.g., "the program content corresponds to my needs," "this program deepens my understanding of the field," and "this program boosts my confidence as a neighborhoods caregiver").
Results
The Results of the Delphi Method
Basic characteristics of Delphi experts
The expert panel was composed of three men and 14 women, including five academics, eight industry experts in long-term geriatric care, three social workers specializing in volunteer training, and one middle-aged/older adult volunteer. The period of service of these experts ranged from 5 to 32 years, with an average experience of 17 years. All of the experts had relevant professional knowledge and skills and extensive practical experience in the field.
The volunteer training programs Basic caregiver training
The results showed that, after two rounds of Delphi surveys, the experts' opinions on the importance of each topic achieved 99% consistency and 93% convergence. In terms of feasibility, their opinions reached 94% consistency and 86% convergence. As these percentages exceeded the 80% threshold, sufficient consensus was deemed to have been reached.
In terms of program content, the experts suggested that neighborhood care volunteers should gain a basic understanding of long-term care resources. Thus, an overview of available aging-society-related and long-term-care resources was added to the program's "Introduction" section. Although in Round 2, the experts suggested introducing mental and physical health assessment tools for older adults to the section "Symptoms of Common Older Adult Diseases and Geriatric Care Principles," in Round 3, three experts opined that introducing these tools could excessively burden the volunteers. Hence, this topic retained its original focus on basic concepts. With regard to the "Fall Prevention" section, the experts believed that a barrier-free environment and assistive devices were both of primary concern to older adults. Hence, case discussions regarding the household environment and daily habits were introduced along with introductions to barrier-free environments, assistive devices, and resources.
For the "Understanding Dementia" section, it was indicated that dementia care warranted more knowledge and skills because of the steady annual increase in dementia incidence and because the skillset necessary to care for older adults with dementia differs significantly from that necessary to care for older adults with disabilities. Therefore, the topic was extended by 2 hours to add an introduction to handling dementia-related behavioral problems. In reviewing the "Older Adult Activities and Leisure" section, the experts attached significant importance to older adults engaging in sustained social engagement, suggesting that this may help eliminate negative stereotypes about their limited involvement in various activities. Consequently, the types and importance of leisure activities for older adults were introduced along with active aging and social engagement concepts. With regard to the "Food Selection and Preparation for Older Adults" section, the experts highlighted that older adults tend to have more dietary requirements associated with chronic diseases. Consequently, topics addressing these special diets were added (Table 1).
Advanced caregiver training
With regard to the "Handling Accidents and Emergencies in Older Adults" section, the experts suggested that introductions to medical techniques should be avoided to minimize volunteer frustration. The trainees were provided with in-class practical experience and taught the basic skills to identify and handle common emergencies related to the symptoms of hypertension, hyperglycemia, and cardiovascular disease. With regard to the "Oral Care for Older Adults" section, two of the experts recommended including hands-on practical training. Hence, the topic content was adjusted to encompass oral care practices, dental flossing techniques, the Bass method of brushing, and oral motor exercises for older adults. The experts also advised introducing sarcopenia during the "Physical Fitness Assessment and Examination for Older Adults" section (Table 1).
Volunteer caregiver instructor training
With regard to the "Roles and Functions of Volunteer Caregiver Instructor" section, two experts specified the need for instructors to acquire communication skills to manage both interactions with older adults and their family members and lateral communications with other volunteers. As communication and cooperation are vital determinants influencing service effectiveness, the time allotted to this section was extended to incorporate additional teamwork and communication activities. For the "Case Management, Screening, Intervention, and Appraisal Follow-up" section, six of the experts argued that the content as presented expected too much of the volunteers, which could reduce the efficacy in execution and application. Hence, the four topics were consolidated under "Concepts of Case Management," which included the follow-up and appraisal of services to older adults and resource networking as well as the imparting of basic concepts of case management to the trainees' instructors. In addition, a new section entitled "Protecting Older Adults" was added based on the expert input citing the essential nature of older adult protection in volunteer caregiver instructors. After two rounds of Delphi reviews and revisions, the program durations of basic caregiver training, advanced caregiver training, and volunteer caregiver instructor training were adjusted from 16 to 18 hours, from 22 to 15 hours, and from 30.5 to 36 hours, respectively (Table 2).
