The Annotated Bibliography includes 5 nursing theories.
Please write in master level
Need nursing knowledge.
Annotated Bibliography
Amber
NR501
Dr.Lipps
February 2, 2022
Health Belief Model: Kocoglu‐Tanyer, Dengiz, K. S., & Sacikara, Z. (2020). Development and psychometric properties of the public attitude towards vaccination scale – Health belief model. Journal of Advanced Nursing, 76(6), 1458–1468.
https://doi.org/10.1111/jan.14349
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Summarize the article.
· Describe how the article relates to the chosen theory/model.
· Reflect on how the article could (or could not) be relevant to future Family Nurse Practitioner practice.
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Social Cognitive Theory: Plotnikoff RC, Lubans DR, Penfold CM, Courneya KS. Testing the utility of three social‐cognitive models for predicting objective and self‐report physical activity in adults with type 2 diabetes. British Journal of Health Psychology. 2014 05;19(2):329-46.
· Summarize the article.
· Describe how the article relates to the chosen theory/model.
· Reflect on how the article could (or could not) be relevant to future Family Nurse Practitioner practice.
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Transtheoretical Model of Behavioral Change: Selçuk‐Tosun, & Zincir, H. (2019). The effect of a transtheoretical model–based motivational interview on self‐efficacy, metabolic control, and health behaviour in adults with type 2 diabetes mellitus: A randomized controlled trial. International Journal of Nursing Practice, 25(4), e12742–n/a.
https://doi.org/10.1111/ijn.12742
· Summarize the article.
· Describe how the article relates to the chosen theory/model.
· Reflect on how the article could (or could not) be relevant to future Family Nurse Practitioner practice.
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Family Systems Theory: Pratt, K. J., & Skelton, J. A. (2018). Family Functioning and Childhood Obesity Treatment: A Family Systems Theory-Informed Approach. Academic Pediatrics, 18(6), 620–627.
https://doi-org.chamberlainuniversity.idm.oclc.org/10.1016/j.acap.2018.04.001
· Summarize the article.
· Describe how the article relates to the chosen theory/model.
· Reflect on how the article could (or could not) be relevant to future Family Nurse Practitioner practice.
Family Assessment and Intervention Model: Aass, Skundberg-Kletthagen, H., Schrøder, A., & Moen, Ø. L. (2020). Young Adults and Their Families Living With Mental Illness: Evaluation of the Usefulness of Family-Centered Support Conversations in Community Mental Health care Settings. Journal of Family Nursing, 26(4), 302–314. https://doi.org/10.1177/1074840720964397
· Summarize the article.
· Describe how the article relates to the chosen theory/model.
· Reflect on how the article could (or could not) be relevant to future Family Nurse Practitioner practice.
<<b>b>Testing the utility of three social‐cognitive models for predicting objective and self‐report physical activity in adults with type 2 diabetes
Plotnikoff, Ronald C;
Lubans, David R; Penfold, Chris M; Courneya, Kerry S.British Journal of Health Psychology; Leicester Vol. 19, Iss. 2, (May 2014): 329-346. DOI:10.1111/bjhp.12085
Objective
Theory‐based interventions to promote physical activity (PA) are more effective than atheoretical approaches; however, the comparative utility of theoretical models is rarely tested in longitudinal designs with multiple time points. Further, there is limited research that has simultaneously tested social‐cognitive models with self‐report and objective PA measures. The primary aim of this study was to test the predictive ability of three theoretical models (social cognitive theory, theory of planned behaviour, and protection motivation theory) in explaining PA behaviour.
s
Participants were adults with type 2 diabetes (n = 287, 53.8% males, mean age = 61.6 ± 11.8 years). Theoretical constructs across the three theories were tested to prospectively predict PA behaviour (objective and self‐report) across three 6‐month time intervals (baseline–6, 6–12, 12–18 months) using structural equation modelling. PA outcomes were steps/3 days (objective) and minutes of MET‐weighted PA/week (self‐report).
The mean proportion of variance in PA explained by these models was 6.5% for objective PA and 8.8% for self‐report PA. Direct pathways to PA outcomes were stronger for self‐report compared with objective PA.
s
These theories explained a small proportion of the variance in longitudinal PA studies. Theory development to guide interventions for increasing and maintaining PA in adults with type 2 diabetes requires further research with objective measures. Theory integration across social‐cognitive models and the inclusion of ecological levels are recommended to further explain PA behaviour change in this population.
The aim of this study was to evaluate the usefulness of Family-Centered Support Conversations (FCSC) offered in community mental health care in Norway to young adults and their families experiencing mental illness. The FCSC is a family nursing intervention based on the Calgary Family Assessment and Intervention Models and the Illness Beliefs Model and is focused on how family members can be supportive to each other, how to identify strengths and resources of the family, and how to share and reflect on the experiences of everyday life together while living with mental illness. Interviews were conducted with young adults and their family members in Norway who had received the FCSC intervention and were analyzed using phenomenography. Two descriptive categories were identified: “Facilitating the sharing of reflections about everyday life” and “Possibility of change in everyday life.” The family nursing conversations about family structure and function in the context of mental illness allowed families to find new meanings and possibilities in everyday life. Health care professionals can play an important role in facilitating a safe environment for young adults and their families to talk openly about the experience of living with and managing mental illness.
Keywords
Being diagnosed with mental illness often has a negative impact on many aspects of a young adult’s life including decreased self-esteem, optimism, confidence, as well as difficulties concentrating and carrying out daily taken for granted tasks (
McCann et al.,
2012
). In addition, young adults experiencing mental illness face the developmental challenges of emerging adulthood that include making the transition from living with, to living apart from parents; obtaining education or vocational training; making their way into the workforce; and finding a life partner (
Arnett et al., 2014
). Being a family member who is caring for a young adult with mental illness can be a highly positive experience through the provision of empathy, love, and support; it may also entail burden and difficulties (Ewertzon, 2015).
Young adults living with mental illness need support from their family as they strive to find healing and recovery; family members unquestionably play a key role in supporting the young adult’s pathway to recovery (Aass et al., 2020;
Lindgren et al., 2015
). Parents of young adults describe involvement in informal and professional mental health care as an isolated involvement with lack of being informed, seen, or acknowledged by health professionals (Andershed et al., 2017). Parents and adult children suffering from long-term mental illness describe dependency and influencing each other’s lives. Nevertheless, parents experience being excluded from care, simultaneously being taken for granted and expected to contribute to the care (
Johansson et al., 2014
). Relatives of inpatients with depression report that health problems, burdens, and worries in everyday life are challenging (Skundberg-Kletthagen et al., 2014). Their lives are often very intertwined with the life of their severely mentally ill family member (Weimand et al., 2010). The well-being of siblings of an individual with a severe mental disorder like psychosis has also been shown to be negatively affected as they experience challenges in relation to be a sibling (Ewertzon et al., 2012).
The range of services for young adults with mental illness in Norway is split among administrative levels. The municipalities have a legal obligation and responsibility for young adults with mental health and mental illness. The regular general practitioner (GP) service in the primary health service plays a key role as a “gate-keeper” of other services and welfare. Community mental health services are staffed by health care professionals such as nurses, social workers, social educators, and occupational therapists. A number of them have supplementary education in mental illness so that they have a preventive role and can offer treatment and follow-up to young adults with mental illness. The importance of involving and acknowledging family as a resource in treatment and care is emphasized (Aass et al., 2020; Schröder et al., 2007; Weimand, 2012) as well as the implementation of strengths-based approaches (
Gottlieb, 2013
). Studies have found that approximately 18%–34% of young people with high levels of depression or anxiety symptoms seek professional help. Research about this population reports perceived stigma and embarrassment, problems recognizing symptoms, and a preference for self-reliance as barriers for help-seeking (
Gulliver et al., 2010
). However, insufficient attention has been paid to the care that young adults receive once they are in the health care system (
Stroud et al., 2015
). Interventions which focus on interactions and the family as a resource for offering unique skills, strengths, resources, and unmet needs are needed. These kinds of interventions may facilitate the experience of mental health treatment and care (
Goudreau et al.,
2006
;
Tedeschi & Kilmer, 2005
) and increase knowledge and the coping abilities of families (Chesla, 2010). As community-services often rely on the commitment of families and their coping capacity, families should be assessed regularly to ensure that they benefit from the necessary support, education, and provision of resources (
World Health Organization, 2013
).
The families in this study participated in three Family-Centered Support Conversations (FCSC). The FCSC is theoretical grounded in Wright and Leahey’s Calgary Family Assessment Model (CFAM) and Calgary Family Intervention Model (CFIM) which are strengths-oriented family nursing assessment and intervention models for families living with illness (Shajani & Snell, 2019;
Wright & Leahey, 2013
). The Illness Beliefs Model (IBM;
Wright & Bell, 2009
) also guided the FCSC and is based on the principle that it is not necessarily the illness itself, but rather the beliefs about the illness that are potentially the greatest source of individual and family suffering. Emphasis must be placed on recognizing that families, as well as health care professionals, have beliefs that both facilitate and constrain their lives, relationships, behavior, suffering, and healing (Wright & Bell, 2009).
Previous family nursing intervention studies have been conducted with individual and group psycho-educational training, tasks, and therapeutic conversations combined with family interviews involving family members of adolescents and young adults with eating disorders and attention-deficit hyperactivity disorder (ADHD) in a hospital unit. Findings revealed improvement and differences in caregivers’ emotional and cognitive support, illness beliefs, emotional functioning, caregiving demands and caregivers, and patient behavioral difficulties (Gísladóttir et al., 2017) and better quality of life and social functioning for caregivers (Gísladóttir & Svavarsdóttir, 2017). Intervention studies with patients and family members in acute psychiatric hospital units, who received family nursing conversations focused on family strengths, reported that family members perceived significant higher emotional and cognitive support after the intervention (Sveinbjarnardóttir et al., 2013). In addition, benefits were observed in families of young people living with severe mental illness regarding revisiting and building new connections among family members, and strengthening and supporting the family network (Sveinbjarnardóttir & Svavarsdóttir, 2019).These family nursing intervention studies were guided by the CFAM and CFIM and/or the IBM as the theoretical framework to inform the interventions offered (Gísladóttir et al., 2017; Gísladóttir & Svavarsdóttir, 2017; Svavarsdóttir et al., 2019; Sveinbjarnardóttir et al., 2013; Sveinbjarnardóttir & Svavarsdóttir, 2019). Nevertheless, to our knowledge, strengths-oriented family support conversation studies with young adults and their family as the unit of care in community mental health services have only been reported to a limited extent. Moreover, interventions need to be explicitly tested in young adults because they can be influenced by many factors includingthechallengesofemergingadulthood, maneuvering developmental transitions, and adjusting to adult mental health care (Lindgren et al., 2015). Therefore, knowledge from this study can provide direction about how to meet young adults and the family’s needs and will also help to expand information about family focused care for this population of families nationally and internationally.
This intervention study used an explorative qualitative design with a phenomenographic approach (Marton, 1988). Phenomenography was chosen to incorporate variety and differences in how the phenomenon was experienced, conceived, and captured at the family level. In this study, we endeavored to capture data at the family level to identify multiple perspectives and focus on the family as a unit. Phenomenographytakesasecond-orderperspective, meaning that it offers different ways of conceiving the phenomenon that are of interest and how it is described (Marton & Booth, 1997). In this study, the phenomena was the family members’ experiences of receiving the FCSC intervention.
Recruitment of Participants
The focus of this study was on families living with mental illness of a young adult family member where family was a self-identified group of two or more individuals who were or were not related by legal or blood relationships and who functioned in such a way that they considered themselves to be a family (Whall, 1986). Health care professionals recruited patients who were young adults living with mental illness in urban and rural communities and asked them both verbally and in writing to participate, both in the family conversation and in a follow-up family research interview. Family members (one or two) were recruited through the young adult patient who asked his or her family members to participate in the study. Family members then gave the patient permission to submit their name and telephone number to health care professionals. Both the patient and the family members gave oral and written consent (
International Committee of Medical Journal Editors, 2018
).
Inclusion criteria for patients: aged 18−25 years, facing mental illness and strain, impaired function associated with distress, symptoms, and diagnosable mental disorders; living alone or with family and/or friends and/or others; could speak and read Norwegian; and had contact with community health services related to mental illness. Exclusion criteria for patients included cognitive impairment; psychotic state; active alcohol or drug abuse; or living in a residential home for persons suffering from mental illness.
Family members over 18 years old who were defined by the young adult to be part of the family, and who were able to speak and read Norwegian. This study excluded family members who showed evidence of cognitive impairment, psychosis, or active alcohol or drug abuse.
