RESEARCH ARTICLE Open Access Constructing A Questionnaire .
Emami and Safipour BMC Health Services Research 2013, 5RESEARCH ARTICLEOpen AccessConstructing a questionnaire for assessment ofawareness and acceptance of diversity inhealthcare institutionsAzita Emami1,2† and Jalal Safipour3*†AbstractBackground: To develop a healthcare environment that is congruent with diversity among care providers and carerecipients and to eliminate ethnic discrimination, it’s important to map out and assess caregivers’ awareness andacceptance of diversity. Because of a lack of standardized questionnaires in the Swedish context, this studydesigned and standardized a questionnaire: the Assessment of Awareness and Acceptance of Diversity inHealthcare Institutions (AAAD, for short).Method: The questionnaire was developed in four phases: a comprehensive literature review, face and contentvalidity, construct validity by factor analysis, and a reliability test by internal consistency and stability assessments.Results: Results of different validity and reliability analyses suggest high face, content, and construct validity as well asgood reliability in internal consistency (Cronbach’s alpha: 0.68 to 0.8) and stability (test-retest: Spearman rank correlationcoefficient: 0.60 to 0.76). The result of the factor analysis identified six dimensions in the questionnaire: 1) Attitudetoward discrimination, 2) Interaction between staff, 3) Stereotypic attitude toward working with a person with aSwedish background, 4) Attitude toward working with a patient with a different background, 5) Attitude towardcommunication with persons with different backgrounds, 6) Attitude toward interaction between patients and staff.Conclusion: This study introduces a newly developed questionnaire with good reliability and validity values that canassess healthcare workers’ awareness and acceptance of diversity in the healthcare environment and healthcare delivery.Keywords: Assessment, Culture, Cultural awareness, Diversity, Environment, Healthcare, Questionnaire development,SwedenBackgroundGlobalization and immigration are changing not only thedemographic composition of society, but also the patternof social relationships and social interaction among individuals. In a multicultural society, members are challengedto preserve their own identity when interacting with othermembers with different socio-cultural backgrounds [1].Sweden, as a part of the European Union, is currentlyundergoing this transition toward multiculturalism and diversity because of rapid and expansive immigration intothe country.* Correspondence: jalal.safipour@ualberta.ca†Equal contributors3Faculty of Nursing, University of Alberta, Alberta, CanadaFull list of author information is available at the end of the articleOne of the main areas of inquiry of public health researchis to investigate the health and well-being of the individualmembers of society in order to provide an environmentthat is inclusive, supportive, and free from discriminationfor all members [2]. Sufficient knowledge about structuraland individual mechanisms that impact user-friendly andculturally sensitive care is lacking, which may result in discrimination in Swedish healthcare institutions [3-5]. Cultural competence is a skill set that can help healthcareproviders create culturally sensitive and user-friendly careservices for people with diverse backgrounds [6].Evidence shows that most misunderstandings betweenhealthcare providers and patients with different culturalbackgrounds arise from providers’ lack of understanding,cultural awareness, cultural knowledge, and flexibility [7].In addition, providers often have a one-dimensional 2013 Emami and Safipour; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,distribution, and reproduction in any medium, provided the original work is properly cited.
