Transcript Slide 1

Inspire
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Development of an Instrument
to Assess Students’ Attitudes
Toward Global Health Issues
Engage.
Iris Mujica, R.N., B.Sc.N., M.Sc., Ph.D.(s)
Principal Investigator
and
Lead.
Michael Ladouceur, R.N., B.Sc.N., M.P.H.
Co-investigator
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Overview
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Background
Relevance of the project
Purpose
Plan of Activities
Description of Instrument development
– Phase 1
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Data analysis
Study Limitations
Lessons learned
Next Steps
 Dr. O. Niemeier Fund
 Nursing Education Research Unit (NERU) Pilot
Fund
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Funding Agencies
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Background
• 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
 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
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• 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
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(Hett, 1993)
- Global Perspectives
(Zhai & Scheer, 2004)
towards cultural diversity
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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
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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)
1. Qualitative data analysis of interviews and
focus group.
1. Thematic analysis
2. N-Vivo software
3. Triangulation of findings
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Item Generation
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Item Generation
Major Construct: Global Health
Four Domains
(1) Determinants of Health.
(2) Cultural Competence.
(3) International Development.
(4) Social Justice.
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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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Cultural Competence
International Development
• cultural desire.
• political systems.
• economic development.
• foreign aid.
• respect for diversity.
• cultural safety.
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The Global Health Concept (4 fields)
Social Justice
Determinants of Health
• income distribution.
• land reform.
• gender equality.
• human rights
• social circumstances.
• child development.
• lifestyle.
Source: Ladouceur & Mujica.
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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 domains
Content 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
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• 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
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Item Validation and Interpretation
Item
The item belongs How
How clear is the
in which
representative of wording?
domain?
the domain is the
item?
1. Cultural
1. Item is not
1. Item is not clear
diversity
representative
2. Item needs
2. Social justice
2. Items need
major revisions to
major revisions to be clear
3. Determinants of be representative
health
3. Item needs
3. Item needs
minor revisions to
4. International
minor revisions to be clear
development
be representative
4. Item is clear
5. Other, please
4. Item is
specify
representative
Final
decision?
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1
2 3 4 5
1
2 3 4
1
2 3 4
1. Item should
be deleted
2. Item should
be kept
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Adapted from: Lyn, M. R. (1986). Determination and quantification of content validity.
Nursing Research 35(6).
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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).
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• 30 items were dropped.
• This process provided “face” and “content” validity for a
45-item instrument.
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Response scale:
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Item Reduction: Pilot Test
1
2
3
4
5
Strongly
disagree
Disagree
Neither
agree nor
disagree
Agree
Strongly
agree
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5-point Likert - type scale was developed for each item.
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We should limit humanitarian
aid to countries with unfriendly
political systems.
SA
A
N
D
SD
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Sample Items
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
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Item Reduction: Pilot Test
Unless and until women are seen
as equal in society, development
assistance will have a muted
impact on health.
SA
A
N
D
SD
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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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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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Item Reduction: Pilot Test
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Example Responses
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Example Responses
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Example Responses
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Item Reduction: Pilot Test
Sampling Frame: Site distribution
McMaster 49/119 students (49%)
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*49/194 students (25%)
Mohawk 39/119 students (33%)
*39/143 students (27%)
Conestoga
119/433 students
27%
31/119 students (26%)
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*31/96 students (32%)
* Percentage of respondents out of the total number of students per site
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Item Reduction: Pilot Test
Sampling Frame: Stream distribution
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Basic
Post Diploma
91/119 students (77%)
1/119 students (1%)
119 students
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RPN to BScN 17/119 students (14%)
Accelerated 10/119 students (8%)
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Item Reduction: Pilot Test
Sampling Frame: Gender distribution
Male
6/120 students (5%)
Female
114/120 students (95%)
120/132 students
12 students
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NR
Note: 120 students responded this question
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Item Reduction: Pilot Test
Sampling Frame: Age distribution
92/120 students (77%)
29-39
21/120 students (18%)
40-49
7/120 students (6%)
120 students
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20-28
Note: 120 students responded this question
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Item Reduction: Pilot Test
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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Eigen values
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Results:
Exploratory = 16 clusters / domains / factors
= too many.
Internal consistency: unable to conduct
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Item Reduction: Pilot Test
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Study Limitations:
• 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?
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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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• Revise tool items, length, wording.
• Repeat phase one cosidering a larger se sample size
• Analyze qualitative data
• Seek funding opportunities
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Next Steps
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Acknowledgements
• Our Funders:
• NERU fund
• Otto Niemeier Fund
• Our mentors:
•Dr. Michelle Butt
•Dr. Noori Akhtar-Danesh
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• 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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References
Monterrey Consensus of the International Conference on Financing for
Development, March, 2002.
Purnell, L.D., & Paulanka, B.J. (2003). Transcultural health care: A culturally
competent 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.
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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.
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References
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.