Health Promotion International Advance Access originally published online on November 1, 2004
Health Promotion International 2004 19(4):471-481; doi:10.1093/heapro/dah409
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HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 4 © Oxford University Press 2004; All rights reserved.
Towards the development of scales to measure ‘will’ to promote heart health within health organizations in Canada
1Alberta Heart Health Project, University of Alberta, Edmonton T6G 2T4, Canada, 2Centre for Health Promotion Studies, University of Alberta, Edmonton T6G 2T4, Canada and 3Alberta Centre for Active Living and Faculty of Physical Education and Recreation, University of Alberta, Edmonton T6G 2T4, Canada
Address for correspondence: Ronald C. Plotnikoff Centre for Health Promotion Studies, University of Alberta, 5-10A University Extension Centre, 8303-112 Street, Edmonton, Alberta, T6G 2T4, Canada E-mail: ron.plotnikoff{at}ualberta.ca
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SUMMARY |
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 TOP SUMMARY BACKGROUNDINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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This paper describes the development and psychometric evaluation of scales measuring the dimensions of ‘will’ (belief, confidence, prior action and desire) for heart health promotion specifically and health promotion in general at both an individual and organizational level. Content validity was established through a series of focus groups and expert opinion assessments, based on a compilation of capacity-assessment instruments developed by other provinces involved in the Canadian Heart Health Initiative and the literature. Psychometric analyses of questionnaire data provided empirical evidence of the construct validity and reliability of the 16 individual and 21 organizational level ‘will’ scales. A series of principal component analyses assisted in verifying the unidimensionality of the measures and all scales yielded high internal consistencies with Cronbach's alpha coefficients ranging between 0.73 and 0.96. These measures can be used by both researchers and practitioners for assessing the ‘will’ to promote heart health specifically and health promotion in general.
Key words: capacity assessment; heart health promotion; scale development
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BACKGROUND |
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TOPSUMMARYBACKGROUNDINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The Alberta Heart Health Project (AHHP) was established in 1990 as a provincial level program of the Canadian Heart Health Initiative (CHHI). The CHHI was initiated to address the consistently high rates of cardiovascular disease among all Canadian provinces. Phase 1 involved collecting detailed heart health information with provincial heart health surveys. The 1990 Alberta Heart Health Survey indicated that 57% of the population exhibited one or more of the three major modifiable heart health risk factors: high blood cholesterol, high blood pressure and use of tobacco (Alberta Health, 1990
). Phase 2 was the demonstration phase, during which the AHHP initiated four projects in 1993 to promote supportive environments for heart healthy lifestyles by facilitating and evaluating community based initiatives aimed at reducing cardiovascular disease (Dressendorfer et al., in press). The CHHI is currently in the third, ‘dissemination’ phase of the project that has the intent of broadly disseminating the learnings of the demonstration phase. In Alberta, dissemination involves exploring the process of capacity building for heart health promotion within the context of Regional Health Authorities (RHAs) as learning organizations. |
INTRODUCTION |
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TOPSUMMARYBACKGROUNDINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Hawe and colleagues (Hawe et al., 1997
) describe capacity as the value added to a system so that it can sustain any particular health promotion and disease prevention program. In other words if an individual and/or an organization has the capacity to do heart health promotion, then they should have the capacity to do health promotion in general or specific to other chronic diseases. The opposite is also true in that general skills may be applied to a specific disease such as heart health. Specific to heart health promotion, The Singapore Declaration for Heart Health Promotion (Advisory Board Third International Heart Health Conference, 1998), details strategies and opportunities for creating the capacity for health promotion action. The Alberta Heart Health Project has reconceptualized the work of The Singapore Declaration to situate capacity building within the context of learning organizations, such as health organizations [see Figure 1 (Smith et al., 2001)]. Capacity is seen as the capability of an organization to promote health, formed by both its will to act and infrastructure (Advisory Board Third International Heart Health Conference, 1998).
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The model depicts: leadership as the foundation upon which the development of capacity rests. Consistent with The Singapore Declaration, ‘will’ to act and infrastructure are the pillars of capacity. The spiral in the model depicts Rogers' stages of diffusion of innovations within organizations (Rogers, 1995
), shown as a non-linear progression of learning for organizational change. The ultimate outcome of capacity building is increased health promotion actions.
