572632

JHNXXX10.1177/0898010115572632Journal of Holistic NursingPsychometric Properties of the EtWeQ / Fridlund et al.

1

Conceptual/Theoretical

Establishing the Psychometric Properties of the Comprehensive Ethos Towards Wellness Questionnaire in a Norwegian Population Bengt Fridlund, RNT, BScEd, PhD, FESC Jan Mårtensson, RN, PhD, FESC

jhn

research-article2015

Journal of Holistic Nursing American Holistic Nurses Association Volume XX Number X XXXX 201X 1­–8 © The Author(s) 2015 10.1177/0898010115572632 http://jhn.sagepub.com

Jönköping University, Sweden

Amir Baigi, PhD Region of Halland, Sweden

Anders Broström, RN, PhD Jönköping University, Sweden

Aim: to replicate and establish the psychometric properties of the 74-item comprehensive Ethos Towards Wellness Questionnaire in a healthy Norwegian population in terms of content and construct validity as well as homogeneity and stability reliability. Method: A questionnaire with a methodological and developmental design was sent on two occasions to 214 healthy middle-aged participants and processed in two phases. Results: The three life context and the ethos indexes at ordinal scale level showed an overall satisfactory construct validity (communalities > 0.30, factor loadings > 0.30, and factor total variance > 50%). On two occasions 4 weeks apart, reliability in terms of homogeneity (Cronbach’s α > .70) and stability (intraclass correlation coefficient > 0.70) were also considered satisfactory for the same four indexes. Conclusions: This newly developed and possibly only questionnaire that focuses on “grasping the big human picture,” based on both philosophical reasoning and empirical recommendations of wellness, was found to be valid and reliable in the screening and follow-up of wellness and ethos in a healthy Norwegian population. Keywords: wellness; holistic; health factors; ethos; work factors; family; spare time; validity; reliability

Introduction Wellness is a multidimensional state of being, describing an individual’s ethos toward health with a focus on well-being and quality of life (Corbin & Pangrazi, 2001; Saylor, 2004). It can be said to reflect the positive dimensions of a holistic attitude including subjective and emotional–relational conditions (Miller & Foster, 2010). The wellness concept represents more than just the absence of negative elements (e.g., illness and disease), as it includes positive elements such as health and happiness. It also involves a context in which the individual exists, is amenable, and creates a role identity, by responding to the behaviors and attitudes of society, family members, relatives, friends, and colleagues.

The meaning or influence of such relationships on wellness is dependent on the individual’s needs and demands, as well as on what resources for support a person can mobilize or receive from others (sense of coherence: Antonovsky, 1979; and social support: House, 1981) to maintain or restore wellness. Overall, the concept predicts the motivation to achieve individual wellness. How work and family life positively or negatively affect the individual’s wellness in relation to job demands, personal resources, and support from coworkers, managers, Authors’ Note: Please address correspondence to Bengt Fridlund, School of Health Sciences, Jönköping University, P.O. Box 1026, Jönköping, S-551 11 Sweden; email: bengt.fridlund@ hhj.hj.se.

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2  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX

and family has been identified in a few recent European studies. Role stress at work and familyrelated stress are described as the major threats to health and wellness (Dziak, Janzen, & Muhajarine, 2010; Niedhammer, Chastang, Sultan-Taïeb, Vermeylen, & Parent-Thirion, 2013; Nordlund et al., 2010; Repetti, Wang, & Saxbe, 2011; Sperlich, Arnhold-Kerri, & Geyer, 2011). Nevertheless, there are no documented wellness interventions based on an ethos perspective, that is, referring to a holistic perspective of an individual’s beliefs and motives that characterize and influence his or her wellness and health. One reason for the lack of such interventions is the absence of validated instruments to measure the concept of wellness due to lack of agreement among researchers on its holistic-dimensional structure (Roscoe, 2009). Recently, the comprehensive Ethos Towards Wellness Questionnaire (EtWeQ) was developed based on such a structure (Fridlund & Baigi, 2014). The instrument had promising psychometric results when tested in a Swedish middle-aged population, but further validation is necessary. Accordingly, the aim of this study was to replicate and establish the psychometric properties of the Swedish EtWeQ in a healthy Norwegian population in terms of content and construct validity as well as homogeneity and stability reliability.