FCSC included the young adult who was suffering from illness, those designated as belonging to his or her family, and a mental health care professional. Operationalized within a non-hierarchical therapeutic relationship, three conversations with each family were conducted by the same mental health care professionals that include a psychiatric nurse, social worker, and social educator with advanced training in mental health. The goals of the FCSC were to (a) shift the focus from a deficit- or dysfunction-based family assessment to a strengths- and resource-based family conversation including those persons who were important in the patient’s life and (b) recognize that family members serve a variety of roles including advocate, care provider, trusted companion, and surrogate decision maker (
Levine & Zuckerman, 1999
; Wright & Leahey, 2013). The mental health care professionals involved in this study had completed a 2-day educational program on family assessment and intervention as well as skills training with different clinical vignettes from mental illness care (Benzeinetal.,2012; Sveinbjarnardóttir et al., 2011; Wright & Bell, 2009; Wright & Leahey, 2013).
Each family member was invited to relate their narrative about their experiences and beliefs in relation to everyday life. Family structure, development, and function were explored and assessed to later reflect on these aspects of family functioning, and the strengths and resources that can have an impact on everyday family life (Benzein et al., 2015; Gísladóttir & Svavarsdóttir, 2011; Wright & Leahey, 2013).
The focus of the second session was on cognitive, affective, and behavioral domains of family functioning and strengths and resources within and outside the family. The impact of problems/illness on the family was assessed. Problem-solving skills, coping strategies, and strengths were elicited, and change invited. Aspects of family functioning, strengths, and resources within and outside the family were reflected on.
The focus of the third session was on families’ experience of everyday life and support strategies for the future. Families were commended for their and individual strengths, competencies, and resources. While three conversations are recommended, the health care professional must evaluate if families need more than three conversations (Benzein et al., 2008, 2012). If families needed additional support conversations, they were free to contact the mental health care professionals.
Family research interviews with open-ended questions were conducted with each of the seven families who received the FCSC intervention. Data were collected 1 to 2 months after the FCSC was completed. The families were allowed to narrate freely about their experience of the FCSC. The initial research interview question asked was: “You have participated in three FCSC. How did you experience the FCSC?” The focus was on how the conversations were experienced and what was experienced. To gain a deeper sense of the experiences, follow-up questions were asked such as: how? who? can you tell more? what do you mean? is it always so? to elicit a richer and more detailed description, and further questions were adjusted to the participants’ response. In each family research interview, consideration was given to the developmental level of the patient (Donalek, 2009) who was asked first to talk about his or her experiences in a relaxed and accepting atmosphere, giving the patient time and space to answer questions, and focusing the conversation in the direction of the phenomenon (Lepp & Ringsberg, 2002). When the patient had no more to say or was reluctant to answer, the family members were asked the same questions. Throughout the family research interview, the dialogue alternated between the family and the interviewer asking questions. The family research interviews were conducted by the first author and took place either at the family’s home, at the mental health care service office, or the university according to the wishes of the participants. Notably, one patient and a partner who participated in the FCSC did not participate in the family research interview due to private concerns. The interviews lasted 50−65 min and were audio-taped and transcribed verbatim by the first author.
Ethical considerations and guidelines with respect to confidentiality, integrity, and the voluntary participation of the participants were followed throughout the study (International Committee of Medical Journal Editors, 2018;
World Medical Association, 2001
). Both the patient and family members received written and oral information and gave their written consent. They were informed that the material would be treated confidentially. The patient gave written informed consent for the publication of patient information (International Committee of Medical Journal Editors, 2018). The Regional Committee for Medical & Health Research Ethics (REC) found the Research Project, Ref: 2017/717, to be outside the remit of the Norwegian Act on Medical and Health Research) and the project could therefore be implemented without its approval. Approval was given by the Data Protection Official for Research (NSD), June 2017, Ref: 54696.
The data were analyzed as a “pool of meanings” (Marton & Booth, 1997) inspired by
Dahlgren and Fallsbergs’ (1991)
steps for analyzing phenomenography studies: (a) Familiarization—the researcher read through the transcripts to become familiar with all the details and establish an overall impression of the data; (b) Condensation—the most significant statements made by the families concerning the phenomenon were condensed to give a short but representative version of the entire dialog; (c) Comparison—significant conceptions were compared to find sources of variation and agreements in how the phenomenon were experienced; (d) Grouping—concepts appearing to be similar were grouped together; (e) Articulating—a preliminary attempt was made to describe the essence of the similarity within each group of concepts; (f) Labeling—descriptive categories were labeled based on findings of suitable linguistic expressions; and (g) Contrasting—description categories were compared to ensure that each category was mutually exclusive and at the same level. The last three steps were repeated several times. The outcome space refers to a horizontal structure in which the descriptive categories reflect the distinctions of the FCSC.
Research Participants
A sample of 19 family members from seven families participated in the FCSC with mental health care professionals in four different municipalities in Norway in the period from December 2017–May 2018. Out of the 19 family members, 17 consented to participate in family research interviews. The sample represented variation with respect to age, gender, education, and occupation (see
Table 1
). Mental illness among the young adults ranged from depression and anxiety distress or disorders, personality disorders, ADHD, and eating disorders.
Table 1. Participating Young Adults and Family Members.
Table 1. Participating Young Adults and Family Members.
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The findings describe the families’ experiences of FCSC under two descriptive categories, “
” and “Possibility of change in everyday life.” The descriptive categories embody five concepts that comprise the outcome space (Marton & Booth, 1997) (
Table 2
).
Table 2. Experiences of the Usefulness of the Family-Centered Support Conversations: The Perspectives of Young Adults and Their Families Living With Mental Illness.
Table 2. Experiences of the Usefulness of the Family-Centered Support Conversations: The Perspectives of Young Adults and Their Families Living With Mental Illness.
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Facilitating sharing reflections on everyday life
The FCSC facilitated an opportunity to share and reflect on the family’s beliefs on the past, present, and future of everyday family life related to symptoms, problems, challenges, worries, and hopes. This descriptive category includes three concepts: the unfamiliar conversations, a team with mutual understanding, and experiencing a change in the patient approach. The category describes the FCSC in regard to potential benefit for individuals and family, state of consciousness, and degree of confidence after reflecting on everyday family life together with a mental health care professional.
How the families experienced the FCSC varied, and for most, it was a new experience, perceived as strange, unpleasant, and uncomfortable but also positive, beneficial, and safe. The patients, who were used to having conversations with mental health care professionals alone, described the FCSC as strange and unpleasant. One patient said, “It’s a bit strange because I don’t usually talk about these things with my mother.” Some of the patient’s symptoms, strain, and difficult thoughts had never been shared with the family prior to the FCSC because it was too hard to talk about. However, when struggling to explain, reveal, and talk with the family about difficult topics such as how mental illness, decreased confidence, and self-esteem affected them in everyday life, the patients were reassured by the presence of the mental health care professional. A patient said, “It’s been almost taboo. I’ve hardly ever wanted to talk about it. So, it was good that she (health care professional) was in charge, then we talked about it.” Other families stated that after each session they talked about how good they felt about the conversations.
The topics of discussion varied within the three conversations and experienced by some as being defined by others or occurring randomly. They talked about how the situation was at the moment, how things had been and what thoughts they had about the future. Sharing thoughts was described as useful and informative, and dwelling on each other’s experience enabled them to see the situation from other angles. One father said, “We realized that we maybe hadn’t understood how bad it really is for A . . . We found out how difficult it is for her through the conversations with the health care professional.” Listening to the patient’s description of everyday life was experienced as painful and surprising, and as a moment of new realization. Prior to the FCSC, they did not know how seriously the patients were affected by mental illness, and what the patient needed in situations that trigger severe symptoms. A father said,
It was much worse than we thought. A bit surprising but good to hear. If the family is going to the store, for example, and she is coming along, she has to be prepared. It can take half an hour till she’s ready to leave. We didn’t understand why she didn’t come in, and we nagged a lot sometimes. We weren’t aware that she had to have this time for preparation . . .
However, for some family members, the FCSC did not lead to new understanding but was a repetition of what they had been through because they had discussed the topics in the conversations beforehand and dealt with them thoroughly. Others described having to “speak loudly” in a sharp tone to make their opinions on how to interact with their patient heard. The justification for this was that they live with them and know what works and does not work concerning symptoms and behavior in everyday life related to the patient’s mental illness.
Topics that family members earlier did not dare to bring up or mention to the patient because they were afraid of stepping too close were naturally brought up and talked about in the FCSC. One mother talked about how she experienced that the patient excluded her from information. She did not know anything about the mental health status or the care process, which led to self-interpretation and conclusions based on assumptions and worrying.
The patients were familiar with most of what the family members shared in the conversations, such as concerns regarding the patient being suicidal, having severe anxiety and being depressed, as well as concerns about education, getting to work, and even keeping a job.
Meetings concerning the patient’s mental health issues with the general practitioner physician, therapist, and social security officer at the Labor and Welfare Service were familiar. However, the families described attending few conversations with focus on family strengths, resources, and support with mental health professionals prior to the FCSC. They described being able to speak honestly and sincerely about emotions and thoughts regarding situations in the past concerning family everyday life for the first time. One mother shared how she felt when the patient had been seriously ill and hospitalized and excluded the family from being informed. The families sorely desired collaboration with the health care professionals, with the aim of working in the same direction. Still they experienced the opposite. A mother said,
We as a family and the help we give A works to a certain extent if the team around us work in the same way. However, when the team don`t work with us but against us, they actually do a lot more damage.
Family members emphasized that they sense when symptoms worsen, but the patients often deny or answer their concerns dishonestly. They do not have to share everything but struggling must be talked about to be able to be supportive. According to one mother, “. . . I ask and then ‘Yes, yes, I`m alright,’ but maybe it’s not alright. I can see it, but each time I ask, she replies, ‘I’m tired’.” A patient said, “I don’t like people knowing too much about me. I want to deal with things myself, not be seen as different.” Getting a third person’s view was helpful in relation to how the patient’s mental illness affects the management of daily activities such as getting to work. A patient replied, “Yes, I also found it a bit reassuring because NN (mental health care professional) could explain to my mother and boyfriend how things were. I’m not always good at explaining and saying things.” The intervention made it possible for family members to learn how they can approve, support, and help, thereby enabling the family members to enlighten each other and mental health care professionals on what works when living with mental illness. One mother experienced becoming aware of how to communicate so that misunderstandings do not occur, and the importance of giving positive feedback and praise. One stepfather said, “He has apparently not appreciated boundaries in relation to us . . . but in one of this meetings he admitted he actually appreciated some boundaries.”
The patients described being absent minded or distracted and perceiving no more than one third of what was going on in conversations and not always being able to explain and express needs. Therefore, it was important to have family members present to help grasp what was said. Others stated that they did not pay attention when family members spoke to health care professionals. Notably, not having all the family present in conversations was seen as a drawback. A mother said, “No, if it’s going to be of any use, I think the four of us have to talk together. That is, if we as a family are to benefit from it”.
The families described mental health care professionals asking several questions concerning how the families were coping at home. In addition to being concerned about the patient, mental health care professionals were sincerely concerned about family members’ time for each other and for taking care of their own relationships. The mental health care professionals described bringing forth strengths and resources within the family through mapping and reflecting on actions and activities they perform in everyday life. One mother said, “He wondered about what you do when things are going well, kind of . . .? What did you do then? What happened that day? And what is good about those days? Both NN (patient) and we were asked that question.”
Mental health care professionals were described as seeking approval from the patients regarding the sharing of information although the latter had given them oral and written consent to access family members’ insights into health information. A father said,
The so-called data protection in psychiatry is a drawback. If NN (patient) had told that I am not supposed to know things, that would be ok for me. That’s something else, but NN (patient) wants to be open and wants us parents to help him, but still mental health care professionals hold back.
Family members said that they urged the mental health care professional to listen to them. Thus, the FCSC had some significance in that health care professionals gained greater understanding through listening to the family describing how they were functioning at home.
The families perceived that mental health care professional focused on statements the family disagreed on and asked for clarification before they moved on. The mental health care professionals commenced the dialogs with a couple of questions and did not interrupt if the conversation flowed freely, so the families experienced the topics as a bit random. Others experienced setting goals from the first, second, and third conversation, so that it was not random in that there was an overall emphasis on positive activities, that is, a focus on things they did well. A mother reported, “We kind of agreed on setting some goals from one meeting to the next. That we should try out whatever made things better.” The health care professionals gave information on health care support and actions aiming to unburden the family as well as suggestions as to how families could solve problems in everyday life, which was perceived as positive. A mother said, “I do know we talked about remedial actions for A. What NN (health care professional) could help us with as regards applying for respite care in order to give us some relief.”
This descriptive category includes two concepts: awareness of strengths and resources and support in everyday life on regular basis. Mapping the family as a whole facilitated the development of new meanings and possibilities and unwrapped strengths, competence, and skills. In addition, it promoted preparedness to deal with everyday life and put in place support strategies for the future.
Mapping the family roles, interaction and functioning within the families was experienced as valuable. In practical terms, this meant assessing who is in the family and how those individuals’ function within the family. Some families developed a diagram of the two-generation family genogram (family tree), while others did the family mapping through spoken dialogue. The family mapping revealed how the patients position themselves and other family members. A patient said, “I put myself as far out as possible because I don’t want to be in the way,” and the father replied, “. . . NN drew me as the core” . . . then he put himself as far out as possible on the tip of a branch . . .”
