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Development of an Instrument to Assess Students’ Attitudes Toward Global Health Issues

Iris Mujica, R.N., B.Sc.N., M.Sc., Ph.D.(s)Principal Investigator

and

Michael Ladouceur, R.N., B.Sc.N., M.P.H. Co-investigator

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Overview

Background Relevance of the project Purpose Plan of Activities Description of Instrument development

– Phase 1

Data analysis Study Limitations Lessons learned Next Steps

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Funding Agencies

Dr. O. Niemeier Fund Nursing Education Research Unit (NERU) Pilot

Fund

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• Growing realization of a reciprocal relationship between local and international health issues.• Health care institutions are more attentive of need to respond to diverse patient populations.• Educational institutions have social responsibility to prepare their nursing students for multicultural care.• International education experiences becoming essential part of higher education in today’s world. (Button et al, 2005; Duffy 2001; Goldberg & Brancato 1998; Scholes & Moore 2000; Wright et al, 2001).

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Background

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Background

Health care agencies becoming more involved internationally through networking, sharing of technology, and comparing data sets.

Exponential growth of the internet, global conferencing and communication have become commonplace.

Many large health care enterprises in Canada and elsewhere are becoming multinational and multicultural in design.

(Button et al, 2005; Duffy 2001; Goldberg & Brancato 1998; Scholes & Moore 2000; Wright et al, 2001).

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Relevance of The Project

1. Nursing is a universal and portable profession.

2. Reciprocal relationship between local and international health issues e.g. HIV/AIDS, TB, H1N1, internationally trained nurses, etc. (‘think globally - act locally’).

3. Positive attitudes toward global health will likely broaden the vision and practice horizons of the graduate Canadian nurse at home and abroad [enlightened self-interest].

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Relevance of The Project

4. Social justice: Canadians have an historic and substantive responsibility to nurture positive attitudes among students toward the well-being of the world community [emancipatory way of knowing].

5. Mission of BScN program: provides 3-unit course in global Health (4H03) and opportunity to do a clinical placement at home or abroad (4J07). Do these educational opportunities change attitudes?

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Purpose

To develop a valid, reliable and practical instrument to measure students’ attitudes towards global health issues.

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Why Assess Attitudes in Higher Education?

1. Provide feedback to students so they can modify their learning approach (formative assessment).

2. Determine whether students have met course aims so faculty can modify teaching approach (summative evaluation).

3. Program evaluation (to make curriculum decisions based on student assessments).

4. Reinforce organizational values (what we believe in).

Adapted from: EFPO (1995), PFD, McMaster University

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What is an Attitude?

• Positive or negative views of a person, place, thing, or event.

• Hypothetical construct that represents an individual's degree of like or dislike for an item.• Expected to change as a function of experience.

• Can be changed through persuasion

• Importance of affective or emotional factors.

(Breckler & Wiggins, 1992; Hovland &Weiss, 1951).

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Plan of Activities

Stage 1. Literature search for existing instruments and items.

Data Bases (Medline, CINAHL, ERIC, Web of Science Sociological abstracts, PsychInfo, HAPI) Government websites, hand searches, books.

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Plan of Activities

Stage 1 • Existing instruments internal and external to SON:

Internal to McMaster- none

External to McMaster - The Global Mindedness Assessment tool

(Hett, 1993)

- Global Perspectives towards cultural diversity (Zhai & Scheer, 2004)

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Plan of Activities

Stage 2. Instrument Development Process (Streiner and Norman, 1995)

Phase 1. Instrument Development

Phase 2. Instrument Evaluation

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Instrument Development Process

Phase One:

1. Item generation

2. Item validation (face & content)

3. Item interpretation

4. Item reduction Factor analysis Internal consistency Scoring

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Item Generation

Literature Focus group: 4 out of 10 level 4 BScN students. Expert Opinion:

- Prof. Anne Ehrlich (McMaster, SON)

- Prof. Barb Carpio (McMaster, SON)

- Dr. Gary Warner (McMaster, Arts & Science Program)

- Dr. Tina Moffatt (McMaster, Dept of Anthropology)

- Dr. Ted Schrecker (Univ. of Ottawa, Scientist/Associate Professor, Institute of Population Health)

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Item Generation

1. Qualitative data analysis of interviews and focus group.1. Thematic analysis 2. N-Vivo software 3. Triangulation of findings

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Major Construct: Global Health

Four Domains

(1) Determinants of Health.