Material and Method Design and Setting The study had a methodological and evaluative design that adhered to the Norwegian Information Act. It was carried out in two phases in a Norwegian context. Participants were recruited from a consecutive sample of healthy people (N = 10.121) who participated in an annual national Norwegian fitness campaign (http://dytt.no/).

The EtWeQ As can be seen in Figure 1, in addition to individual basic characteristics (7 items), the questionnaire contains a total of six indexes: two health indexes (healthiness, 17 items; unhealthiness, 14 items), three life context indexes (work, 9 items; family, 9 items; spare time, 9 items), and the comprehensive Ethos Brief Index (9 items). The items in the Individual Basic Characteristics, the Healthiness, and the Unhealthiness Indexes are responded to with

Yes/No or with a figure (how much, how often). The three life context indexes Work Life Context Index, Family Life Context Index, and Spare Time Life Context Index, as well as the comprehensive Ethos Brief Index are scored on a scale from 0 (very bad) to 10 (very good). All indexes are weighted, based on, and adapted to, recommendations from national guidelines or authorities (Fridlund & Baigi, 2014). The Healthiness Index yields 2 points per constituent for a positive health outcome with full adherence, 1 point for partially adhering to (i.e., around 10% to 15% above/below the stipulated recommendations), and 0 points for not adhering to the recommendations. For example, in the item sleep, 6 to 8 hours sleep = 2 points; 5 to 6 or 9 to 10 hours sleep = 1 point; and 10 hours sleep = 0 point. In the Unhealthiness Index, the absence of unhealthiness or adherence to national guideline recommendations yields a score of 1 point per constituent. For example, 1 point indicates no known cardiovascular disease and experiencing no negative stress at all; and 0 points indicate illness, ill health, or vicious life habits (e.g., experiencing negative stress several times a week to daily). Finally, the three Life Context Indexes as well as the comprehensive Ethos Brief Index were weighted on the same basis, that is, 80% or more per index equals 2 points, 79% to 60% yield 1 point, and 59% or less 0 points. The scores of the health indexes were summarized as sum totals with minimum to maximum points of 0 to 34 for the Healthiness and 0 to 14 points for the Unhealthiness Index. Cutoff values were set: excellent (≥80%), good (60% to 79%), and not so good (1, including items with communalities >0.30, factor loadings >0.30, and a total variance of >50% (Rattray & Jones, 2007). Homogeneity reliability was tested using Cronbach’s alpha coefficient (>.70; Rattray & Jones, 2007), while repeatability stability reliability was tested by means of the intraclass correlation coefficient (ICC; >.70).

Participants and Sampling For methodological reasons, especially when performing a factor analysis, a sample of 5 to 10 participants per item is stipulated; therefore, at least 100 participants were required for each nineitem index. Two hundred fourteen participants were thus considered more than adequate and were recruited from the annual Norwegian nationwide fitness implementation program (http://dytt.no/), that is, >2% of 10,121. The focus of the program was engaging in healthy exercise as well as adherence to national medical and behavioral guideline recommendations regarding diet and social habits. The responses of the first participants to complete the questionnaire on two occasions (i.e., within a 4-week period) were collected for analyses. The distribution with regard to sex, age, and highest educational level was women 83%, mean age 41.7 years (SD = 10.7), and third-level education 48%; men 17%, mean age 43.0 years (SD = 10.4), and thirdlevel education 38%.

all theoretical and conceptual analogy in addition to the affinity with the original Swedish version, it was decided to retain the constituents and index as the overall statistical figures were acceptable. The Life Context Indexes and the comprehensive Ethos Brief Index loaded on four distinct factors with a total variance in each factor from 53% to 68%. Variation in factor loadings for each of the factors was as follows: 0.57 to 0.82 for the Work Life Context Index, 0.59 to 0.86 for the Family Life Context Index, 0.57 to 0.92 for the Spare Time Life Context Index, and 0.51 to 0.86 for the comprehensive Ethos Brief Index (see Table 1).