The family mapping was experienced as a moment of realization because the family members had not previously considered the connections between themselves in that way. Mapping was experienced as giving both the family and mental health care professional’s insight and the opportunity to become acquainted with or conscious of unspoken realities.
Regardless of whether it entailed drawing the family tree or just talking about who is in the family and how they function, family mapping was described as beneficial due to the family becoming more aware of what they meant to each other and did together, because when things went wrong, the feeling of remorse often cast a shadow over everything. A mother said, “It’s pretty useful to go over it and see that we actually do positive things too, which is good.” Awareness of interactions within the family and own reactions when things went wrong or there was a conflict was the subject of discussion, and importantly, this had rarely been discussed before. One mother described becoming aware of whether they paid each other respect or took each other into account.
Families described doing the best they could based on their assumptions. They learned to emphasize the importance of giving the patients approval for things they achieved rather than focus on problems when they did not cope. Others knew already that the whole family functioned as a team with strengths and resources.
The patients found it easier to speak exclusively with mental health care professionals who were involved in their care. They reported that mental health care professionals viewed things differently than family members who saw them daily. Yet family involvement in care was worth having. A patient stated, “Think there should be more conversations. As mentioned, in everyday life the effect fades away after a while. No, I feel as if there’s not much talk of it anymore. Things return to the usual, old routines.” Further contact with mental health care professionals was also desirable for family members, who missed having someone to talk to when they came up short in supporting their ill family member. Family members described being in need of guidance on issues concerning themselves being at work, worrying about the patient who was home alone—potentially suicidal and not getting to work. Others felt it was up to the patient to decide together with the mental health care professional when family should take part in future conversations, despite the fact that the mental health care professional had told family members to get in touch when they wanted another meeting.
Family members expressed a need for the patient to live close to the family because it provided a feeling of being safe and supported. However, mental health care professionals emphasized the importance of the patient being as independent as possible to tackle everyday life in the future with extra support and help from the health care services in daily activities. Both the mental health care professionals and the family felt that progress had been made during the FCSC. The families described patients as being in a better state of mental health and function level now than 2−3 years ago. A mother stated, “I feel you have come quite a long way, that you are in better health now. In any case, we have a completely different starting point now.” Nevertheless, the families stressed the value of mental health care professionals asking if they could contribute with help and support, even though the families did not necessarily need this.
The aim of this study was to explore how young adult patients living with mental illness and their families experienced the FCSC. Findings highlighted the families’ desire to be included in mental health care through FCSC that focused on how to be supportive and acknowledged family strengths and resources. Sharing beliefs about everyday life and assessing and reflecting on family function and structure facilitated new meanings and possibilities in everyday life. Mental health care professionals play an important role in facilitating a safe environment for sharing in a non-hierarchical and co-creating relationship.
Facilitating Shared Reflections on Everyday Life
The findings of this study highlighted that on the one hand that patients wanted to include their family in the FCSC to achieve increased understanding, while still dealing with things on their own; on the other hand, they feared to be looked upon differently, resulting in their concealment of certain aspects of mental illness in daily living. Significantly, it was challenging for the patients to talk to family about difficult and taboo topics such as how mental illness affected them—at school, at work, and in social life—and their decreased confidence and self-esteem. However, with mental health care professionals by their side, the patients in this study felt more confident about including family members and disclosing their problems.
Moen et al. (2014)
similarly describe family members valuing a neutral third person leading the discussion and ensuring that they kept to the subject. This indicates that mental health care professionals build trustful relationships with the patient and family members, framing family support conversations as a safe arena. Sveinbjarnardóttir and Svavarsdóttir (2019) assert that mental health care professionals who have the knowledge, training, and capacity to build a partnership with the family as the unit of care can improve patient services.
According to
Woodgate et al. (2017)
, disclosure or non-disclosure is often grounded in the fear of being stigmatized, treated differently, and/or fear of being rejected by their family. Even though it was hard, disclosure enabled understanding and acceptance from the family and facilitated a dialogue about how to best help and support the patient. The findings of Schröder et al. (2006) indicate that de-dramatizing mental illness reduces or avoids stigmatization of the person with mental illness. On the one hand, disclosure made family members realize shortcomings in their own understanding due to exclusion or concealment. This was also painful because they became aware of how much the patient was struggling to manage everyday life. On the other hand, family members had the opportunity to get answers to issues they did not know about or to questions they had not dared to ask earlier. Stengård and Appelqvist-Schmidlechner (2010) and Woodgate et al. (2017) similarly describe how patients living with mental illness often seem to underestimate the need for help from others and try to deal with their problems on their own, experiencing difficulty communicating their thoughts at times. They expressed the need for additional pathways to share how they feel.
In Norway, the age of majority is 18 years and, from that point on, an individual can decide whether family members are to be given information regarding one’s health issues (
Ministry of Health and Care Services, 1999
). Family members in this study emphasized that the patient does not have to tell them everything, but it is important to share symptoms, status of illness and suffering, as it enables them to give help and support. Similarly, Andershed et al. (2017) found parents’ need to know about symptoms, the illness, the illness trajectory, and treatment and how to read and understand signs of suffering.
How health care professionals relate and listen has implications for families and matters to them (Wright & Leahey, 2013). Families in this study experienced that mental health care professionals were concerned about how the families were doing at home, whether family members had time for each other and took care of their relationships as well as the patient’s health well-being. This is in contrast to Weimand and colleagues (2011) who found family members reported not being seen, listened to, or understood in mental health and psychiatric in- and outpatient care. Interpersonal relationships and good communication between health care professionals, patient, and family members are key factors in quality of care from the perspective of family members (Schröder et al., 2007). According to
Freire (2018)
, families and health care professionals who encounter each other in dialogic relationships are equally partners, aiming for mutual understanding and finding new words to describe reality, thus enabling change. A dialogical approach is related to and dependent on humility, faith in humans, trust, hope, and critical thinking. According to the CFAM (Wright & Leahey, 2013), the relationship between the mental health care professionals and families is characterized as non-hierarchical and a co-creating of reality. Nevertheless, this study supported the earlier findings of Ewertzon et al. (2010) that cooperation between staff and family members was problematic in the sense that families experienced that their opinion on how to best interact with the patient was not valued. To build a family–nurse relationship,
Wright and Leahey (2013)
recommend it is useful for health care professionals to reflect on his or her contribution to the therapeutic relationship before meeting with the family and, at the end of the meeting, to invite the family’s reflections about the family–nurse relationship.
A growing body of literature emphasizes the importance of exploring beliefs that shape individual and family narratives of everyday life when living with illness and coping strategies within families (
Bell & Wright, 2011
; Wright & Bell, 2009). Personal narratives and reflections are significant and joined closely together and are intended to facilitate the appearance of new beliefs and the discovery of alternatives or new meanings that can have an impact (Benzein et al., 2015). Findings showed that beliefs appeared in the family’s narratives, evolving through their history together as a family and revealed when others could confirm and give further examples. Similar to
Wright and Bell (2009)
, we found that understanding beliefs develops in interaction with others over time; however, beliefs are not static and evolve like nurses and families do. In addition, the revealing of new beliefs made acceptance for mutual realities possible and increased understanding for each other’s perspectives on everyday life. This was significant, not only for the families but also for the mental health care professionals. Benzein et al. (2008) suggests that health care professionals’ task is to listen to what the families really says and not what the health care professionals think the families says or means. In this way, health care professionals can take a participatory position in the conversation rather than an influencing one. Families in this study reported that their own beliefs were respected and viewed as equally legitimate by mental health care professionals. However, some experienced that mental health care professionals were more concerned about protecting the patient’s legal rights regarding confidentiality. According to Weimand and colleagues (2013), the trusting alliance between nurse and patient is governed by confidentiality and respect for the patients’ autonomy (
Dreyer & Strom, 2019
). Mental health care professionals were perceived to be continuously seeking approval from the patients regarding sharing information, despite the latter having given consent. This indicates that mental health care professionals are afraid of acting illegally (Weimand et al., 2013), or misunderstand the law of confidentiality, resulting in barriers for collaboration between families and professionals (Aass et al., 2020;
Solomon et al., 2012
). Notably, the FCSC were significant in the sense that mental health care professionals showed increased understanding of family everyday life after listening to the family’s narratives. Confidentiality protects the patient but can also be viewed as an obstacle preventing relatives receiving information and participating in care (Schröder et al., 2007). Even though confidentiality makes it difficult for mental health care professionals to talk to family members, there is some scope within statutory regulations that enables a kind of transparency and does not prohibit health care professionals from listening to the family (Weimand et al., 2011).
Findings revealed that assessing family roles, interaction, and function either through visualization of a family genogram or through a spoken dialogue facilitated the process of self-reflection and opened up for a new understanding and awareness of what family members meant to each other. According to Wright and Bell (2009), the process of self-reflection is essential to the co-evolution of new, more facilitating beliefs, meanings, and opportunities. In this study, the use of a structural assessment tool like a genogram seemed to have significance for visualizing and facilitating reflections of family positions and hierarchy, who participates in everyday life, and how communication, emotions, and interactions influenced family behaviors. Wright and Leahey (2013) state that the purpose of the genogram is to describe and understand family members’ relationships with each other; however, the visual impact of the genogram on families seems to concretize these family connections in a new and meaningful way. The families in this study described family deficits, strengths, and resources and became more aware of not only how they interact and activities they do together but also what they meant to each other. When health care professionals focused on strengths, the families reported that it was good to hear that they were doing something right.
Gottlieb (2013)
describes a focus on strengths as helping families to see themselves in a new light. When health care professionals adopt a salutogenic approach, opportunities and resources rather than deficits are emphasized (Benzein & Saveman, 2008; Langeland, 2014). Nevertheless, mental health care programs for youths often tend to focus on what is going wrong in families rather than what is going right and fail to see and appreciate the family’s strengths and competencies. In addition, families are perceived as lacking ability to solve problems or cope without the help of the professional (Gottlieb, 2013). According to Stengård and Appelqvist-Schmidlechner (2010), this can have the potential of stigmatizing, undermining motivation, or discouraging young people from becoming involved in support programs.
The families agreed on the importance of proceeding with support-conversations with mental health care professionals as an arena for continuity of sharing and guidance. However, they did not agree on who should decide when and how often the conversations should occur. The patient and the mental health care professionals wanted family members to initiate meetings, while family members believed it was up to the patient, together with the mental health care professionals, to decide. Community services often rely on family commitment, support-capacity, and competencies (World Health Organization, 2013). Consequently, a family–mental health care professional relationship should include and be characterized by family and mental health care professionals each bringing expertise, strengths, and resources to the relationship and the valuing of reciprocal and non-hierarchical relationships where each person’s contribution is acknowledged and valued (Aass et al., 2020;
LeGrow & Rossen, 2005
).
Although the FCSC was intended to influence support in family everyday life, the specific outcome can never be predicted in advance. Families carry out their functions through their subsystems (Wright & Leahey, 2013), and findings in this study revealed that the inclusion of many family members was needed if the FCSC was to make an impact on everyday life. According to Wright and Leahey (2013), to be effective, there must be a fit between the intervention offered and the structure of the family. When fit is absent, there is a possibility of no effect. The families decided who participated in the FCSC and this varied across different persons at various times. Handling this with flexibility and adjusting to the family’s situation is recommended (Benzein et al., 2012). This underscores the importance of health care professionals assessing family functioning and structure and asking who is in the family and whether others should be invited (Wright & Leahey, 2013). Mental health care professionals should ensure a specific focus on family structure because it is insufficient to focus on a family everyday life situation with problem solving when the specific family structure is unknown (Wright & Leahey, 2013; Svavarsdottir & Gisladottir, 2019).
In this study, the four criteria offered by
Guba (1981)
were used to ensure trustworthiness. Credibility was strengthened by the sample of seven families ensuring variation in different ways of experiencing the phenomenon (Marton & Booth, 1997) and by the broad sample in terms of different family relationships, gender, and age, which gave rich descriptions (Sandelowski, 1986). Dependability was ensured by asking the families the same open-ended questions and gave the participants the opportunity to contribute experiences if they had not been covered during research interview. The first author carried out all the research interviews. To strengthen trustworthiness and authenticity, the authors have reported the findings with quotes from both patients and family members. Confirmability was enabled by establishing an “audit trail” (
Guba, 1981
) describing all steps in the analysis process. Analyzingfamilyresearchinterviewsinthis phenomenographic study was challenging because the experience of the therapeutic conversations was shared across multiple families. However, the involvement of all researchers in the analysis process was a strength. Transferability: We believe this study contributes relevant knowledge that may apply to other families within similar contexts. One possible weakness may be the risk of the interview reflecting the experiences of individuals rather than the family as a whole. However, data on both individual and family level were generated by focusing on the family as a unit. The family members in the study are distinct individuals yet they share a common history, strengths, and belief systems and have close contact with one another. Collecting data on a family level increases knowledge and the discovering of the shared family experiences and family meaning that emerge with an illness experience (Chesla, 1995; Eggenberger & Nelms, 2007). The assumption is that family experiences of the FCSC are the sum of the subjective views of each individual family member (Åstedt-Kurki et al., 2001). The families spoke openly in the interview situation and were willing to share their experiences with each other, even if their stories included new thoughts that the family had never discussed. Participating in family research interviews can be a beneficial learning experience for the family as they become more aware of each other’s beliefs and opinions. One limitation, however, could be if family members are not able or willing to be open and share their experiences with each other (Eggenberger & Nelms, 2007;
Moen et al., 2014
).