Posttraining Program Feedback
Basic characteristics of volunteer trainees
Fifty volunteer trainees were recruited, with ages ranging from 40 to 72 (average = 59.4) years. Most were women (84.0%). In terms of highest level of education, most held a senior high or vocational school degree (40%) and roughly one third (31.4%) had at least attended university. The most common occupation before retirement was commercial and business services (48.6%), followed by housekeeping (28.6%). Nearly 20% of the trainees had no prior volunteering experience, and those who had reported an average of 5.1 years of volunteering experience.
Satisfaction with training programs
All of the participants completed basic caregiver training, 46 completed advanced caregiver training, and 39 finished all three training programs. The average score for overall satisfaction was 4.59 (SD = 0.56) for the basic caregiver training program, 4.74 (SD = 0.47) for the advanced caregiver training program, and 4.81 (SD = 0.40) for the volunteer caregiver instructor training program. The trainees responded mostly with "agree" or "strongly agree" to the evaluation items. Regarding program content, their average satisfaction scores for the basic, advanced, and instructor programs were 4.57 (SD = 0.55), 4.72 (SD = 0.48), and 4.79 (SD = 0.41), respectively, with "the content is practical" earning the highest average score across all three levels. Scores for satisfaction with the program's effectiveness were 4.57 (SD = 0.59), 4.70 (SD = 0.51), and 4.81 (SD = 0.40), respectively, with "I can learn new concepts and skills" earning the highest average score across all three levels. The scores for self-evaluation were 4.53 (SD = 0.60), 4.73 (SD = 0.48), and 4.78 (SD = 0.41), respectively, with "this program deepens my understanding of the field" earning the highest average score across all three levels. Overall, the training programs were well received by the trainees (Table 3).
According to the trainees' responses on the evaluation form, topics deemed most useful were "Symptoms of Common Older Adult Diseases and Geriatric Care Principles," "Fall Prevention," and "Older Adult Activities and Leisure" in the basic caregiver training; "Handling Accidents and Emergencies among Older Adults" and "Strength Training for Older Adults and Practice" in the advanced caregiver training; and "Food Safety: Is My Diet Healthy and Nutritious?", "Strategies for Leading Older Adult Activities and Promoting Activity Engagement," "Protecting Older Adults," and "Group Project: Program Leadership" in the volunteer caregiver instructor training.
Discussion
Most volunteers in Taiwan are currently middle-aged and older adults, who are often averse to excessively stressful activities and may have inadequate confidence. Learning content should be older adult centric and practice oriented (Boulton-Lewis, 2010). The experts' opinions obtained from the Delphi surveys were consistent with the literature. The level of difficulty in each training program was adapted to the attributes of middle-aged and older volunteers. Overly specialized content was removed per the experts' recommendations to avoid possible frustration and its negative impact on the volunteers' motivation to participate.
The results of the program satisfaction questionnaire for middle-aged and older volunteers reflect the effectiveness of using the ARCS model as a basis for developing volunteer training programs. Regarding "Attention" and "Relevance," the topics focus on issues currently being confronted by these volunteers. Content that is useful and meets the needs of participants is likely to enhance motivation to learn.
With regard to confidence, the design used in these programs enabled learners to develop confidence gradually. The trainees in this study agreed that the level of difficulty of the programs was moderate and it could help improve trainee confidence in becoming volunteer caregivers.
With regard to satisfaction, the instructor training program focused on cultivating leadership skills and the ability to provide health education. Hands-on practicums were included to enable trainees to apply knowledge and actualize their potential, allowing them to see the impact of learning outcomes immediately and to realize self-confidence through their successful learning. Prior research has also found that learners value being able to learn and share experiences with other volunteers, which enhances their self-confidence (Wilesmith & Major, 2020). On the basis of the trainees' responses on the posttraining evaluation form, average scores of 4.7 or higher were earned for the practicality of the program content, relevance to care practice, and self-perceived confidence as a caregiver. This finding shows that the program design was effective in achieving the four facets of the ARCS model.