While there is a dearth of literature describing capacity and its components (Smith et al., 2001), what is available confirms the importance of ‘will’ in driving organizational and individual change in creating capacity for health promotion (Hawe et al., 1997; Goodman et al., 1998; The Singapore Declaration 1998; Riley et al., 2001a; Riley et al., 2001b). ‘Will’ is similar to ‘predisposition’, which is described by Riley and colleagues (Riley et al., 2001a) as the motivation to undertake heart health promotion activities and includes belief in the importance of implementing heart health promotion activities. May (May, 1982) states the term ‘will’ relates to intention and has qualities of independence, personal freedom and decision-making. Kim and Kim (Kim and Kim, 1996) note that ‘will’, with regards to the adoption of an innovation, involves intention, which is determined by attitude towards the innovation in question. Similarly, Hollander (Hollander, 1999) uses motivation as a simile for ‘will’ and argues that a loss of political ‘will’ is associated with a loss of legitimacy and conviction. The current project bases its definition of ‘will’ on that of The Singapore Declaration (Advisory Board Third International Heart Health Conference, 1998) where ‘will’ is taken to imply the process of conceiving and implementing a program, leading to action.
The first step in the process of developing ‘will’ is acquiring knowledge and beliefs that are derived from modeling or example (Advisory Board Third International Heart Health Conference, 1998). This conceptualization is similar to constructs of the Health Belief Model (Strecher and Rosenstock, 1997) that include susceptibility, severity, benefits and barriers of an action, cues to action (e.g. reinforcement) and self-efficacy. As such, confidence is defined as a ‘belief strong enough to lead to a willingness to act’ (Advisory Board Third International Heart Health Conference, 1998). Gaining conviction, the next stage involves combining beliefs and desire, and is a precursor to building confidence and establishing values. One's perceived confidence (i.e. self-efficacy) based on Bandura's (Bandura, 1986) Social Cognitive Theory is a key social-cognitive construct predicting behaviour change. The Singapore Declaration asserts that ‘confidence must precede action’ (Advisory Board Third International Heart Health Conference, 1998).
While some of the dimensions of ‘will’ are drawn from theories, such as self-efficacy (Bandura, 1986), the components of ‘will’ have not been empirically tested in relation to capacity building. There appears, at least on the surface, to be a high degree of overlap between many of the components of ‘will’ listed in The Singapore Declaration. It is essential to validate these dimensions of ‘will’ in order to examine it's role in capacity building. The objective of this study therefore, was to validate the measurement properties of individual and organizational level scales to measure ‘will’ to do health promotion in general and heart health promotion more specifically among key respondents from the health sector, including board members, senior/middle-management and service providers. We have conceptualized organizational ‘will’ as an element of capacity, similar to readiness, and consisting of the guidance of decision-makers and managers (Advisory Board Third International Heart Health Conference, 1998). This study is part of a larger research project to develop scales to measure the three components of capacity identified earlier in the paper. While, this paper focuses on the ‘will’ scales, additional manuscripts are being written on the leadership and infrastructure components of capacity.
Throughout the paper, reference is made to both ‘will’ to do heart health promotion and health promotion in general. While some of the scales are specific to heart health promotion, others are more general to health promotion but however do encompass heart health promotion.
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METHODS |
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TOPSUMMARYBACKGROUNDINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Instruments
The ‘will’ scales were developed to measure beliefs, confidence, prior action and desire to promote health. The variables selected for inclusion in the ‘will’ scales were based on those used in other provincial heart health research efforts (i.e., Nova Scotia, Ontario, Saskatchewan and British Columbia) and the literature (Advisory Board Third International Heart Health Conference, 1998
) supporting an association between ‘will’ and capacity for health promotion.
Instrument development
A two-day ‘think tank’ was held with CHHI researchers from the provinces of Saskatchewan, British Columbia, Ontario and Manitoba with the purpose to discuss their experiences with tools assessing individual and organizational capacity to do heart health–general health promotion. From this, a table was constructed listing the different components of ‘will’ and the specific items found within each component. This assisted the identification of constructs to be measured along with establishing content validity. Some items and response choices were modified to meet the AHHP research needs. All ‘will’ items were compiled into two questionnaires addressing organizational capacity and individual capacity, respectively. The individual capacity questionnaire required the respondents to reflect on their own level of capacity to do heart health promotion specifically and health promotion in general, whereas the organizational capacity questionnaire required the individual to reflect on the organization as a whole in its capacity to do heart health promotion and general health promotion.