The research interviews included issues that were sensitive for the families. As a psychiatric nurse, the interviewer (first author) was skilled in talking to patients with mental illness and their families and was aware of the power balance in the interview (Marton & Booth, 1997).
Family conversations like the FCSC, which is theory-driven (Wright & Bell, 2009; Wright & Leahey, 2013), have a major strength in that they are based on research and previously tested, although to our knowledge not with young adults living with mental illness and their family. The FCSC in this study were examined in real-world community mental health settings and contribute to knowledge about family nursing intervention with this unique population of families.
This study extends knowledge about the usefulness of FCSC for families and their young adult child living with mental illness. From the participating families’ perspective, there is a desire to be included in mental health care through FCSC focusing on how to be supportive and identify family strengths and resources. One way to meet this need is to offer FCSC as a central complement to usual mental health care practice. The family participants benefit from listening to and reflecting on each other`s beliefs about their daily life and their family functioning. Mental health care professionals play an important role in facilitating a safe environment for sharing.
To acknowledge that mental illness is a family affair and thus focus on the family as the unit of care requires a conceptual shift, even a paradigm shift, by health care providers. Clinicians require specific knowledge and skills to enter into these important conversations with families living with mental illness. Resources such as the International Family Nursing Association (IFNA) Position Statements on Generalist Practice (
IFNA, 2015
) and Advanced Practice (
IFNA, 2017
) with families may be useful to guide the development of knowledge and skills necessary for family-centered practice. Further exploration is needed about the family beliefs about mental illness and how the family perceives support and the quality of care offered to them. Finally, this study should be followed by further research evaluating FCSC intervention with a larger sample size of families, with the inclusion of a comparison group, and conducting more mixed methods studies about the benefits of bringing the family together for family-centered conversations in the context of mental illness.
The effect of a transtheoretical model-based motivational interview on self-efficacy, metabolic control, and health behaviour in adults with type 2 diabetes mellitus: A randomized controlled trial
Abstract
: This study aimed to determine the effect of a transtheoretical model-based motivational interview method on self-efficacy, metabolic control, and health behaviour in adults with type 2 diabetes mellitus.
Methods: A randomized controlled study design was used. The study was conducted with 50 individuals with type 2 diabetes mellitus, divided into an intervention group and a control group. The researcher held motivational interviews with the patients in the intervention group. Both groups were observed at the beginning of the study and 6 months after the baseline interview. The study data were collected between January 8 and November 18, 2014.
Results: Comparing the intervention and the control groups, the differences in the level of self-efficacy and participants’ metabolic values were significant (P < .05). The number of participants in the action stage of the intervention group for nutrition, exercise, and medication use significantly increased compared with the control group (P < .05).
Conclusion: The transtheoretical model-based motivational interview method increased the self-efficacy level of participants with type 2 diabetes mellitus, which helped them improve their metabolic control and health behaviour stages over this 6-month period.
Family Functioning and Childhood Obesity Treatment: A Family Systems Theory-Informed Approach
ABSTRACT Childhood obesity recommendations advise providers to use family-based care for the treatment of youth and adolescent obesity. Family-based care, defined as the inclusion of a caregiver and a youth, is commonly conducted through behavioral interventions that target the dietary and physical activity behaviors of the attending parent-youth dyads. However, focusing on behaviors isolated to the parent and youth neglects the rest of the family members, and the larger rules, routines, communication, and dynamics in the family. Family-based interventions grounded in family systems theory (FST) target family dynamics to influence weight-related behaviors through higher-level changes in the family. The utility of using FST in childhood obesity treatment has not been extensively conceptualized or applied. Few outcome studies have reported on variables representative of FST, and even fewer FST interventions have been conducted. Because of the lack of detail on the application of FST to childhood obesity treatment, providers are left with little clarity on how to use FST in clinical encounters. We provide the background and evidence for use of FST, detail how families organize around weight-related behaviors that contribute to obesity, and on the basis of their organization, what type of treatment might be beneficial, FST-informed or family-based behavioral interventions. Finally, a suggested family-based clinical algorithm is provided detailing the use of FST through assessment, intervention, and follow-up that can be refined over time by providers and researchers committed to viewing obesity in the context of the family and family dynamics. KEYWORDS: family environment; family intervention; obesity; systems change; weight management; youth ACADEMIC PEDIATRICS 2018;18:620–627 Approximately one-third of youth and half of adults living in the United States are overweight or obese.1 Youth with 1 parent with obesity have a 2 to 3 times greater odds of becoming obese.2 The strong correlation between youth and parental obesity is evident in childhood obesity treatment, in which youth and parents experience congruent changes in their weight status.3,4 Because of the high prevalence of overweight and obesity, it is likely that many parent-youth dyads currently have or will develop obesity. In 2007, Barlow and colleagues developed expert committee recommendations,5 which state that providers should be family-based in their treatment of youth with obesity, focusing on weight-related behavior change, not just education. Family-based treatment typically involves a targeted caregiver (often a parent) and youth.5 Behavioral approaches to weight loss, primarily delivered through family-based behavioral therapy (FBBT), effectively produce weight loss and behavior change.6,7 Interventions using FBBT target youth and parents’ specific weight-related skills and behaviors including: monitoring, goal setting, rewards, problem-solving, behavioral contracting, and relapse prevention.8–10 FBBT interventions have shown robust short-11,12 and modest longterm (10-year) success.8 However, the homogeneous samples of middle to upper class, Caucasian, 2-parent families used in these studies challenge their generalizability to all families.8–10 Although FBBT interventions have shown some success, changing youth and/or parent behaviors has an unknown effect on the overall interpersonal dynamics of families in treatment. Family dynamics might have a reciprocal and WHAT’S NEW This report explores family functioning around weightrelated behaviors that might contribute to obesity, and if different treatment approaches might be beneficial for families: family systems theory-informed or familybased behavioral interventions. A family-based clinical algorithm detailing how family systems theory could be used in the assessment and study of childhood obesity is provided. ACADEMIC PEDIATRICS Copyright © 2018 by Academic Pediatric Association Volume 18, Number 6 620 August 2018 undetermined effect on the weight-related behaviors of youth and their family. Without addressing the dynamics among families, youths’ newly adopted behaviors might not be sustainable without reorganization of family routines, rules, and communication around weight-related (diet and physical activity) behaviors that contribute to obesity. FAMILY SYSTEMS THEORY AND CHILDHOOD OBESITY TREATMENT Family systems theory (FST) views the family as a complex, interacting system, and provides a framework for understanding family functioning as an “open, ongoing, goalseeking, self-regulating social system,13” with 4 basic assumptions: • Elements of a system are interconnected. • Systems are best viewed as a whole. • Environment interacts with the system in a feedback loop. • System is a heuristic model used for understanding, and is not reality. The tenets of FST include: families determine membership; subsystems exist, such as parent-child, spouse, and sibling relationships; families strive to maintain equilibrium; resources are needed for adaptation and change; existence of family rules; and likely the most important tenet describing behaviors, first- and second-order change. Firstorder change is how a family receives input from their surrounding environment. Second-order changes require the reorganization of rules and routines to make lasting firstorder changes and changes to the overall family environment. FST-based interventions expand the treatment plan beyond individual behaviors to the dynamics and relationships among family members.14 Relevant to childhood obesity, overall family dynamics around weight-related behaviors are targeted in treatment, either indirectly through FBBT, or inadvertently by engaging multiple family members in treatment.15,16 According to FST, change happens at the family level to influence overall family functioning and longterm individual behavioral change.17 Few researchers have conceptualized FST for the treatment of childhood obesity,15–18 and fewer yet have designed interventions to evaluate outcomes consistent with FST.19,20 Exploration of FST-based treatment is warranted, because it has been used in disease states for which adherence is vital to positive health outcomes, such as substance use,21 HIV,22 and type 1 diabetes mellitus.23–26 Additionally, impaired family dynamics, in FSTinformed studies, have been associated with adolescent depression, anxiety,27,28 substance use,29 and eating disorders.30 Few scholars have conceptualized how the core tenets of FST can be applied to childhood obesity treatment.12,15,17,18,31 For example, Skelton et al described use of FST for childhood obesity treatment, including “…understanding family rules and rituals to facilitate the goal setting process.”17 pp 893 However, previous conceptualizations of FST applied to childhood obesity treatment do not describe how change actually happens for families in treatment, and how family routines, habits, and overall processes can contribute to obesity; this can be described as families “organizing” around weight-related behaviors, and is a more nuanced view of youth and family routines specific to diet and activity. This is a significant limitation of previous work, which approached the treatment of all families the same way, regardless of their interpersonal dynamics and their organization around diet and activity. On the basis of their family functioning and organization, families might be better served by FST or FBBT interventions to target overall family dynamics or individual youth and/or parent behaviors, respectively; further guidance on determining which families could benefit from the different approaches are discussed. Using the FST concepts of first- and second-order change,32 clinicians can assist families to enact sustainable longterm behavior modification. For example, as a first-order change, parents might decide to limit a child’s screen time (individual behavior).32 Second-order changes could include scheduling time to play active games together instead of unscheduled sedentary activities like television (family routines),32 establishing family-wide limits on media use (family rules), and having conversations during family meals around positive health messages (family communication). FBBT interventions promote first-order change (change in parent and/or child behavior), but overall family functioning remains the same without changing family routines, rules, and dynamics. FST-informed interventions promote secondorder change, in which the family as a whole changes their interactions (family functioning), establishing new routines, rules, and communication dynamics. Table 1 lists firstorder change targets using FBBT and second-order targets on the basis of FST. FBBT AND FST-INFORMED INTERVENTION OUTCOMES In the most recent systematic review evaluating the methodological rigor of pediatric weight management through FBBT and FST, only 2 FST-informed interventions were published, versus 13 FBBT.27 Flodmark and colleagues Table 1. Targets of FBBT and FST Interventions FBBT FST Behaviors and Practices Routines and Dynamics First-order Change Self-monitoring Second-order Change Family structure Goal setting Family rules Problem solving Family communication Behavioral contracting Family responsiveness Relapse Family involvement Prevention Family strengths FBBT indicates family-based behavioral treatment; FST, family systems theory. ACADEMIC PEDIATRICS FAMILY FUNCTIONING AND CHILDHOOD OBESITY TREATMENT 621 randomized 10- to 11-year-old youth into 3 different groups: treatment as usual, diet/exercise, and diet/exercise with 6 family therapy sessions; the family therapy group maintained a significantly smaller increase in body mass index (BMI) than the treatment as usual group at 1 year.33 This study had one of the lowest attrition rates (11%), second highest rating for methodological rigor, highest treatment effect score, and was the second most effective study of the entire review. Kitzman-Ulrich et al randomized 12- to 15- year-old adolescents into 3 different arms for 16 weeks: family-group therapy (ie, multiple families in group) with psychoeducation, psychoeducation only, and wait-list control.34 There were no significant differences between groups for BMI z-score after 16 weeks, methodological rigor was average, and the treatment effect score was among the lowest in the review. On the basis of treatment effect score alone, the studies grounded in FBBT scored higher than the FST-based studies (3.2 vs 2.5), although it is clear that there are evident differences between the 2 FST-based studies (score of 4 vs 1), bringing down the FST mean score. Because there were only 2 FST and 13 FBBT studies, limited conclusions can be drawn.27 The authors recommended that future work is needed to explore potential uses of FSTinformed interventions.27 Others have used specific strengths-based models of FST in childhood obesity. Similar to how FBBT is combined with motivational interviewing35,36 to identify strengths to propel families forward with their goals, FST scholars have sought methods to expand family-wide strengths to challenges with behavior change. The most common strengths-based FST approach is solution focused,37 in which providers work with families to identify what is working well, and how to extend these strengths to their current challenges. For example, a parent and child might work together to ensure the child completes her homework every night; this could be extended to engaging in discussions about meal preparation and engaging in physical activity together. These interventions have been used in other countries with mixed results.38,39 Additional studies are needed to determine what family-level factors (ie, family functioning) to target as outcomes to fully explore the utility of FST in obesity treatment. POTENTIAL PREDICTORS AND OUTCOMES REPRESENTATIVE OF FST FST-specific variables are rarely assessed in childhood obesity treatment studies, especially as predictors of outcomes. Yet, they likely exert great influence on health behaviors of the family. Most research has centered on constructs of parenting.15 Family functioning (FST-pertinent variable) is mistakenly combined with concepts of parenting,19 however, family functioning is distinctively different from parenting. Previous reviews conducted on parenting style and obesity40–42 have connected aspects of the parent-child dynamic (ie, parenting style, parenting behavior, parenting practices) and obesity, but have not captured family dynamics, which extends beyond the parent-child interaction to the entire family and other specific relationships (sibling, couple, etc). Despite the existence of FST-based studies, most of these studies have still relied on assessments of the constructs of parenting, likely because of the ease in measurement, in which consistently impaired parenting styles are associated with youth obesity.31,40–42 Specifically, an authoritative parenting style is associated with lower weight status in youth and healthier behaviors.31 Unfortunately, associations between parenting and the overall family dynamic have not been explored with respect to childhood obesity. Capturing the reciprocal nature of parenting and family dynamics would provide important data to consider for familybased treatment, and interest in this area continues to grow.43 FAMILY FUNCTIONING AND RELATIONSHIP TO CHILDHOOD OBESITY Although less frequently assessed in childhood obesity treatment, family functioning is also associated with youth obesity.44–46 The most comprehensive review to date found 17 studies that assessed the relationship between family functioning and youth overweight/obesity.19 Twelve noted significant associations between impaired family functioning, risk of developing overweight/obesity, and current overweight/obesity in youth. Recently, Zeller and colleagues assessed family functioning among adolescents undergoing weight loss surgery.20 Impaired family functioning was prevalent in a third to a half of families; better family functioning was positively correlated with adolescent weight loss 1-year post-surgery. Haines and colleagues reported that patients with higher family functioning and positive family relationships had healthier weight-related behaviors.46 Although the evidence suggests that assessing family functioning in childhood obesity clinical encounters is warranted, there is essentially no information about how family functioning might change over the course of treatment, nor have these studies evaluated the effect of intervening on family functioning. FAMILY ORGANIZATION AROUND WEIGHTRELATED BEHAVIORS According to FST, families organize around the routines, rules, and dynamics that are established over time. This organization becomes the way the family operates, and can either promote healthy or impaired family functioning. Families might have healthy functioning with respect to weightrelated behaviors, such as having leisure-time activities that are physically active. Conversely, families can also have impaired functioning, such as frequently eating fast food with little to no meal planning, preparation, or quality time conversing during a meal. By using FST to inform childhood obesity treatment, 2 types of family patterns might emerge— families that organize around unhealthy weight-related behaviors that lead to obesity, or around healthy weightrelated behaviors that assist the family in maintaining a healthy weight. This way of viewing organization around weight-related behaviors (heathy or unhealthy) can assist providers in tailoring their encounters to focus on family dynamics that support healthy behaviors, and modify those organized around unhealthy behaviors. Table 2 provides examples of family organization around behaviors that might contribute to obesity. 