In this study, training programs were designed and developed from the perspective of learners, and information relevant to helping volunteers adapt to aging in a self-actualizing way was provided. This knowledge may also be applied to caring for family members and community-dwelling older adults in need of assistance. Strategies using programs such as this can help alleviate long-term care workforce shortages and help achieve active aging through social engagement, thus forming a virtuous circle of mutual assistance and benefits. Importantly, the findings support that improving the skill of volunteers and investing in their education is helpful to both recruiting and retaining volunteers (Same et al., 2020). Related research has pointed out that volunteers who provide services with altruistic motives can obtain greater psychological satisfaction and happiness, which increases intention to continue volunteering (Stukas et al., 2016). The programs developed in this study were designed for the egoistic motivation of attracting participants and the altruistic motivation of providing follow-up services, improving the physical and mental health of volunteers, and bringing positive results to the community.
Kemp (2002) asserted that the ability of volunteers to learn relates closely to their level of satisfaction with their volunteer service experience. Some volunteers attach great importance to the self-improvement associated with education and training, with higher-quality training programs promoting higher levels of satisfaction (Finkelstein, 2008). Hence, developing suitable training programs may not only facilitate volunteer learning but also exert a profound influence on the future recruitment and depth of involvement of volunteers.
Community care needs are diverse, individualized, and complex. Thus, the Delphi surveys included both academic and clinical experts from social work, nursing, care management, long-term care, and other care-related fields. The experts were asked to offer program recommendations regarding situations that volunteer neighborhood caregivers may encounter while providing community healthcare services to older adults. By participating in a series of training programs and providing services to older adults in the community, it was hoped that volunteers would be able to assess related health issues, identify care-recipient needs more sensitively, and offer services with greater self-confidence.
The training programs were divided into three levels: basic, advanced, and instructor training. The volunteers received training suited to the nature of the services they would be providing. The results of previous research indicate that arranging training for middle-aged and older volunteers before and during service can reinforce their healthcare knowledge and skills. Capacity building also enabled the volunteers in the programs in this study to identify the gaps in knowledge and skills encountered during their service, thereby helping them confront and overcome these adversities (Din, 2018). As middle-aged and older volunteers possess extensive life experience and generally a more holistic perspective and better problem-solving skills than younger volunteers, future studies may also develop in-service programs that focus on problem solving using discussions of illustrative neighborhood service case studies.
Conclusions
Few studies on healthcare training for community volunteers have been published in the literature. This work is Taiwan's first study on training programs for neighborhood caregivers. The volunteer training programs for neighborhood caregivers developed in this study were structured based on the Delphi method and adopted a progressive, multilevel design that transitioned from understanding health issues to developing health coaching skills. This approach was intended to improve the ability and motivation of volunteers to engage in neighborhood healthcare services over time. The program outcome evaluations showed continuous improvement in the satisfaction of the trainees through the three-level curriculum, with an overall satisfaction score of 4.81. In addition, those who had completed all three levels of the training perceived the program content as practical and agreed that the programs taught them new concepts and skills and deepened their understanding of the field. Because the programs were evaluated in this study from the perspective of the users (trainees), the results offer a reference for government and long-term geriatric-care-related service providers charged with designing and implementing effective, stage-appropriate volunteer caregiver training programs.
Acknowledgments
This work was supported by the Chang Gung Medical Research Project (grant number: CMRPF3G0062). We want to express our sincere gratitude to all of the experts who participated in the Delphi surveys and the community members who attended our training programs. Additional funding was provided under Grant Numbers CMRPG5G0183 and EMRPD1K0391.
Author Contributions
Research and concept design: HLH, AMKW
Data collection: HLH, YTL, YLS, HLC
Data analysis and interpretation: PCK, HLH, YTL
Drafted the article structure and the manuscript: PCK, HLC, HLH
Critical revision of the article: PCK, HLH
References