(2) Cultural Competence.

(3) International Development.

(4) Social Justice.

Item Generation

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Global Health

Focuses on issues that directly or indirectly affect health but that can transcend national boundaries.

Health equity among nations and for all people is a major objective.

Highly interdisciplinary and multidisciplinary within and beyond health sciences.

(Koplan, M.J., 2009)

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The Global Health Concept (4 fields)

Source: Ladouceur & Mujica.

Cultural Competence

• cultural desire.

• respect for diversity. • cultural safety.

International Development

• political systems.• economic development.

• foreign aid.

Social Justice

• income distribution.• land reform.

• gender equality.• human rights

Determinants of Health

• social circumstances.

• child development.• lifestyle.

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Working Definitions

(1) Determinants of Health: “the economic and social conditions in which people live that shape the health of individuals, communities, and jurisdictions as a whole” (WHO, 2003; Raphael, 2008).

(2) Cultural Competence: an ability to interact effectively with people of different cultures. Comprised of four components: (a) awareness of one's own cultural worldview, (b) attitude towards cultural differences, (c) knowledge of different cultural practices and worldviews, and (d) cross-cultural skills (Purnell & Paulanka, (2003).

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Working Definitions

(3) International Development: The development of livelihoods and greater quality of life for humans. It therefore encompasses governance, healthcare, education, gender equality, disaster preparedness, infrastructure, economics, human rights, environment and issues associated with these (The Monterrey Consensus, 2002).

(4) Social Justice: The fair distribution of advantages, assets, and benefits among all members of a society (Rawls, 1971).

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Item Validation and Interpretation

75 (items) were developed in 4 different domainsContent and Face Validity:• Experts in the field- Dr. Olive Wahoush (SON) - Prof. Barb Carpio- Dr. Gary Warner - Dr. Tina Moffatt- Dr. Ted Schrecker - Prof. Anne Ehrlich

• Key informant interviews: 5 level 3 BScN Student

• A questionnaire including the 75-item was developed considering the following criteria:

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Item

The item belongs in which domain?

How representative of the domain is the item?

How clear is the wording?

Final decision?

1. Cultural diversity

2. Social justice

3. Determinants of health

4. International development

5. Other, please specify

1. Item is not representative

2. Items need major revisions to be representative

3. Item needs minor revisions to be representative

4. Item is representative

1. Item is not clear

2. Item needs major revisions to be clear

3. Item needs minor revisions to be clear

4. Item is clear

1. Item should be deleted

2. Item should be kept

Item

1 2 3 4 5

1 2 3 4

1 2 3 4

1 2

Adapted from: Lyn, M. R. (1986). Determination and quantification of content validity. Nursing Research 35(6).

Item Validation and Interpretation

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Item Validation and Interpretation

Response Rates: • Experts (3/6) & students (2/5) = total of 5.

• Items were retained if >80% agreement among respondents (4/5).

• Items with inconsistency of responses were not included (Lynn, 1986).

• 30 items were dropped.

• This process provided “face” and “content” validity for a 45-item instrument.

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Item Reduction: Pilot Test

Response scale:

5-point Likert - type scale was developed for each item.

Disagree Neither agree nor disagree

Agree Strongly agree

Strongly disagree

1 2 3 4 5

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Item Reduction: Pilot Test

We should limit humanitarian aid to countries with unfriendly political systems.

SA A N D SD

In poor countries most health problems are caused by people’s inappropriate behaviour.

SA A N D SD

Benefits for Aboriginal people consume a major part of the federal budget.

SA A N D SD

Unless and until women are seen as equal in society, development assistance will have a muted impact on health.

SA A N D SD

Sample Items

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Item Reduction: Pilot Test

• Participant Recruitment:- Permission from UNEC was obtained to access

Level 3 nursing students from all three sites.

- Information letter and the research tool were posted on Survey Monkey via LearnLink.

- E-mail reminders were sent to non-respondents in the second and third weeks after the first e- mail.

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Example Questions

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Item Reduction: Pilot Test

Data Analysis:• students completed the questionnaire on Survey Monkey.

• SPSS: frequencies, demographic data, factor analysis.

• total of 132 responded but only 119 out of the 433 level III students completed the survey (27%).