622 PRATT AND SKELTON ACADEMIC PEDIATRICS Families that organize around healthy as well as unhealthy weight-related behaviors might be particularly receptive to first-order change through FBBT interventions, because they might have some positive established rules, routines, and communication that could be extended to address unhealthy weight-related behaviors. These families might only need to change 1 or 2 specific behaviors, not their overall family dynamic. Conversely, families who predominantly organize around unhealthy weight-related behaviors are unlikely to have implicit rules that support health, established routines, and overall family dynamics that support changing unhealthy behaviors to healthy ones. They might benefit from second-order change through FST interventions, in which the family changes the way they operate through higher-level changes around family rules, routines, and dynamics. It is hypothesized that families who are organized around healthy behaviors tend to have established rules and routines and positive communication, whereas those who organize around unhealthy behaviors might lack those traits. In short, FST-informed interventions should be designed, conducted, and evaluated for their short- and longterm effectiveness in childhood obesity treatment. Implementation of FST within primary- and tertiary-care programs is likely to be a challenge, with unknown acceptability by families and clinicians alike. Additionally, assessments should measure variables representative of FST (family functioning) across treatment to determine which variables should be targeted (as strengths as well as growth areas) in future interventions. Finally, and arguably most relevant for treatment, providers who view youth with obesity in the context of his/her family need to know how to counsel families who organize around healthy or unhealthy weight-related behaviors, and how to incorporate components of FST into their encounters. The authors of this report recently assessed family functioning in a sample of youth (ages 2–18 years) and parents (N = 329) in pediatric primary care to assess for associations between reports of family functioning and youth weight status; parents who reported impaired family functioning also reported that their youth had a higher BMI z-score compared with families who reported healthy family functioning (Pratt et al, unpublished data, November 2017). Future research should seek to: 1) assess family functioning among youth in pediatric weight management programs, 2) assess for changes in family functioning throughout treatment, 3) assess how changes in family functioning correlate with changes in weight-related behaviors and weight status, 4) determine if family functioning can predict youth and family members’ behavior change and weight loss, and 5) compare family functioning between families in pediatric weight management programs and non-treatmentseeking families with youth with obesity. Additionally, future feasibility and acceptability studies, particularly performed with a diverse group of families, are essential to ensure that future targets (like family functioning) are received well by youth and families. A TEMPLATE FOR FST-INFORMED ASSESSMENT IN CHILDHOOD OBESITY TREATMENT AND RESEARCH Figure 1 depicts a suggested algorithm for use of FST, either in exploratory clinical or research settings. This algorithm might help determine: 1) how families organize around healthy or unhealthy weight-related behaviors, 2) which family-based approach (FST, FBBT) might be advantageous for treatment, and 3) family-based evaluation and re-methods to monitor progress. This framework should undergo further testing and refinement to determine its fit with youth and families in childhood obesity treatment. At a minimum, it provides a starting point to consider the utility of FST in obesity treatment programs, and for providers to view children’s weight status and weight-related behaviors within the context of the family system. FAMILY CLINICAL CHARACTERISTICS The first step in providing family-based care using a FST framework is not just to situate the youth within the family context as previously suggested,5 but to view the “family as the patient.” This shift allows providers to assess clinical outcomes inclusive of the entire family. Thus, all family members who are willing and able should be invited to attend before the initial visit, or steps should be taken to incorporate them. At the initial visit, the team should describe their approach to family-based care: “You will meet with multiple members of our team today who are going to get to know your family, and your food and activity habits.” This example situates the family as the patient and does not target the youth and/or parent as having “a problem.” Table 2. Characteristics of Families’ Organization Around Healthy and Unhealthy WRB Characteristic Unhealthy WRB Healthy WRB Food preparation Individually done Family-wide participation Limited family participation Family meals Limited Frequent Unscheduled Scheduled Meals away from home Frequent Limited Physical activity Limited family participation Family-wide participation Individually done Screen time No/limited rules for use Clear rules and limits for use Messages communicated Shape, size, weight Health Sleep No/limited routine, rules Clear routine, rules WRB indicates weight-related behaviors. ACADEMIC PEDIATRICS FAMILY FUNCTIONING AND CHILDHOOD OBESITY TREATMENT 623 Family history should include where the youth in treatment spends most of her time, including shared custody or childcare arrangements. Details of the family structure should include the parenting arrangements, and how many youth and adults live in the home. This helps providers determine who can support and assist the youth with goals, and if information needs to be communicated to additional family members not present in clinic. Aspects of the family’s culture should be assessed, including cultural and religious/ spiritual celebrations that involve food or activity. Last, asking about recent life events (separation/divorce, death/loss, employment) will help determine the relevant needs of the family and how treatment can be tailored to their unique circumstances. HOW DOES THE FAMILY ORGANIZE AROUND HEALTHY OR UNHEALTHY WEIGHT-RELATED BEHAVIORS? Figure 1 provides a suggested template to assess family organization around weight-related behaviors that lead to obesity. Additionally, family history of obesity and previous attempts at weight loss, successful as well as unsuccessful, should be noted, along with any insights into the success and/or failures of past attempts. A genogram (Fig. 2) can be a valuable tool in this process. FAMILY FUNCTIONING Because of the prevalence of impaired family functioning among families of youth with obesity,19,20,46 assessing family functioning through standardized questionnaires aids providers in determining strengths and growth areas in the family. Researchers have used the McMaster Family Assessment Device (FAD),47 the Family Adaptability and Cohesion Evaluation Scale,48 and the Family Environment Scale.49 The FAD is the most commonly used; it has 60 items and 7 scales that assess family functioning on a Likert scale of 1 to 4,47 with each scale having clinical cutoff scores.50 Examples of questions from each scale are as follows. For problem-solving: “After our family tries to solve a problem, we usually discuss whether it worked or not.”; communication: “When someone is upset the others know why.”; roles: “We make sure members meet their family responsibilities.”; affective responsiveness: “We are reluctant to show affection to each other.”; affective involvement: “You only get the interest of others when something is important to them.”; behavior control: “We have rules about hitting people.”; and general functioning: “In times of crisis we can turn to each other for support.” In the past, researchers have consistently reported α ≥ .70,49 including youth with obesity.19,20,47,51,52 The 7 scales have Figure 1. Suggested algorithm for use of FST in family-based obesity treatment. FST indicates family systems theory; SES, socioeconomic status; FAD, Family Assessment Device; and PA, physical activity. 624 PRATT AND SKELTON ACADEMIC PEDIATRICS maintained internal consistency within Hispanic and African American families.52 The 12-item FAD General Functioning scale is an acceptable proxy for overall family functioning,52 and has been used to assess family dynamics in weight management populations.51,53 The FAD or the FAD General Functioning scale can be used to determine if families are above or below the cutoff score(s) for healthy functioning, and what areas might be a strength (ie, communication) or that are more vulnerable (ie, rules). Assessing family organization around weight-related behaviors and family functioning could determine if families should receive FBBT or FST-informed interventions. FBBT is likely more effective for families who do not organize extensively around unhealthy weight-related behaviors and have areas of healthy family functioning, and has been extensively described elsewhere.10 FST-INFORMED APPROACH Depending on the FAD results, specific components of FST to target in treatment could include family structure and boundaries, behavioral control, communication, rules, family involvement, and family responsiveness. Families with impaired family functioning might be best served by improvements in general family functioning first, because prioritizing weight-related goals might not be successful longterm in families not supportive of change. In other words, it will be more difficult for families with impaired family functioning to change their weight-related behaviors, particularly if these behaviors are a part of their routine, such as watching television every night during dinner to avoid having conflictual conversations. Family structure refers to having an appropriate hierarchy or boundary between the adult and youth subsystems. Boundaries should allow outside members to come into the family as needed for support or friendship, but should not be rigid to the point at which the family might become isolated, or too flexible where the household is chaotic. Families with healthy boundaries and structure presenting for childhood obesity treatment likely have adults who take responsibility for providing healthy meals and opportunities for physical activity. In families without healthy boundaries and structure, the youth might have the “power” in the family or have chaotic organization. If so, treatment might focus on supporting the caregiver(s) to assume an authoritative parenting role, and extending those practices to weightrelated behaviors such as food preparation and providing opportunities for activity. In families with healthy functioning, rules around weightrelated behaviors might be implicit; the provider can explore these rules. For example, an explicit rule in families is that they have to finish the food on their plate before having dessert. Whereas an implicit rule might be that youth know if they ask their father for a snack he will say yes, rather than their mother who will say no. In childhood obesity treatment, it is important to find effective ways to communicate families’ implicit rules around eating and physical activity explicitly, to determine how these rules can change to support a healthy lifestyle. For families with healthy family functioning, FST might not be necessary if only changes in select health behaviors are needed (first-order change), which can be accomplished through FBBT. However, if families have healthy family functioning and multiple health behaviors need to be addressed, FST could be used to ensure that changing multiple behaviors does not have undesirable effects on family functioning (second-order change). A universal challenge is long-term maintenance of changes in behaviors and weight status; it might be that FST is required to sustain successful long-term change in families, rather than individuals. When communication is impaired in families, teaching basic skills like “I-statements”54 can help family members effectively listen to each other without eliciting defensiveness or blaming. Instead of saying “You’re not being social when you eat in your room by yourself,” the parent could Age: Occupation: Weight Status: Notes: Age: Occupation: Weight Status: Notes: Age: Weight Status: Notes: Age: Weight Status: Notes: Age: Weight Status: Notes: Figure 2. Family systems theory genogram. ACADEMIC PEDIATRICS FAMILY FUNCTIONING AND CHILDHOOD OBESITY TREATMENT 625 say, “I miss eating dinner with you. I want to hear about your day.” Family members can practice listening and reflecting back statements and feelings, rather than responding immediately. Family weight talk (body weight and shape, not health) and teasing are developing areas of research, especially among couple and parent-youth dyads.55,56 When determining treatment goals, clarity on how youth and parents communicate with each other is often needed. For example, youth might believe their parents are nagging them about their goals, when parents feel they are supporting their children’s efforts. To foster healthy communication around treatment goals, providers can ask the youth and family members to determine acceptable ways to reinforce goals in the home that are not perceived negatively. For example, parents and youth could agree that the parents might remind a youth once (but not twice) to wait until everyone is served dinner before taking a second helping. Family responsiveness is how receptive family members are to one each other’s needs. In treatment this includes how willing family members are to participate in weightrelated goals with youth. Family involvement is how much family members take part in each other’s life or how involved they are with each other. It is possible for family members to participate in health-related goals, but not be responsive to the youth’s needs. For example, a sibling might participate in weekly walks with the youth in treatment, but he or she might not be responsive to feedback that they are walking too fast. EVALUATION In childhood obesity treatment, success is determined by youth behavior change and ultimately, weight loss. According to FST, success involves changing the family dynamics so that successful behavioral change can take place. If families are not successful with FBBT, determined according to clinical (absence of weight loss) or behavioral measures (sustained unhealthy behaviors) providers should consider reevaluating family functioning. If families receiving FSTinformed treatment improve their family dynamics or functioning, and potentially achieve behavior change, then behavioral aspects can be incorporated into treatment. Because changes in family functioning are expected to have a “downstream effect” resulting in changes to weightrelated behaviors, changes in weight status might be slower than what is expected or experienced in traditional FBBT. This is an important consideration for future research, particularly in testing the hypothesis that second-order change is needed for long-term behavior and weight change in families. Subsequently, providers will need to address the family’s expectation for youth weight loss, particularly in noting that improvements in family functioning might be necessary before improvements in youth weight status are expected. In addition, aspects of family functioning and associations with weight-related behaviors and weight status over treatment must be captured. In other words, a research priority is to identify the key aspects of family functioning and dynamics that improve youth weight status to lead to more focused family-based treatment. For example, communication might be a key element of family functioning that predicts adolescents’ weight-related behavior change, whereas family rules might not. If families are not improving their overall dynamic, then family functioning should be reassessed to determine areas needing attention, including recent life events that might warrant prioritizing (separation, job loss). If family members require more intensive therapeutic work around recent life events or stressors, referrals to family therapy can be made. CONCLUSIONS On the basis of the limited research that indicates impairments in family functioning among families of youth with obesity, future research needs to use assessments grounded in FST. Additionally, determining how families organize around weight-related behaviors might allow providers to tailor treatment on the basis of the needs of the family. The family-based clinical algorithm provides a framework for future testing and exploration. Details on costs and delivery of FST services also need to be further explored.