The instruments were then subjected to two expert opinion focus groups; each focus group was comprised of five health promotion professionals (including consultants, graduate students, faculty and staff from national and provincial health agencies) to further establish and verify content validity of the questionnaires. One focus group reviewed the individual instrument; the other reviewed the organizational tool. Focus group participants initially completed the questionnaire and were asked to identify any expressions or items that appeared unclear. Subsequent modifications were made to the instruments.
Pilot versions of the two questionnaires were drafted and tested. Three health promotion-based organizations from Alberta served as the pilot sample. The organizations represented local, provincial and national level organizations, but did not include the target group. The pilot test aimed to identify questionnaire item ambiguities and to verify the clarity of the questions. Pilot test respondents included comments on the instruments, which were later recorded and taken into account when developing the final version of the questionnaires. The instruments were sent out to 37 key individuals, who were part of the CHHI, to verify the content validity of the ‘will’ dimensions.
Final questionnaires
Final versions of the individual- and organizational-level questionnaires were sent to 158 individuals across all of Alberta's 17 RHAs. Data from 144 respondents were used to verify the construct validity of the a prior established scales. No significant changes were made to the instruments following psychometric analysis, and hence became the study's final questionnaires.
The ‘will’ component of individual capacity questionnaire contained 90 items designed to measure confidence (three scales, 15 items), beliefs (four scales, 15 items), prior action (five scales, 40 items) and desire to promote health (four scales, 20 items). The ‘will’ components of the organizational capacity questionnaire consisted of 149 items also designed to assess beliefs (three scales, 15 items), prior action (eleven scales, 77 items) and desire to promote health (seven scales, 57 items). Pilot work revealed that it was too difficult to measure confidence at an organizational level.
Subjects and procedures
Between six and 18 sets of questionnaires were sent to 158 participating RHA individuals. A site coordinator at each RHA was asked to recruit two RHA board members, and based on staff numbers, between two and eight senior/middle managers and service providers. Site coordinators were sent packages including the questionnaires, return envelopes, an information sheet describing the project and consent forms for participants. The package included instructions about timelines and the questionnaire distribution, completion and collection process. Participants were given one month to return the completed instruments. A member of the research team contacted site coordinators by telephone one month following the distribution to follow-up on questionnaire completion. If requested, participants were granted a two-week extension to return the instruments. The return of 144 completed paired individual and organizational-level questionnaires from three organizational levels [i.e. board members (n = 30), senior/middle management (n = 58) and service providers (n = 56)] yielded a response rate of 91%. Each respondent completed both the individual and organizational ‘will’ instruments.
Analysis: assessment of construct validity
Scales were developed using the following procedures. Items to be included in the scales were established a priori according to measures established previously in former research efforts of other CHHI provincial projects described above. The five-point Likert-type scale categories for individual and organizational ‘will’ are provided in Tables 1 and 2, respectively. The various response options ranged from ‘1’ (e.g. not at all/poor) to ‘5’ (e.g. completely/excellent).
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The structure of the scales was then tested using factorial analytical techniques [principal component analysis (PCA)] (Tabachnick and Fidell, 2001
). In this study PCA was used to confirm the unidimensionality of theoretically predetermined scales and/or to reduce a large number of variables into more parsimonious and manageable factors. Separate PCAs were conducted for each of the a prior grouped items of each of the a prior scales. In other words we performed 20 separate PCAs. The dashed-lines in Tables 1 and 2 illustrate the groupings by which the PCAs were conducted. PCA was performed on all original theoretically predetermined scales. Any missing data were replaced with the variable mean. Original scales either factored into several subscales or held together confirming scale unidimentionality. Statistical Package for Social Science version 10.0 (SPSS) was used for all calculations. Bartlett's test of sphericity and Kiaser–Meyer–Olkin (KMO) test of sampling adequacy were initially performed on the data and confirmed the appropriateness of conducting PCAs (Tabachnick and Fidell, 2001). The Bartlett's test for sphericity showed that the correlation matrix was at an appropriate level to perform factor analysis on the data for each scale, with all scales reaching a significance level of p < 0.001. KMO test of sampling adequacy was calculated for all original individual and organizational ‘will’ scale variables. The KMO measure provides a value between 0 and 1. Small values for the KMO indicate that a factor analysis of the variables may not be appropriate, since the correlations between variables cannot be explained by the other variables (Norusis, 