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

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

2. Overview • Background • Relevance of the project • Purpose • Plan of Activities • Description of Instrument development • Phase 1 • Data analysis • Study Limitations • Lessons learned • Next Steps

3. Funding Agencies • Dr. O. Niemeier Fund • Nursing Education Research Unit (NERU) Pilot Fund

4. 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).

5. 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).

6. 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].

7. 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?

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

9. Why Assess Attitudes in Higher Education? • Provide feedback to students so they can modify their learning approach (formative assessment). • 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

10. 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).

11. 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.

12. 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)

13. Plan of Activities Stage 2. Instrument Development Process(Streiner and Norman, 1995) Phase 1. Instrument Development Phase 2. Instrument Evaluation

14. Instrument Development Process Phase One: Item generation Item validation (face & content) Item interpretation Item reduction Factor analysis Internal consistency Scoring

15. 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)

16. Item Generation • Qualitative data analysis of interviews and focus group. • Thematic analysis • N-Vivo software • Triangulation of findings

17. Item Generation Major Construct: Global Health Four Domains (1) Determinants of Health. (2) Cultural Competence. (3) International Development. (4) Social Justice.

18. 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) 18

19. The Global Health Concept (4 fields) International Development • political systems.• economic development.• foreign aid. Cultural Competence • cultural desire. • respect for diversity. • cultural safety. Social Justice • income distribution.• land reform.• gender equality.• human rights Determinants of Health • social circumstances. • child development.• lifestyle. Source: Ladouceur & Mujica.

20. 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).

21. 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).

22. 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 • Key informant interviews: 5 level 3 BScN Student • A questionnaire including the 75-item was developed considering the following criteria:

23. Item Validation and Interpretation

24. 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.

25. Item Reduction: Pilot Test Response scale: 5-point Likert - type scale was developed for each item. 1 2 3 4 5 Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree

26. Item Reduction: Pilot Test Sample Items

27. 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.

28. Example Questions

29. 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%).

30. Example Responses

31. Example Responses

32. Example Responses

33. Item Reduction: Pilot Test Sampling Frame: Site distribution McMaster 49/119 students (49%) *49/194 students (25%) Mohawk 119/433 students 27% 39/119 students (33%) *39/143 students (27%) 31/119 students (26%) *31/96 students (32%) Conestoga * Percentage of respondents out of the total number of students per site 33

34. Item Reduction: Pilot Test Sampling Frame: Stream distribution Basic 91/119 students (77%) Post Diploma 1/119 students (1%) 119 students RPN to BScN 17/119 students (14%) Accelerated 10/119 students (8%)

35. Item Reduction: Pilot Test Sampling Frame: Gender distribution Male 6/120 students (5%) Female 114/120 students (95%) 120/132 students NR 12 students Note: 120 students responded this question 35

36. Item Reduction: Pilot Test Sampling Frame: Age distribution 20-28 92/120 students (77%) 120 students 29-39 21/120 students (18%) 40-49 7/120 students (6%) Note: 120 students responded this question 36

37. 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.

38. Eigen values

39. Item Reduction: Pilot Test Results: Exploratory = 16 clusters / domains / factors = too many. Internal consistency: unable to conduct

40. 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?

41. 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.

42. Next Steps • Revise tool items, length, wording. • Repeat phase one cosidering a larger se sample size • Analyze qualitative data • Seek funding opportunities

43. Acknowledgements • Our Funders: • NERU fund • Otto Niemeier Fund • Our mentors: • Dr. Michelle Butt • Dr. Noori Akhtar-Danesh • Our experts, key informants and students.

44. 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 Educator23, 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).

45. 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. 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.

46. 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.