Development and psychometric properties of the public attitude towards vaccination scale – Health belief model
Abstract
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ZHTHIS LINK GOES TO A ENGLISH SECTION
Aim
The aim of this study was to develop and psychometrically evaluate the Public Attitude Towards Vaccination Scale – Health Belief Model.
A methodological and prospective psychometric study.
Method
A three-phase construct was used to develop the Public Attitude Towards Vaccination Scale – Health Belief Model and to determine its psychometric properties: (1) creation of the item pool/conceptualization; (2) evaluation of the items; and (3) psychometric evaluation. This scale was tested using the construct validity (exploratory and confirmatory factor analyses) and the reliability analysis. A psychometric assessment of the scale was conducted with 586 individuals. Data were collected between January – April 2018.
Results
Items of the scale were obtained by appraising the literature concerning vaccination and the other Health Belief Model scale and conducting interviews with mothers. The content validity ratio of this scale calculated according to experts’ opinions ranged between 0.769 and 1.00. According to the exploratory factor analysis, there were five factors with an eigenvalue higher than 1 in the scale. These five factors accounted for 68.9% of the total variance. In confirmatory factor analysis, values of fit indices were excellent or acceptable. This scale had high internal consistency and test–retest reliability.
Conclusion
This study successfully developed the Public Attitude Towards Vaccination Scale – Health Belief Model. In addition to researchers, this scale can be used by nurses while providing counselling for people with vaccine hesitancy/refusal.
This measurement tool can be used to understand and address ‘vaccine hesitancy’ by researchers. The results of the research using this measurement tool will provide valuable information to policymakers for preventing vaccine hesitancy. The validity and reliability of this scale can easily be conducted in different languages.
Over the years, infant and child mortality rates have markedly decreased. The main intervention that caused this decrease was immunization/vaccination services (Bustreo, Okwo-Bele, & Kamara,
2015
). Vaccination is considered the most important and influential medical discovery (WHO, Unicef, & WorldBank,
2009
). Routine infant immunization programmes have become widespread and the diversity of vaccines administered within the scope of these programmes has increased (United Nations Children’s Fund, World Health Organization, The World Bank, & United Nations,
2017
; Whitney, Zhou, Singleton, & Schuchat,
2014
). The benefits of vaccination can be briefly summarized as the prevention of diseases and premature death as well as decreased hospital admission rates and health expenditures (McGovern & Canning,
2015
; Roush,
2007
; Whitney et al.,
2014
). However, vaccines can provide the mentioned benefits depending on whether: (1) immunization services offer vaccines to significant health problems; (2) the principles of vaccine supply and storage are followed; (3) vaccines are delivered to the target population; and (4) there are competent and qualified health professionals, a good surveillance programme, and public trust in vaccines (Gilkey et al.,
2014
; Groom et al.,
2015
; Smith & Maurer,
2014
).
Despite the continuous improvement in vaccine technology and immunization programmes, public trust in vaccines has decreased and the number of families who refuse vaccination or experience vaccine hesitancy has increased in recent years (Dubé et al.,
2018
; Healy, Montesinos, & Middleman,
2014
; Kettunen, Nemecek, & Wenger,
2017
; Larson, Jarrett, Eckersberger, Smith, & Paterson,
2014
; Larson et al.,
2015
). Decreased immunization coverage rate leads to reduced herd immunity (Tustin et al.,
2017
), increased disease-associated mortality and morbidity rates, and emergence of outbreaks (Phadke, Bednarczyk, Salmon, & Omer,
2016
).
Vaccines recommended for specific populations and age groups are determined by country-specific advisory committees. However, nurses, particularly public health nurses, have the responsibilities of providing opportunities to children to access vaccines at the individual level, providing training to raise awareness and acting as an advocate by continuously examining the relevant population (Smith & Maurer,
2014
). Therefore, public health nurses have essential roles and opportunities of fighting vaccine refusal in terms of understanding the public and positively affecting their attitude. Moreover, measurement tools are required to understand and address vaccine hesitancy (Larson et al.,
2015
). The Health Belief Model (HBM) is frequently used by public health nurses to understand and improve health protective behaviours. This study aimed to develop a measurement tool based on HBM to evaluate public attitude towards vaccination.
The global child mortality rate has shown a downward trend in recent years. The number of under-five mortality rate dropped from 12.6 million in 1990 to 5.6 million in 2016. Reportedly, most child deaths were due to treatable diseases, which could have been prevented by effective interventions (United Nations Children’s Fund et al.,
2017
). Although the decline in child mortality is a collective outcome of improvements in healthcare, education, technology, and economy, vaccination considerably contributes to child health and public health. Vaccines, particularly those for measles and tetanus, are associated with decreased child mortality (McGovern & Canning,
2015
). Vaccination prevents the incidence of diseases and dramatically reduces hospital admission and mortality rates among children (Roush et al.,
2007
). There is strong evidence showing that vaccination prevents the death of millions of children annually and such great success is only possible by immunizing most of the population (Bustreo et al.,
2015
; Roush et al.,
2007
; United Nations Children’s Fund et al.,
2017
). Recently, vaccine refusal/vaccine hesitancy has become widespread among communities as an obstacle to herd immunity. This poses a threat to all public health achievements accomplished by vaccination and increases the risk of outbreaks in communities. The WHO reports that measles outbreaks in several parts of the world are reaching peak levels, thereby straining the healthcare system and causing significant complications and death (WHO,
2019a
). In the European Region, some countries (Albania, Czechia, Greece, and the United Kingdom) have lost their measles elimination status, whereas some countries have encountered severe outbreaks of infectious diseases due to reduced vaccination rates (WHO,
2019b
).
Vaccine hesitancy is described as a delay in vaccine acceptance or refusal despite the availability of vaccination services (MacDonald,
2015
). Opposition to vaccination originated in the 1790s, when vaccine was used as a medical technique. Religious values played a vital role in anti-vaccination movements. However, the current anti-vaccination movements are based on questioning the effectiveness and risks of vaccines. The alleged relationship between autism and measles–mumps–rubella (MMR), which has first been put forward by Andrew Wakefield in the UK in 1998, has paved the way for the international spread of anti-vaccination (Dubé, Vivion, & MacDonald,
2015
).
Vaccine hesitancy is a complex situation that has to be explicitly investigated for individual vaccines (Larson et al.,
2014
; MacDonald,
2015
; MacDonald, Butler, & Dubé,
2018
). Factors affecting vaccination adherence include individual characteristics such as education and religion as well as social factors such as culture, economy, rural/urban areas, and social environment (Ghani, Dalhatu, Adam, & Ghazalli,
2015
). According to the literature, the causes of vaccine hesitancy among parents include lack of confidence in vaccine ingredients, healthcare system, media, and pharmaceutical industry (Dubé et al.,
2018
; Gilkey et al.,
2014
). Based on the availability of excessive vaccines (Kettunen et al.,
2017
) and lack of information (Khan et al.,
2015
), sceptics often believe that vaccines cause severe complications and certain diseases (Maglione et al.,
2014
). According to Larson et al. (
2015
), factors influencing vaccination at the individual level include the following: (a) experiences related to vaccination; (b) beliefs and attitudes about health and prevention; (c) knowledge and awareness; (d) trust in the healthcare system and service providers as well as personal experience; (e) risk/benefit (perceived); and (f) social norms concerning vaccines being necessary/harmful. Dubé et al. (
2018
) demonstrated a significant relationship among knowledge, trust, positive attitude, and parents’ intention to vaccinate according to the theory of planned behaviour. In a study based on change in planned behaviour, education, and social marketing, it was found that this multilayer intervention contributed to reduced inequalities in childhood immunization and it was underlined that culturally tailored interventions, in particular, were more effective (Willis et al.,
2016
).
According to the literature, beliefs are the leading personal cause of vaccine refusal. In particular, belief-based interventions emerge as a solution for vaccine refusal. Similarities between the psychological antecedents of vaccination (Betsch et al.,
2018
) and the concepts of HBM are remarkable. The conceptual basis for HBM focuses on the idea that health behaviour develops from the perception or beliefs about disease. This model reveals perceived severity, importance, benefits, and barriers related to health behaviour, which is being investigated (Hayden,
2014
). HBM, which has successfully been applied in several cultures, is frequently used in different fields by nurses to understand and manage health beliefs (Jeihooni, Hidarnia, Kaveh, Hajizadeh, & Askari,
2015
; O’Connor, Martin, Weeks, & Ong,
2014
; Tuzcu, Bahar, & Gözüm,
2016
; Zareban, Karimy, Ahmadi, Darmiyan, & Taher,
2015
). There are several vaccination studies based on health beliefs, which can be useful in understanding vaccine refusal and developing effective interventions (Armstrong, Berlin, Schwartz, Propert, & Ubel,
2001
; Smith et al.,
2011
). However, there is a lack of a measurement tool in the literature that could facilitate model-based evaluation about vaccine hesitancy.
Considering the fact that many countries fail to overcome vaccine hesitancy (MacDonald et al.,
2018
) and that a scale enabling the measurement and resolution of vaccine hesitancy is necessary (Larson et al.,
2015
) developing a scale based on HBM, which is effective in managing public attitude, is considered essential. The developed measurement tool aimed at focusing on the public rather than on certain age groups or parents because vaccination is not only a personal health protective behaviour but also a public health practice. The expected success of vaccination can be made possible by high-level vaccination coverage. In addition, the consequences of vaccine rejection concern the entire community due to the possibilities of outbreaks (WHO,
2019a
,
b
). Vaccination requires the common determination of the public. Vaccine hesitancy is becoming increasingly common in specific population subgroups; hence, it is crucial to understand who is experiencing vaccine rejection and the underlying reasons (Larson et al.,
2015
). Religious beliefs are often an important factor in vaccine hesitancy due to the opposition to science; therefore, rumours and misconceptions should be addressed in particular. It should be remembered that the entire society may be at risk because vaccine hesitancy spreads through media and the internet (Dubé, Gagnon, Nickels, Jeram, & Schuster,
2014
).
This study aimed to develop the Public Attitude Towards Vaccination Scale – Health Belief Model (PAVS-HBM) and to evaluate its psychometric properties.
This was an instrument development study. A three-phase construct was used to develop PAVS-HBM and to determine its psychometric properties: (1) creation of item pool/conceptualization; (2) item evaluation; and (3) psychometric evaluation.