1993). Values higher than 0.5 are considered satisfactory for factor analysis. KMO test for each set of predetermined variables reached values of at least 0.66 or above. Once the sampling adequacy was confirmed, PCA with Kaiser normalization and varimax rotation were performed on the variables with the original extraction factors (Tabachnik and Fidell, 2001). Components were conserved if eigenvalues were > 1.0 and the level of variance accounted for by each component was recorded (see Tables 1 and 2). An item was considered to belong to a given component if its loading was 0.40 or higher (Tabachnick and Fidell, 2001) and was at least 0.2 higher than any cross-loaded item (Bourke, 1984; Plotnikoff, 1994). In a few instances, items were retained if cross-loading was less than 0.2 in order to retain the item and not sacrifice content validity of the scale. A fully detailed version of Tables 1 and 2 containing scale items with cross-loading results can be viewed at http://www.ualberta.ca/~ahhp/. After examining item loadings, the appropriate number of components were conserved and interpreted. In order to verify the reliability of the components (scales), alphas were calculated for each scale. The higher the Cronbach alpha value the greater the internal consistency of the measure. An alpha >0.9 is a sign of redundancy among the items, but due to the small size of the sample in the present study, these results are judged satisfactory. Bivariate correlation testing of the new scales using Pearson's correlation coefficient was also performed to examine their uniqueness from each other. |
RESULTS |
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TOPSUMMARYBACKGROUNDINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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After the PCA and reliability analyses, scales were created and named. Descriptive statistics for the individual and organizational ‘will’ scales, including the number of items per scale, mean scale scores and standard deviations, item loading range, percent variance accounted for by each scale and the scale alpha are presented in Tables 1 and 2, respectively. As noted above, the dashed-lines in Tables 1 and 2 illustrate the groupings by which the PCAs were conducted. Factor loadings for all scales in the study ranged from 0.42 to 0.92. Factor loadings of +0.30 are considered to be significant: loadings of +0.40 are deemed more important: and loadings of +0.50 or greater are considered to be very significant (Hair et al., 1992
). Internal consistency measured by Cronbach's alpha for all ‘will’ scales ranged from 0.73 and 0.96.
Table 1 lists the individual ‘will’ scales under the headings of confidence, beliefs, prior action and desire. PCA resulted in three scales pertaining to confidence in ability to address determinants of health (psychosocial/environmental risk conditions, physiological risk factors, behavioural risk factors). Analysis with respect to beliefs in addressing the determinants of health resulted in the determinants of health items factoring into four components (physiological, environmental, psychosocial, behavioural). Twenty items pertaining to actions that are characteristic of health promotion factored into two components. The first component was interpreted as a general health promotion action scale and the second as a risk factor scale. PCA was performed on the prior action determinants of health items (composed of 15 original items), which extracted two components. The components were examined for content and named prior action in addressing: traditional risk factors and psychosocial/environmental risk factors. There are five action strategies that characterize health promotion and are commonly referred to as the Ottawa Charter Action strategies (World Health Organization, 1986). PCA retained one factor confirming this scale's unidimensionality. Desire to promote health has been conceptualized as a key component of the equation resulting in will to take action on health promotion. An initial grouping of 20 items characteristic of health promotion actions factored into four subscales, which were interpreted as desire to do: research and planning, community work, address risk factors and team work.
Table 2 provides an overview of the descriptive statistics and psychometric properties for measures of organizational ‘will’. Scales are grouped under the following headings; beliefs, prior action and desire. Respondents were asked to: ‘Indicate how strongly you believe your organization should address each of the following factors’. An initial set of 15 items describing the different determinants of health were factored into three components and named psychosocial/environmental, physiological and behavioural. Eleven scales were developed for health promotion prior action. An initial grouping of 15 items factored into three different subscales were named; traditional, psychosocial/environmental and income risk conditions. The next three scales were derived from an initial general health promotion statement scale, with 15 different items describing typical health promotion statements or statements suggestive of support for health promotion initiatives. The three scales were interpreted as prior action around: public and community actions, general health promotion actions and planning and evaluation. The unidimensionality of the Ottawa Charter action strategy scale was confirmed by PCA. PCA confirmed the unidimensionality of the following four health promotion scales: assessment, planning, implementation and evaluation. PCA analysis confirmed the undimensionality of desire to do ‘health promotion general scale’, ‘public and community action’ and ‘planning and evaluation’.