Emami and Safipour BMC Health Services Research 2013, 5biomedical perspective rather than a holistic perspectivein caring for patients [8-10]. One way of assessing theawareness and acceptance of diversity and how it impactsthe interactions and communications taking place inhealthcare settings is to use a questionnaire to study theself-reported perceptions and experiences of individualswho interact in healthcare institutions [11].A valid and reliable questionnaire for investigatingawareness and acceptance of diversity among staff working in healthcare settings has been lacking in Sweden.Another research project attempted to provide a validand reliable cultural competence questionnaire but theresult indicated weak validity and reliability, and a lackof consistency in the structure of the scale [10]. Therefore, this study aimed to construct a more valid and reliable questionnaire to map out and assess awareness andacceptance of diversity among healthcare staff, based ona study at two elderly care institutions in Stockholm.This project was a part of a larger research investigationexploring how healthcare institutions in Sweden address diversity and equal rights in regard to the workplace environment and healthcare delivery. The main objective for thelarger project was to enhance healthcare institutions’ awareness of the importance of a perspective that is sensitive toculture and diversity, and to prevent ethnic discriminationin the work environment as well as in the delivery of care.The framework for constructing the questionnaire wasbased on the notion that the society and the individual create each other; culture is learned and shared and is a resultof intersections of different qualities, such as gender, socioeconomic status, education, as well as historical, geographical, political, and societal circumstances [12,13]. In thisway, individuals actively create their collective experiencethrough social interactions in social contexts.Many nursing science researchers have used the concept of cultural competence in studies that focus onnurses care of patients with different cultural backgrounds [8,14,15]. The concept is complex and manydefinitions are given in the literature. Moreover, by notaddressing the complexity of cultural competence andwhat it should stand for, some of these studies may unintentionally reinforce stereotypes by reiterating certaincultural norms and distinctions as universal predictorsfor people’s behavior [16]. In constructing the questionnaire for this project, we attempted to go beyond theconcept of cultural competence and to shed light onawareness and acceptance of diversity and its impact onthe social interactions between individuals with diversebackgrounds who work in healthcare institutions.The questionnaire was aimed at the entire healthcare institution, i.e., including both care-providing and non-care-providing staff and their relationships with patients andthe patients’ significant others. This questionnaire wasintended to serve as a tool for obtaining data concerningPage 2 of 10awareness and acceptance of healthcare providers as theyinteract with people with diverse backgrounds.MethodsConstruction of the questionnaireThe Assessment of Awareness and Acceptance of Diversity in Healthcare Institutions questionnaire (AAAD) wasdeveloped in several phases to ensure validity and reliability. The first phase was selection of items by experts. Thereliability and validity of the questionnaire was examinedin several pilot tests with different scale constructionmethods, including face, content, and construct validity.These were conducted by using expert groups, factoranalysis, and a reliability test on internal consistency andstability (Figure 1).This research received ethical approval from the ResearchEthics Committee at the Karolinska Institutet-Stockholm(reference 2009/463-31). Permission to distribute the questionnaire was obtained from the Nursing Homes andHome-based Care settings. A cover page was added to thequestionnaire describing the project and stressing thatthe participation was voluntary. Questionnaires were completed anonymously and the questions were constructed topreserve confidentiality (personal details such as names,personal numbers, and addresses were not included). Acode known only to the research team was included oneach questionnaire in order to identify the workplace notindividuals. In other words, when the questionnaires werereturned in the envelopes, not even the research team wasable to identify the participants.Statistical analysisSeveral statistical analyses were applied in the last stagesof the pilot tests of constructed items for testing reliability and validity of the questionnaire. The items wereconstructed in a Likert-type scale and the items could bescored individually as well as summed in groups. Theitems phrased negatively were reverse coded. Reliabilityof the questionnaire was tested using two methods: aninternal consistency test (with a Cronbach’s alpha coefficient) and a stability test (either test-retest or split-halftest with a Spearman-Brown coefficient or a GuttmanSplit-Half coefficient).Test-retest reliability refers to whether a questionnaireyields a consistent measurement over time [17]. To estimate the test-retest reliability of the AAAD subscales anditems, a Spearman correlation was used for all subscalesand single items, and a percentage of agreement (PA)was used for the subscales and single items with a lowSpearman correlation. The closer the correlation coefficient(r) is to 1.0, the stronger the correlation [17]. A PA of 80 isusually regarded as a good level of test-retest reliability.Internal consistency describes estimates of reliabilitybased on the average correlation among items within a