Thematic analysis of the literature and qualitative research were conducted at this stage (Carpenter,
2018
). Items of the scale were obtained by reviewing the literature on vaccination, investigating HBM scales and conducting thorough interviews with two mothers: one who had vaccinated her children (34 years; high school; having two children) and another who had refused vaccination (37 years; high school; having three children). Interviews covering topics such as communicable diseases, benefits of vaccination, concerns about vaccination, reasons for (or not) vaccinating their children, thoughts about vaccine requirements, vaccination-related experiences, and evaluation of healthcare services were conducted with these mothers. Interviews were transcribed using thematic analysis (Maguire & Delahunt,
2017
). Responses received from the mothers were classified based on these HBM subdimensions: perceived severity, susceptibility, benefit, barrier, and health motivation. Moreover, a confidence subdimension was created owing to the frequent repetition of statements about confidence.
Measurement tools or questionnaires that could be related to vaccine refusal were selected by reviewing the literature on vaccination and the items found were classified based on the HBM subdimensions. In this step, the selected items are those that refer to the vaccine–infectious disease relationship, vaccine barriers, number of vaccines and vaccine ingredients, and religious beliefs (Armstrong et al.,
2001
; Dubé et al.,
2018
; Ghani et al.,
2015
; Gilkey et al.,
2014
; Healy et al.,
2014
; Larson et al.,
2014
,
2015
). Items of the HBM scales were adapted as items related to vaccination. This review is often the source of items related to health responsibility and sensitivity. However, three sources of information contributed directly or indirectly to each item (maternal interviews, vaccine literature, and HBM scales). A 25-item draft scale with six subdimensions was created after combining the literature findings with the mothers’ opinions and items obtained using the HBM scales.
Item evaluation was performed using the content validity index (CVI), which evaluates the scale integrity of a construct (Polit & Beck, 2006; Shi, Mo, & Sun, 2012; Yaghmaie,
2003
). A draft scale was sent to specialists at this stage. In total, the following 26 specialists were invited to evaluate the scale:
· Academic nurses with a doctorate in public health nursing and at least one published paper on culture-related health beliefs (14 specialists),
· Nurses with at least a bachelor of science in paediatric nursing and who work on vaccination or communicable diseases (four specialists),
· Primary health professionals working as a nurse and midwife (four specialists), and
· Those with a doctorate in statistics and publications on measurement and evaluation. These psychometric experts are professionally medical doctors and work at the Department of Biostatistics of the Faculty of Medicine (four specialists).
The specialists classified each item of the scale as ‘unnecessary’, ‘necessary but needs correction’, and ‘necessary’, and the CVI and content validity ratio (CVR) were calculated. CVR was calculated by dividing the number of specialists who classified an item as ‘necessary’ (G) by the total number of specialists divided by 2 (N/2) and subtracting 1 from the resulting number [(G/(N/2)) − 1]. This calculation is performed for each item and the items remaining based on the calculated table value according to the number of experts are retained in the scale (Alpar,
2014
). Ayre and Scally (
2014
) reported that the critical value of CVR should be 0.385 for 26 specialists (Ayre & Scally,
2014
). CVI is the average of the CVR value of the remaining items in the pool. This calculation is performed separately for the subdimensions and the CVI value is expected to be >0.67 (Alpar,
2014
). No items were removed from the scale, but two new items were added according to the recommendations of the specialists. Statements were corrected in eight items.
The new 27-item scale, created as a result of the corrections and additions recommended by the specialists, was sent to five different specialists. Concordance among the specialists was assessed using Kendall’s W value (Bowling & Ebrahim,
2005
). Furthermore, some grammatical and spelling errors in the scale were corrected.
Scale readability was evaluated using the Flesch–Kincaid formula adapted to Turkish by Atesman. Test readability is expressed by a value ranging between 0 and 100, with the calculated figure of close to 100 indicating the readability level of the text to be easier. In brief, first, the length of words and sentences is evaluated in a 100-word section selected from the scale. Second, the average sentence length (L) is the number of words divided by that of sentences. Third, the average word length (N) is the number of syllables divided by that of words. Lastly, results are obtained using the following formula: 198,825 − (40,175N − 2,610L; Temur,
2003
).
Psychometric evaluation was performed to determine the construct validity [exploratory factor analysis (EFA) and confirmatory factor analysis (CFA)] and reliability of the scale. EFA determined a factor structure based on data and explains the amount of variance (Thompson,
2004
). Principal component analysis (PCA) and varimax rotation were used in EFA. PCA is a mathematical technique used to explain information with fewer variables and minimum information loss in a multivariate dataset. Field (
2013
) suggested PCA in factor analysis (Field,
2013
). In this study, orthogonal (varimax) rotation was used because it was aimed at revealing independent factors instead of correlated factors. Factors with an eigenvalue of >1 were considered significant. In addition, factor number was evaluated using a scree plot. For normally distributed items, the range of skewness and kurtosis (between −1 and 1 for both skewness and kurtosis) was used. Moreover, Kaiser–Meyer–Olkin (KMO) test and Bartlett’s test of sphericity were performed. KMO test measures correlations between variables and the suitability of factor analysis and the results are expressed as values ranging between 0 and 1. A KMO coefficient of 1 indicates that a variable was correctly estimated by other variables, whereas a value of >0.8 can be considered significant. The fact that each item was loaded on a factor of >0.40 was considered an essential criterion in factor analysis (Büyüköztürk,
2004
).
During scale development, CFA can be used to confirm the number of factors and their relationship with items. The COSMIN checklist recommends the use of CFA and describes it as a method with a very good quality. CFA has several goodness-of-fit indices (GFIs; Kline,
2011
; Schreiber, Nora, Stage, Barlow, & King,
2006
; Thompson,
2007
). In this study, CFA was conducted using the results of χ2/SD, GFI, adjusted GFI (AGFI), comparative fit index (CFI), root mean square error analysis (RMSEA), root mean square residual (RMR), standardized root mean square (SRMR), incremental fit index (IFI), Parsimony Normed Fit Index (PNFI), and PGFI indexes. These are considered good fit values: χ2/SD < 2, CFI > 0.95, RMSEA < 0.08, RMR < 0.5, SRMR = 0.00–0.05, IFI > 0.95, and PNFI and PGFI > 0.50. However, these are considered acceptable fit indices: χ2/SD < 5, CFI > 0.90, RMSEA < 0.10, RMR < 1, SRMR = 0.05–0.10, and IFI > 0.90 (Bayram,
2010
; Jackson,
2007
; Schreiber et al.,
2006
; Thompson,
2007
).
Internal consistency, the corrected item-subscale correlation, and test–retest were performed to assess reliability. Internal consistency evaluates the correlations between items and subscale. Cronbach’s alpha (α) of ≥0.70 indicates that internal consistency is acceptable (Mallery & George,
2003
). A higher alpha value (>0.90) may indicate redundant items in the scale (Kiliç,
2016
) Regarding test–retest reliability, the measurement tool is expected to produce close (similar) results over time. A high correlation coefficient and similar mean score between 2 measurements are considered to indicate high reliability (Alpar,
2014
). In this study, the scale was applied to the same individuals at 15-day intervals.
In the development and psychometric evaluation of this scale, the stages and analyses suggested by the COSMIN checklist were taken into consideration (Terwee et al.,
2012
).
Two mothers and 31 specialists (26 + 5) participated in phase 1 and phase 2 of the study. Participant characteristics have been described earlier. Psychometric evaluation of the study (phase 3) was conducted in a metropolitan region, where individuals with different socioeconomic statuses lived in the same community. Thus, it was aimed to be a comprehensive study in terms of gender, age groups, education, and economic status. Individuals aged between 18-65 years, those without communication difficulties and those without the diagnosis of a psychiatric disorder were enrolled in this study. Pregnant women were excluded from the study to avoid possible biases towards vaccination. This study aimed to reach a moderate sample size for psychometric research. There should be at least 5–10 observations per item in factor analysis. Therefore, 270 participants were found to be sufficient for EFA analysis of the 27-item draft scale. The recommended sample size is at least 300 participants for CFA analysis (Alpar,
2014
; Çokluk, Şekercioğlu, & Büyüköztürk,
2012
). As a result, psychometric evaluation of the scale was conducted with 586 individuals and data were collected from 30 individuals at 15-day intervals for test–retest analysis. The database was randomly halved into 286 and 300. CFA and EFA were performed on separate samples.
Health facilities located in the research area were used to reach out to the participants. The participants were contacted via the district hospital and primary health centre located in that area. Quota sampling was performed to collect a group of participants representing the public in terms of marital status, education and sex for data collection. The population structure of a relevant area was considered. In total, 54.9% of the participants were females and 58.0% were married. Regarding educational status, 2.6% had received education for <5 years, 19.7% were primary school graduates (5 years), 14.3% were secondary school graduates, 33.8% were high school graduates, 26.1% were university graduates, and 3.5% were postgraduates. Written consent was obtained from all participants before the study and the questionnaire was completed within 10–15 min.
The PAVS-HBM instrument includes 26 questions on five dimensions which are perceived susceptibility (4 items), perceived severity (4 items), perceived benefits (5 items), perceived barriers (8 items), and health motivation (5 items). The items of PAVS-HBM are evaluated with a 5-point Likert scale, from 1 (strongly disagree) – 5 (strongly agree). Except for the perceived barriers subdimension, higher scores show positive belief. On the other hand, lower scores indicate positive beliefs in perceived barriers section. Data were collected between January – April 2018. Besides the scale draft, a scale that included information on age, sex, education, and marital status was used.
Data were analysed using IBM SPSS® Statistics for Windows, version 24.0 and AMOS®. CVI and CVR were calculated for the evaluation of scale items by the specialists. Concordance among the specialists who evaluated the draft scale that was created after content review was assessed using Kendall’s W analysis. Structural validity of the scale was assessed using EFA and CFA. Cronbach’s alpha and test–retest analyses were performed for reliability analysis.
The University Human Research Ethics Committee approved the study (Number: 2018/105.03.558). Ethical approval covered all stages of the research (interview with mothers, opinion of experts, and psychometric study).
The draft scale (25 items and 6 dimensions), created as a result of reviewing the literature, evaluating similar scales and interviewing the mothers, was evaluated by the specialists and their evaluations were analysed using CVI and CVR. CVR of the scale ranged between 0.769-1.00. CVIs of the subdimensions were 0.80, 0.84, 0.90, 0.86,
0.786
, and 0.916 for perceived severity, importance, benefit, barrier, trust, and health responsibility, respectively, which were all significant (p < .05).
At this stage, the specialists recommended some corrections related to sentence structure, grammar rules, and intelligibility and the scale was revised according to these recommendations. Two new items were added to the latest version of the scale as well. This scale was sent to five specialists. Concordance among these specialists was assessed using Kendall’s W value (Kendall’s W: 0.002 p: 0.998). Consequently, a 27-item scale was obtained. At the same time, the readability level of the scale was determined. For values determined as L = 6.6 and N = 3.08, readability was calculated using Atesman’s formula: 198,825 − (40,175N − 2,610L) = 95,526 (easy).
According to EFA, KMO coefficient was 0.87 and Bartlett’s test of sphericity result was 4,193.4 (p < .001). Based on these results, it was found that the data had a multivariate normal distribution, sample size was adequate, and it was appropriate to EFA. There were five factors with an eigenvalue >1 in the scale. The scree plot also showed that the eigenvalues start to form a straight line after the fifth principal component. The variance ratio of each item was >56% and there were no overlapping items according to commonalities. These five factors accounted for 68.96% of the total variance. The percentages of variance explained by each factor were 28.8%, 17.9%, 10.6%, 7.5%, and 3.8%. Table
1
shows the items associated with each factor. In EFA, it was observed that the statements in the confidence subdimension of the scale draft were included in the benefit subdimension; thus, the scale had five subdimensions. There was no item with crossloadings in varimax rotation (Table
1
).