Pearson correlation coefficient testing of the individual and organizational ‘will’ scales revealed a bivariate component score correlation range of 0.00–0.67, for individual capacity scales and 0.00–0.79 for the organizational capacity scales significant at the 0.01 level (two-tailed) (see Tables 3 and 4).
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DISCUSSION |
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TOPSUMMARYBACKGROUNDINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The analyses indicate that both the individual and organizational ‘will’ scales have good content and construct validity for measuring beliefs, prior action, confidence (at an individual level) and desire to promote health. The satisfactory results of these reliability and validity tests can be attributed to the strength of the face and content validity process undertaken by the other provincial heart health initiatives such as Saskatchewan, Ontario and Nova Scotia. This study contributes to the literature in that few instruments (Hawe et al., 2000
) of this type have published data on their validity and reliability, including those from which we drew questions. The ‘will’ scales are potentially useful for evaluating both perceived organizational ‘will’ and individual ‘will’ to do health promotion, a key component of capacity (Hawe et al., 1997; Goodman et al., 1998; Pearson et al., 1998; Riley et al., 2001a; Riley et al., 2001b; Smith et al., 2001). The organizational capacity instrument proved to be a challenge on many levels. First, it was difficult to write a statement that would guide the respondent to respond on behalf of the organization as a whole. On the desired scales we were limited to asking the respondent to indicate the level of involvement they would be satisfied with for the organization. Secondly, respondents appeared to find it difficult to reflect on the organization as a whole. This is in part due to the very large size of the RHAs and the potential for individuals' lack of knowledge about organizational ‘will’ for health promotion. On the other-hand it may be hypothesized that if the ‘will’ to do health promotion were an integral part of the organization, then employees would be aware of any actions, plans, etc., for health promotion. One might argue that if the organization had the will to do health promotion then it would be easier to respond to the organizational ‘will’ statements.
The questionnaires are limited to perception, especially in terms of prior action and desire to promote health in that they only ask respondents what they perceive is happening without asking for specific evidence. Researchers may want to validate their findings with qualitative and auditing techniques such as review of documents (e.g. business plans and annual reports). If the ‘will’ to do health promotion were an integral part of an organization, then one would expect that this would be reflected in such documents.
In assessing these results, several caveats need to be noted. Caution is advised when interpreting the analysis given the relatively small sample size (n = 144). While content and partial construct validity were established for each scale, continued research examining both individual and organizational ‘will’ to do health promotion is needed to provide criterion-related validity. As these scales are relatively new, repeated administration for further refinement is warranted. For instance a test–retest research design could assess instrument stability. Research on larger and more representative samples of workers from the health sector is recommended. A much larger sample size could also provide the ability to perform additional confirmatory factor analytical work required to further establish the construct validity of the measures. Given there are no gold standards for measurement of ‘will’ to do health promotion (Ebbesen et al., 2004) researchers may want to establish scale norms for the next generation of the instruments. Again, such work would require large and representative samples. Finally, research should also aim at developing a shortened version of the instruments in an attempt to minimize respondent burden.
Implications for practice
The instruments may be employed by health promotion practitioners who aim at increasing capacity to do health promotion, of which ‘will’ is an essential component, at either an individual or organizational level. The scales may help identify gaps (i.e. specific areas where there is a lack of ‘will’) of individual and organizational ‘will’ whether it be belief, confidence, desire or action. In return, focused interventions can be designed to increase ‘will’. The scores obtained from the tools can be used as a guide to planning by identifying individual and organizational strengths and weaknesses to do health promotion. Further, the scales have utility in assessing and tracking individual and organizational ‘will’ longitudinally.
The ‘will’ response scales are anchored at ‘1’ and ‘5’, with ‘1’ reflecting a total absence, and ‘5’ a strength or total presence of the component in question. Although the benchmarks for ‘will’ to do health promotion have yet to be established, the authors suggest that a score lower than 2.5 may be considered as weak ‘will’, 2.5–3.5 an indication of a mediocre level of ‘will’, and scores greater than 3.5 a reflection of strong ‘will’. Identified domains with weak scores may be highlighted as key areas to focus on for in-service education sessions with front-line service providers. Senior and middle managers may use such results to guide planning for health promotion and target any identified weak areas.
The ‘will’ scales can also be used in conjunction with infrastructure and leadership scales to test theoretical models of health promotion actions, such as the one presented in this paper. The development of such instruments is an important step towards the design of a more effective assessment of capacity.
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REFERENCES |
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