Emami and Safipour BMC Health Services Research 2013, 5Figure 1 Study process, from item selection to testing reliability and validity of the scale.Page 3 of 10
Emami and Safipour BMC Health Services Research 2013, 5Page 4 of 10test or subscales [17-19]. Chronbach’s alpha coefficientswere used to estimate the internal consistency of thesubscales in the questionnaire.Factor analysis was applied to assess the validity of thequestionnaire and to identify items underlying each factor[20]. The Kaiser-Meyer-Olkin (KMO) and Bartlett’s Testwas applied to test factorability of the data. A KMO valuecloser to 1 is good and 0.6 is acceptable. Items with KMOvalues less than 0.5 or low communality are usually considered as items that can be dropped from the analysis.reliability. The second part of the questionnaire was directed towards all categories of staff who worked in ahealthcare institution, while the third part was only for careproviders. The second and third parts had 46 items andconcerned communication, attitudes, and discrimination inrelation to the patients and their significant others in careproviding situations. Thus only these 46 items wereprocessed for future validity and reliability assessment.ResultsIn the first pilot study, the questionnaire was sent tohealthcare scientists in a related field. They were given anoverview of the theoretical framework of the study andasked to answer the questions as well as to comment onthe items in particular and the questionnaire in general.Participation was voluntary. Two recipients declined participation; one of them stated that the questions were toosensitive to discuss in public arena, and the other did nothave time. At least 8 scientists evaluated the items, showing that the terminology used in many of the items, especially the word discrimination, was indeed too loaded.Participants emphasized that they became annoyed whilereading the questions. Some expressed fear over sharingtheir knowledge about existing problems related to discrimination in their workplace, and many expressed thatthe items related to discrimination in the workplace wereconfusing. They suggested that some of the items weredifficult to understand, and most participants said that itwas too time-consuming to answer the questionnaire.Based on the comments received in this phase, a “thinkaloud” process was performed in the next step of revisingthe questionnaire. A researcher experienced in constructingsimilar questionnaires was asked to read the instructionsand items aloud. She then shared her thoughts as sheread and answered items to the research team. The use ofthis method resulted in many constructive commentsconcerning wording, understanding, and layout.As a result, the questionnaire was shortened and thewording was simplified to ensure that respondents couldeasily understand the items and complete the questionnaire quickly. For example, the words ethnicity and discrimination were deleted from the questionnaire sincethey seemed to contribute to anxiety and confusion. Theword ethnicity was replaced by the phrase “people with aSwedish background and people with backgrounds incountries other than Sweden.”In this phase, based on the expert views, the itemswere categorized as follows:Phase IInitiating the construction of the questionnaire—facevalidityFirst, a literature review on subjects related to the researcharea was carried out to provide an initial basis for selectingitems (in Swedish) to be included in the questionnaire. Anexpert group was established, consisting of four researchersin transcultural care, one anthropologist, one sociologist,one social welfare officer, one deputy assistant undersecretary, the parliamentary commissioner for discrimination,one expert from the Swedish Integration Board (officiallycalled the “Discrimination Ombudsman” (DO)), and oneperson from the Swedish Center Against Racism (CMR).The first draft of a questionnaire including 73 items wasgiven to the expert group, and then revised accordingly,with the expert group supplying new comments by email.For example, the expert group raised possible negative associations that the word discrimination might arouse andsuggested replacing it with equal rights.Generally, comments from this group suggested thatsubjects such as discrimination, cultural awareness, andethnicity needed to be dealt with delicately and sensitively.The group surmised that people would be usually anxiousabout and reluctant to talk openly and to answer questionsabout these issues. Another problem during the processwas the use of verbiage and phrases that could becomprehended by people in all the different professionalcategories with different occupational, educational, social,economic, and ethnic backgrounds as well as by peoplewith different native languages that we planned to includein the study population. The experts emphasized thatthe terminology used in the questionnaire had to bestraightforward and immediately understandable by all respondents and should be as short as possible to preventrespondent exhaustion. The items were revised based onthese comments and suggestions for using the most appropriate phrasings for constructing the items of the questionnaire and the written information and guidelines forfilling out the questionnaire.The questionnaire had three basic parts. The first partcontained socio-demographic questions, which did notneed to go through the process of assessing validity andPhase IIPilot studies—content validitya) social interaction between staff and between staffand patients, b) attitude toward communication withpeople with different backgrounds, c) constitution ofstereotypes, and d) discrimination in the workplace.