TABLE 1. Exploratory factor analysis of the Public Attitude Towards Vaccination Scale – Health Belief Model (N = 286)
|
Factor 1: Barrier; Factor 2: Benefit ; Factor 3: Health motivation ; Factor 4: Susceptibility ; Factor 5: Severity |
Factor 1 |
Factor 2 |
Factor 3 |
Factor 4 |
Factor 5 |
|||||||||||||||||||||||||||||||
|
If I have my baby/child vaccinated, he/she will have a lower risk of communicable diseases |
0.031 |
0.122 |
0.171 |
0.842 |
0.186 |
|||||||||||||||||||||||||||||||
|
If I do not have my baby/child vaccinated, he/she will always be at risk for communicable diseases |
−0.027 |
0.152 |
0.236 |
0.746 |
0.275 |
|||||||||||||||||||||||||||||||
|
Childhood vaccinations are important for baby/child health |
−0.010 |
0.169 |
0.217 |
0.869 |
0.194 |
|||||||||||||||||||||||||||||||
|
The prevalence of communicable diseases could be reduced if all infants and children were vaccinated |
−0.094 |
0.163 |
0.183 |
0.793 |
0.336 |
|||||||||||||||||||||||||||||||
|
If I do not have my baby/child vaccinated and if he/she contracts a communicable disease, the disease may be more severe than usual |
−0.068 |
0.306 |
0.066 |
0.345 |
0.717 |
|||||||||||||||||||||||||||||||
|
If there is no vaccination there can be an outbreak of communicable diseases |
− 0.121 |
0.375 |
0.060 |
0.399 |
0.673 |
|||||||||||||||||||||||||||||||
|
If my baby/child contracts a communicable disease because he/she was not vaccinated, there may be growth and development-related problems |
−0.085 |
0.299 |
0.040 |
0.245 |
||||||||||||||||||||||||||||||||
|
If unvaccinated babies/children contract a communicable disease, they may become disabled or die |
− 0.049 |
0.253 |
0.093 |
0.222 |
0.817 |
|||||||||||||||||||||||||||||||
|
Having babies/children vaccinated protects them from communicable diseases |
− 0.075 |
0.781 |
0.178 |
0.204 |
0.150 |
|||||||||||||||||||||||||||||||
|
Having babies/children vaccinated protects other children and the public from communicable diseases |
−0.030 |
0.797 |
0.087 |
|||||||||||||||||||||||||||||||||
|
Having babies/children vaccinated prevents the economic and labour losses due to communicable diseases |
0.116 |
0.721 |
0.074 |
0.108 |
||||||||||||||||||||||||||||||||
|
I do not have any information about the vaccines recommended for babies/children (such as what type of vaccines and where, when and how these vaccines are administered) |
0.596 |
0.090 |
0.173 |
0.153 |
−0.040 |
|||||||||||||||||||||||||||||||
|
Babies/children do not need vaccination if they regularly have check-ups |
0.729 |
0.025 |
−0.011 |
0.033 |
−0.043 |
|||||||||||||||||||||||||||||||
|
Today, babies and children do not need vaccination as much as they used to, since communicable diseases are under control |
0.767 |
0.114 |
0.119 |
0.016 |
−0.086 |
|||||||||||||||||||||||||||||||
|
I think there are too many vaccines and too many kinds of vaccines recommended for babies/children, which is harmful |
−0.014 |
−0.009 |
0.018 |
−0.125 |
||||||||||||||||||||||||||||||||
|
I think vaccination may have some drawbacks in terms of my religious beliefs |
0.735 |
−0.020 |
0.039 |
−0.150 |
0.082 |
|||||||||||||||||||||||||||||||
|
I think that some ingredients in vaccines may negatively affect the health of my baby/child |
0.787 |
0.000 |
0.064 |
−0.017 |
− 0.013 |
|||||||||||||||||||||||||||||||
|
Babies who are regularly breastfed do not need immunization |
0.810 |
−0.070 |
−0.107 |
−0.057 |
||||||||||||||||||||||||||||||||
|
Having a disease provides better immunity than vaccination |
0.757 |
−0.048 |
−0.012 |
0.015 |
||||||||||||||||||||||||||||||||
|
Vaccination is the safest way to protect from communicable diseases |
0.794 |
0.098 |
0.151 |
0.075 | ||||||||||||||||||||||||||||||||
|
Vaccines developed for babies/children have gone through comprehensive research and investigation |
0.819 |
0.049 |
0.109 |
0.121 | ||||||||||||||||||||||||||||||||
|
Vaccines do not contain substances that are harmful to babies/children |
0.063 |
0.754 |
0.076 |
−0.055 |
||||||||||||||||||||||||||||||||
|
Every parent should follow the immunization schedule recommended by the Ministry of Health |
0.776 |
0.259 |
||||||||||||||||||||||||||||||||||
|
As an individual of the society, I would have my child or grandchild vaccinated during infancy/childhood |
−0.052 |
0.117 |
0.847 |
0.187 |
0.021 |
|||||||||||||||||||||||||||||||
|
All babies/children should be vaccinated to promote public health |
−0.018 |
0.144 |
0.853 |
0.231 |
0.080 |
|||||||||||||||||||||||||||||||
|
I follow new information and debates about vaccines |
0.208 |
0.036 |
0.779 |
0.013 |
0.084 |
|||||||||||||||||||||||||||||||
|
I would like to receive information about vaccines from healthcare personnel |
0.128 |
0.822 |
0.081 |
0.091 |
||||||||||||||||||||||||||||||||
|
Eigenvalue |
7,795 |
4,859 |
2,875 |
2,049 |
1,042 |
|||||||||||||||||||||||||||||||
|
% of variance |
28.871 |
17.994 |
10.648 |
7.589 |
3.859 |
|||||||||||||||||||||||||||||||
|
Explained total variance |
68.960 |
|
· Coefficients in bold express the primary factor loadings.
CFA was used for five subdimensions, with 27 items determined by EFA. Regarding CFA performed for the first model, there was a high covariance between the statement ‘Vaccines do not contain substances that are harmful to babies/children’ in the benefit subdimension and ‘I think that some agents in vaccines may negatively affect the health of my baby/child’ in the barrier subdimension. Therefore, the previous statement was removed from the benefit subdimension and the model was retested. The standardized regression and variance values of the items were significant in the resulting model. Factor loading for items reportedly should be at least 0.30, which is satisfied by the factor loading used in this study. The obtained fit indices were as follows: χ2/SD = 2.57, GFI = 0.903, AGFI = 0.881, CFI = 0.943, RMSEA = 0.05, RMR = 0.02, SRMR = 0.05, IFI = 0.943, PNFI = 0.801, and PCFI = 0.827. These values are excellent or acceptable (Figure
1
).
FIGURE 1
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PowerPoint
Confirmatory factor analysis of the Public Attitude Towards Vaccination Scale –Health Belief Model χ2/SD = 1.836; GFI = 0.88; AGFI = 0.86; CFI = 0.95; RMSEA = 0.05; RMR = 0.08; SRMR = 0.06; IFI = 0.95; PNFI = 0.79; and PCFI = 0.85 (n = 300)
Subdimensions of the scale had high reliability coefficients ranging between 0.85-0.90 and the Cronbach’s alpha coefficient of the scale was 0.86. Subdimension-scale correlation coefficients ranged between 0.61-0.85. No items caused increased Cronbach’s alpha coefficient when deleted. The scale was administered twice to 30 participants in the study group at 15-day intervals. The mean values obtained in the first and second measurements were not significantly different (p> .05). Therefore, the scale was not considered time dependent. Concerning the subdimensions of this scale, correlation values between the two measurements were between 0.83-0.96. Both measurements were found to be significantly correlated (Tables
2
and
3
).
TABLE 2. Reliability analysis of The Public Attitude Vaccination Scale – Health Belief Model and Final Form
|
(n = 586) |
Item-subscale correlation |
Reliability coefficient |
| Susceptibility |
0.907 |
|
|
0.759 |
||
|
0.856 |
||
| 0.786 | ||
| Severity |
0.896 |
|
|
0.711 |
||
|
If there is no vaccination, there can be an outbreak of communicable diseases |
0.789 |
|
|
If unvaccinated babies/children contract a communicable disease, they may become disabled or die. |
0.772 |
|
| Benefit |
0.858 |
|
|
0.742 |
||
|
0.747 |
||
|
0.637 |
||
|
0.623 |
||
|
0.619 |
||
|
Barriers |
0.874 |
|
|
0.632 |
||
|
0.718 |
||
|
Today, babies and children do not need vaccination as much as they used to. since communicable diseases are under control |
0.751 |
|
|
0.834 |
||
|
0.700 |
||
|
0.826 |
||
|
0.755 |
||
| Health motivation |
0.857 |
|
|
0.678 |
||
|
0.726 |
||
|
0.774 |
||
|
0.796 |
TABLE 3. Test–retest results for The Public Attitude Towards Vaccination Scale – Health Belief Model (N = 30)
|
First evaluation |
Second evaluation |
t test |
p |
r |
|
|
χ (SD) |
|||||
|
Perceived susceptibility |
16.2 (1.8) |
16.2 (1.7) |
−0.109 |
0.914 |
0.867 |
|
Perceived severity |
15.4 (2.3) |
15.5 (2.2) |
−0.258 |
0.798 |
0.833 |
|
Perceived benefits |
23.1 (3.2) |
22.8 (3.4) |
−0.134 |
0.894 |
0.832 |
|
Perceived barriers |
18.1 (4.4) |
17.4 (4.2) |
0.885 |
0.383 |
0.963 |
|
20.1 (2.2) |
20.6 (2.0) |
−1.477 |
0.854 |
· * p < .001.
The primary goal of public health nursing is to protect and improve health. Individual behaviour change is the main intervention to achieve this goal (Smith & Maurer,
2014
). The common ground for many theories and models that are based on behaviour change is to positively affect an individual’s attitude (Champion & Skinner,
2008
; Glanz, Rimer, & Viswanath,
2008
). Immunization is an important health protective behaviour for improvement of public health. Although significant global accomplishments have been made in immunization (WHO
2019a
,
b
), immunization services have again become a field of interest for nurses with the recent increase in the prevalence of vaccine refusal (Paterson et al.,
2016
). It is important to determine the attitudes and opinions of individuals and accordingly make interventions that aim to address vaccine refusal (Larson et al.,
2014
). In this study, a measurement tool that evaluates public attitude towards vaccination was developed based on HBM.
Items of the scale were determined using different sources through the literature and interviews. Basically, the literature concerning vaccination and HBM was used as a source for determining the item pool. Interviews were conducted with mothers: one who had vaccinated her children and another who had refused vaccination. The concepts of HBM included susceptibility, perceived severity, benefits, barriers, and health responsibility. Moreover, confidence was a concept that strongly stood out at this stage. The final scale was prepared according to the opinions of the specialists. Therefore, a comprehensive form was prepared with ideas obtained from various unprofessional and professional sources. This enabled the scale to be easily understood by the public and to analyse the attitudes within an extensive framework. The fact that the measurement tool was readable for individuals with low-level education indicates that it was easily understandable.
Perceived susceptibility is a personal perception of the risk of contracting a disease (Glanz et al.,
2008
). On the other hand, perceived severity is an individual’s perception of the consequences of a disease. Benefit is the awareness of an individual about the benefits of a recommended health protective behaviour. Barrier is the perception of the factors that prevent engagement in a health protective behaviour or that make such engagements difficult. Health motivation indicates an individual’s general interest in and curiosity about health and how much the individual cares about his/her health (Champion & Skinner,
2008
). Awareness about these public attitudes under these headings would result in further realistic interventions that provide an optimal solution. This scale can be used to plan personalized interventions and for the public due to its culture-related nature.
During scale development, it is first recommended to conduct EFA, followed by CFA that evaluates the determined factor structure (Yaşlıoğlu,
2017
). According to the KMO coefficient and Bartlett’s test of sphericity in EFA, it was found that the data had a multivariate normal distribution, sample size was adequate, and it was appropriate to conduct factor analysis (Alpar,
2011
; Burns & Grove,
2001
). EFA revealed that the items of the confidence subdimension did not constitute another dimension. The items of confidence were obviously gathered using the same factor with the items of benefit (Table
1
). Therefore, the scale had five factors, which accounted for 68% of variance. In multifactorial designs, an explained variance between 40% and 60% is considered sufficient (Çokluk et al.,
2012
). However, a higher value was achieved in this study. Accordingly, it is possible that the scale was comprehensive in terms of explaining the public attitude towards vaccination.
CFA is an extension of EFA, which evaluates the underlying data structure and it is used to test whether there is a sufficient relationship among the determined factors and whether these factors are sufficient to explain the model (Erkorkmaz, Etikan, Demir, Özdamar, & Sanisoğlu,
2013
). indexes can be selected and used in CFA (MacCallum & Austin,
2000
; Schreiber et al.,
2006
; Thompson,
2007
). In this study, the conceptual structure of the scale was successfully identified with CFA according to χ2/SD GFI, AGFI, CFI, RMSEA, RMR, SRMR, IFI, PNFI, and PGFI fit indexes.
Reliability of the measurement tool was first assessed using item subdimension total correlation coefficients, which yielded considerably high values, although values of >0.30 are considered sufficient (Büyüköztürk,
2004
). High correlation for an item indicates that the item was effective and sufficient for measuring the target behaviour. Cronbach’s alpha coefficients for all subdimensions and the entire scale were high (0.80 < α < 90; Alpar,
2014
). Items in the scale subdimensions were highly consistent with each other as a whole. High correlation values concerning the time independence of the scale were also remarkable.
HBM is closely associated with the personal attitudes. This scale was created based on the Turkish culture and its validity and reliability study was conducted in Turkish. On the other hand, studies on the attitude towards vaccination or vaccine refusal conducted on different cultures have also defined the factors that affect the said attitude under similar headings. Therefore, the validity and reliability study of this scale should also be conducted in other countries and in different languages.
The PAVS-HBM scale was determined to be valid and reliable. Nurses can use this scale while counselling individuals experiencing vaccine hesitancy/refusal and using it to evaluate the effectiveness of vaccine hesitancy interventions in experimental research. Individual experiences, beliefs and attitudes, awareness, trust in the healthcare system, perceived risk/benefit, and the thought that vaccines are necessary/harmful are the determinants of vaccine refusal at the individual level (Larson et al.,
2015
). We believe that this measurement tool will considerably contribute to the literature in terms of reflecting this framework.