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Example Responses

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Example Responses

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Example Responses

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McMaster

Mohawk

Conestoga

49/119 students (49%)

*49/194 students (25%)

39/119 students (33%)

*39/143 students (27%)

119/433 students

27%

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31/119 students (26%)

*31/96 students (32%)

Item Reduction: Pilot Test

* Percentage of respondents out of the total number of students per site

Sampling Frame: Site distribution

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Basic

Post Diploma

RPN to BScN

Accelerated

91/119 students (77%)

1/119 students (1%)

17/119 students (14%)

10/119 students (8%)

119 students

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Sampling Frame: Stream distribution

Item Reduction: Pilot Test

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Male

Female

NR

6/120 students (5%)

114/120 students (95%)

12 students

120/132 students

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Sampling Frame: Gender distribution

Item Reduction: Pilot Test

Note: 120 students responded this question

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20-28

29-39

40-49

92/120 students (77%)

21/120 students (18%)

7/120 students (6%)

120 students

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Sampling Frame: Age distribution

Item Reduction: Pilot Test

Note: 120 students responded this question

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Data Analysis:• Frequency of endorsement was conducted considering that if the endorsement frequency was > 0.8 the item would be eliminated.

• Reverse coding was conducted on 16 items

• Factor analysis- Items with correlation coefficients > 0.8 or 0.9 would be eliminated. No items presented high correlation coefficients.- Eigenvalue-one rule was also tried.

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Item Reduction: Pilot Test

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Eigen values

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Results: Exploratory = 16 clusters / domains / factors = too many.

Internal consistency: unable to conduct

Item Reduction: Pilot Test

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• Sample sizes very small (too few subjects per item)

• Poor consensus concepts • Number participating in validity exercise too small.

• Use of a 5-point Likert scale.

• Wording of the question: too long, too ambiguous?

Study Limitations:

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Lessons Learned

• Need to increase sample size (5 respondents per item = 225 minimum) We had 119.

•  Need to increase number of ‘experts’ interviewed. Attrition will lose some.

•  Increase number of key informants (i.e. students).

• Consider order of questions.

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Next Steps

• Revise tool items, length, wording. • Repeat phase one cosidering a larger se sample size

• Analyze qualitative data

• Seek funding opportunities

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Acknowledgements

• Our Funders:• NERU fund• Otto Niemeier Fund

• Our mentors:•Dr. Michelle Butt

•Dr. Noori Akhtar-Danesh

• Our experts, key informants and students.

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References

Button, L., Green, B., Tengnah, C., Johansson, I., & Baker, C. (2005). The impact of international placements on nurses' personal and professional lives: literature review. J Adv Nurs 50(3), 315-324.

Duffy, M., Harju, L., Huittinen, L., & Trayner, C. (1999). An innovative model: International undergraduate education. Nursing and Health Care Perspectives 20, 26-31.

Goldberg, L. & Brancato, V. (1998). International education: a United Kingdom nursing student partnership. Nurse Educator 23, 30-34.

Hett, E. J. (1993). The development of an instrument to measure globalmindedness. Unpublished Doctoral Dissertation, University of San Diego.

Lyn, M. R. (1986). Determination and quantification of content validity. Nursing Research 35(6).

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Monterrey Consensus of the International Conference on Financing for Development, March, 2002.

Purnell, L.D., & Paulanka, B.J. (2003). Transcultural health care: A culturallycompetent approach (2nd ed.). Philadelphia: Davis.

Raphael, D. (2008). Introduction to the social determinants of health. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives. (2nd ed., pp. 2-19). Toronto: Canadian Scholars' Press.

Rawls, John. (1971). A Theory of Justice. Cambridge: The Belknap Press of Harvard University Press.

Scholes, J. & Moore, D. (2000). Clinical exchange: one model to achieve culturally sensitive care. Nursing Inquiry 7, 61-71.

References

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SPSS Base 18.0 Application Guide. (2009). Chicago: SPSS Inc.

Streiner D. & Norman, J. (1995). Health measurement scales: a practical guide to their development and use. New York : Oxford University Press

World Health Organization. (2008). The Solid Facts. Commission on the Social Determinants of Health. Retrieved March 15, 2008, from http://www.who.int/social_determinants/en

Wright, M.G., Zerbe, M., & Korniewicz, D.M. (2001). A critical-holistic analysis of nursing faculty and student interest in international health. Journal of Nursing Education 40(5), 229-32.

Zhai, L. & Scheer, S. (2004). Global perspectives and attitudes toward cultural diversity among summer agriculture students at the Ohio State University, Journal of Agricultural Education. (45)2.

References