Instrument to Critique - Development and Validation of the Client Diagnostic Questionnaire - Assignment Example

Instrument to Critique Introduction In Jordan, a health promotion program aimed at high school has been developed recently. This program,which is still in development, is intended to reduce general risk behaviours and increase protective behaviours among the high school students in a variety of areas like alcohol use, dietary behaviours, drug use, hygiene, mental health, physical activity, protective factors, sexual behaviours, tobacco use, violence and unintentional injury. This is a part of the worldwide ongoing health promotion program conducted by the World Health Organization (WHO) to obtain information on the health behaviour and protective factors among students aged 13-15 years (WHO 2007). The objectives of this program are to help countries in developing their priorities; assessment of school health and youth health promotion; establish programmes and advocate for resources for school and youth health programmes and policies; facilitate within country and across country comparisons regarding the occurrence of health risk and protective factors and to establish surveillance systems for health risk behaviours and protective factors(WHO 2007). The WHO has developed the Global School based Student Health Survey (GSHS) in WHO member countries to obtain the information on health risk and protective factors(WHO GSHS) . This survey has a common methodology aimed at schools and has a self-administered questionnaire, which includes core questionnaire modules, core expanded questions and country specific questions. This questionnaire has been developed for Jordan also. This one is being planned to use as the instrument to evaluate whether the health promotion strategies in Jordan have an impact on the health risk behaviours and protective factors of high school students in the city. This paper aims at critically evaluating the validity of the instrument used to measure the impact of health promotion strategies in Jordan. It critically examines the strengths, weaknesses and relevance of the questionnaire developed by WHO as an instrument to a high school bases health promotion program in Jordan. 2. Critical Analysis of the Evaluation Instrument The sample of students from 8th to 10th grades for the survey has been selected through two stage cluster sampling with 25 schools being selected with probability proportional to school enrolment size in the first stage and 70classrooms randomly selected from each classroom in the second stage. Thus, altogether a sample of 2243 students has been selected for the survey. 87 multiple-choice questions have been prepared and the correct choices need to be marked by circles on a computer scanable answer sheet. The questions cover the demographic characteristics of each student, dietary behaviour, personal hygiene, mental health, physical activity, protective factors, tobacco use, violence and unintentional injury during the past 12 months in most cases and for the past 30 days in some cases. These questions cover the frequency of each of the above in the recent past and not the exact quantity(WHO 2007). Appropriateness to the target group The main advantage of this questionnaire is that it is self administered by the student .It is self-explanatory and is easily readable and understandable by the students. It gives examples to show clearly how the answers need to be marked. Thus, the format is easily understandable by the students. It enquires about information on particular behaviours The number of questions is also appropriate so that students can answer them effectively. Thus the instrument can be considered appropriate to the target group ie the children aged 13 to 15 years in Jordan in terms of readability, length and format. Instrument development and administration In spite of all these advantages, since the questionnaire measures the frequency of health risk factors and protective behaviours it can give only poor details with respect to the exact quantity of the various factors involved. Here the students are simply categorized based on the frequency of various health factors and behaviours included. However, a controversial subject whether precision can be sacrificed for administrative easiness and simplicity (Sempos etal 1985). In addition, it is essential to know the exact amount of various health behaviours and risk factors among the students to get a complete picture of the impact of health promotion program. This is needed to meet the goals and objectives of the program completely. There is possibility of under estimation or overestimation if a particular activity is not involved in the questionnaire under each group. This is particularly true in the case of dietary behaviour if a particular food is not included in the questionnaire. There can be bias in favour of the included food item in this case(Block 1982). In the case of physical activity, only questions regarding the frequency of total and rigorous physical activity are covered. However, it cannot precisely assess whether the physical activity is at sufficient levels prescribed by the guidelines or the exact amounts of moderate and vigorous physical activity done by many studies(Marshall etal 2005). Hence, the instrument has to be validated based on other established reference methods. The 24-hour recall method, which has been extensively used in many studies and programs may be used as one evaluation method for the validation of this instrument(Johnson etal 2001). This can also be self administered and the questions may be about the amount of various health risk factors including the amount of food consumed, amount of various types of physical activity done and other protective behaviours on the previous day. However, there can be limitations for this method also because of the lack of memory in recalls and high costs involved in it etc. The data obtained from the frequency questionnaire used in the health promotion program may be compared with this 24-hour recall method to examine the validity of the results. Each component in the frequency questionnaire can be validated based on certain established reference methods in addition to the 24-hour recall method. In the case of dietary behaviours, the instrument can be validated based on a food diary method with interview after the survey with frequency questionnaire(Johnson etal 