Emami and Safipour BMC Health Services Research 2013, 5The revised questionnaire was sent to 20 people whowere working in a healthcare setting to identify whetheror not the items could be understood by the targetpopulation. Based on the comments gathered from thesecond piloting, the questionnaire was again revised.This time three items about stereotypes in general weredeleted, and the total number of questions was decreased to 43.Phase IIIConsistency of itemsThe revised questionnaire was distributed to all of thestaff working (295 individuals) in healthcare setting #1for the third piloting round. The 295 copies of the questionnaire, which included an information letter aboutthe study, instructions for completing the questions, information flyers for all the staff, and special deliveryboxes for the questionnaire were delivered to the headsof each unit in the participating healthcare setting. Intotal, 205 (69%) of the 295 recipients completed andreturned the questionnaires. None of the head nursesheard any negative comments from the staff about wording, the concepts, or items.The results of the pilot study showed a good internalconsistency with a Cronbach’s alpha range of 0.62 to0.85 for most the subscales after deleting items with lowcorrelation with other item groups.Phase IVAssessment of the stability of the itemsBased on the results of the internal consistency test,some minor revisions also were made to the questionnaire including rewording of an item and the addition ofone heading to add more clarity. Furthermore, a testretest was conducted to assess the reliability of the questionnaire. Prior to data collection for the test-retest, theresearchers held an information seminar for the headnurses at the selected elderly care unit and another forall the staff at the selected unit in healthcare setting #2,which would be included in the main study. Informationflyers were also delivered to the unit to increase theawareness of the potential respondents about the study.The questionnaire, including the information letter withbackground information and instructions for completingthe questionnaire, were distributed to the total staff (119people) who were working during one specific shift atthe selected elderly care unit.All of the respondents received two copies due to thefact that researchers could not identify the sample population after delivering the questionnaires for follow-up.The questionnaire was handed out together with the instruction to answer the questionnaire twice with a maximum seven-day interval between the response days. APage 5 of 10total of 98 individuals (88%) filled out the questionnaireat least once while 68 people (61%) filled it out twice.The Cronbach’s alpha coefficients in this study ranged,for subscales, from 0.65 to 0.81. The items with the Spearman correlation coefficient for test-retest that ranged from0.6 to 0.91 were retained in the questionnaire. In thisphase, two items with low correlation coefficients (0.39and 0.50) were excluded from the questionnaire. The expert group gathered one more time and the items were reduced to 33 based on statistical results from phases IIIand IV.Phase VThe final validity and reliability testIn the last phase of constructing this questionnaire, all theremaining items were tested for validity and reliability. Atotal of 841 people out of 1016 (83%) who worked inhealthcare setting #2 in Stockholm participated in thisstudy; 85% of those were care-providing staff (nurses,physiotherapists, doctors, and psychologists). Mangers distributed the questionnaires and respondents depositedthem in a box provided for this purpose. The unit selectedfor the test-retest study was excluded from participating inthe main study. The percentage of females was 83.9% and47.5% of them had been born in a country other thanSweden (see Table 1).A validity test was done by means of principle factoranalysis for all items remaining in the questionnaire.After communality check and KMO analysis (cut-off0.6), some items were dropped from the questionnaireand 26 items remained for final factor analysis. Theresult of the factor analysis for evaluating dimensionalityof the items indicated six factors among the 26 items(Table 2). The KMO was 0.82 for all items and theTable 1 Demographic characteristics of the samplepopulatio
RESEARCH ARTICLE Open Access Constructing a questionnaire for assessment of awareness and acceptance of diversity in healthcare institutions Azita Emami1,2† and Jalal Safipour3*† Abstract Background: To develop a healthcare environment that is congruent with diversity among care providers and care
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