2001).The students may be asked to record all the food items in taken in a small diary for two three days. Then the information provided on the food may be clarified with interview by trained professionals and thereby assess the portion sizes .The portion sizes or weights of the portion of food consumed may be determined sing food atlas or photographs of all food items taken by the researchers based on previously defined criteria. The students themselves can grade their food intake as higher or lower based on the photographs. The results from this food diary method may be compared with the results from the frequency questionnaire to evaluate the validity of the questionnaire as an instrument. In addition to these, the dietary history method may be used as another evaluation method to check the validity of the instrument(Burke 1947). In the case of physical activity, the results from the questionnaire may be validated based on the results reported by Computer Science and Accelerometer (CSA)(Marshall etal 2005). The students may be told to wear a CSA physical activity monitor for the next few days after the survey based on frequency questionnaire. The data for physical activity reported by this may be considered as a criterion for the validity of the physical activity data obtained from the survey. Both the data need to be compared and if there exists an agreement between the two, then the instrument under consideration can be considered as valid. For checking the validity of data obtained for mental health and sexual behaviours, the diagnosis made by an independent mental health professional may be used as a relevant criterion. There needs to be very high agreement between the data based on the two as shown by many studies (Aidala etal 2004). The agreement between the data collected using the instrument and other relevant criteria can be estimates using k statistic and Pearson’s correlation coefficients. The most important advantage of the frequency questionnaire is that it can be validated based on relevant criteria. Thus, the instrument meets the objectives of the program provided it is validated based on these criteria. The instrument can be administered immediately and cheaply. Since the answers are marked on a computer scanable data sheet, they can be coded and analyzed very easily. Generalisability The main disadvantage of this type of instrument is that it may not be comparable across countries due to the cultural differences between the people that may affect the health risk factors and protective behaviours. In this case, however, this limitation is taken care of by WHO. It has developed country specific questions for all WHO member countries also other than the core questions and expanded questions. Hence, this instrument can be extended to other members of the target group. This instrument can also be used in other programs and other contexts. For example, it has been used as a diagnostic screening tool for non-mental health professionals to find the extent of psychiatric disorder among HIV infected individuals and to examine the extent of physical activity among patients by the family doctors. It has also been used to assess the extent of specific nutrient intakes among various populations(Thompson etal 2009). In all the cases, the instrument needs to be validated by a relevant criterion. Conclusion As a part of the ongoing health promotion program of the WHO in the WHO member countries, Jordan also has a health promotion program aimed at high school students there aged from 13 to 15 years. This has been intended to reduce health risk factors and increase protective behaviours among high school children. For estimating the impact of this health promotion program, the frequency questionnaire-covering question on the leading cases of mortality and morbidity among high school children has been selected as the instrument. The critical evaluation of this instrument shows that it is quite easily readable and appropriate to the target group. Besides, it can be easily administered and very cheap. In spite of the advantages of the instrument, it does not assess the exact quantity if various factors involved and only the frequency. The precise quantity is also needed to completely assess the impact of health promotion programs on children. Besides there can be measurement error due to over or underestimation if a particular factor is not included under a certain group. Hence, the instrument needs to be validated against relevant criterion like 24-hour recall method. Further data for each component of the questionnaire needs to be validated by relevant and established criteria separately. In fact, one of the main advantages of the instrument here is that it can be tested for its validity. Several studies based on frequency questionnaire have fond high agreement between the data obtained from frequency questionnaire and other criteria using techniques like k statistic and Pearson’s correlation coefficients. Hence, the instrument can be considered as valid and reliable in general. References Aidala A ., J Havens, C. A. Mellins, S. Dodds,K. Whetten, D. Martin, L. Gillis and P. KO.2004 . Development and validation of the Client Diagnostic Questionnaire (CDQ): a mental health-screening tool for use in HIV/AIDS service settings. Psychology, Health and Medicine.9.3 362-379 Block G. 1982. A review of validations of dietary assessment methods. Am J Epidemiol 115. 492–505. Burke B. 1947. The dietary history as a tool in research. J. Am. Diet. Assoc. 1041 -1046. Johnson B., A. Hackett,  M. Roundfield and A. Coufopoulos .2001. An investigation of the validity and reliability of a food intake questionnaire. J Hum Nutr Dietet. 14. 457-465 Marshall A L., B J Smith, A E Bauman and S Kaur.2005. Reliability and validity of a brief physical activity assessment for use by family doctors. Br J Sports Med .39:294–297. Sempos C T., Johnson N E and Smith E L . 1985. Effects of intraindividual and interindividual variation in repeated dietary records. Am J Epidemiol . 121: 120–30. Thompson, AH ., Trina P. Robertson and Deborah E. Sellmeyer .2009. Validation of Two Food Frequency Questionnaires for Dietary Calcium Assessment. Journal of the American Dietetic Association 109. 7 . WHO GSHS Global Student based Student Health Survey.2007. http://www.who.int/chp/gshs/en/index.html . WHO.2007 Jordan Global Student based Student Health Survey Country Report WHO Read More