Homogeneity and Stability Reliability The constituents of the six indexes were considered feasible and understandable, as well as readable and easy to score repeatedly. Homogeneity reliability, in terms of Cronbach’s alpha coefficient, was considered good in all four Life Context/Ethos Brief Indexes on both occasions, that is, 0.94 and 0.92 for the Work Life Context Index, 0.92 and 0.93 for the Family Life Context Index, 0.94 and 0.96 for the Spare Time Life Context Index, and 0.88 and 0.89 for the comprehensive Ethos Brief Index (see Table 2). The ICC figures for the Work Life Context Index, the Family Life Context Index, the Spare Time Life Context Index, and the comprehensive Ethos Brief Index were 0.63 to 0.86, 0.71 to 0.83, 0.62 to 0.83, and 0.72 to 0.86, respectively. Two constituents were somewhat below the stipulated level of 0.70 for stability reliability, that is, 0.63 in the Work Life Context Index and 0.62 in the Spare Time Life Context Index. Both constituents were, however, retained because the figures were not critical and their items contributed to the indexes as well as to the above-mentioned conceptual and theoretical reasoning.

Results Discussion

Construct Validity The meaning of each constituent and its relation to each index and the Swedish version were scrutinized both statistically and theoretically. The content and readability were deemed satisfactory, and thus no changes were necessary. The comprehensive Ethos Brief Index was found to have one low communality score (0.26). However, in view of the over-

Only one other instrument that measures ethos, the 75-item Personal Wellness Profile (PWP) questionnaire, has been identified (Brown, Geiselman, Copeland, Gordon, & Richard-Eaglin, 2008). The PWP is a newly developed instrument based on national medical and behavioral guidelines, but in contrast to the EtWeQ, it has no philosophical roots.

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Psychometric Properties of the EtWeQ / Fridlund et al.   5 Table 1.  Construct Validity (Explorative Factor Analysis With Principal Component Analysis and Varimax Rotation With Kaiser Normalization), n = 214 Life Context/Comprehensive Index Including Constituents/ Factors Loadings Work Life Context Index   My workplace cares about me   I adapt to workplace needs and demands   I feel balance and harmony in my work   I thrive with my work colleagues   I thrive with my managers   I thrive in my work role   I feel meaningful in my workplace   I contribute to the development of my workplace   I feel appreciated and receive the salary and benefits that I deserve Family Life Context Index   My family cares about me   I adapt to my family’s needs and demands   I feel balance and harmony in my family   I thrive with my family   I thrive in my home   I thrive in my family role   I feel meaningful to my family   I contribute to the development of my family   I feel appreciated and receive love and friendship in return for the contributions that I make Spare Time Life Context Index   My friends and relatives care about me   I adapt to my friends’ and relatives’ needs and demand   I feel balance and harmony in my social life   I thrive among my friends and relatives   I thrive during my spare time   I thrive among my friends and relatives in my spare time role   I feel meaningful to my friends and relatives   I contribute to the development of my friends and relatives   I feel appreciated and receive love and friendship in return for the contributions that I make Ethos Brief Index   I am satisfied with my work   I am satisfied with my family   I am satisfied with my housing   I am satisfied with my social life   I am satisfied with my financial situation   I am satisfied with my leisure time   I am satisfied with my living habits/lifestyle   I am satisfied with my health   I am satisfied with my overall life situation

The EtWeQ has its ontology in humanism and its epistemology in the emic world, which means that it covers how an individual thinks, how an individual perceives the world, the rules of behavior, what has

Total variance (%)

Work

Family

Spare Time

Ethos

53

Communalities   0.62 0.32 0.62 0.53 0.53 0.58 0.68 0.49 0.46

0.79 0.57 0.79 0.73 0.73 0.76 0.82 0.68 0.68 61

  0.64 0.35 0.71 0.73 0.38 0.71 0.72 0.61 0.60

0.80 0.59 0.84 0.86 0.62 0.84 0.85 0.78 0.78 68

  0.68 0.33 0.79 0.74 0.55 0.74 0.84 0.61 0.82

0.82 0.57 0.89 0.86 0.74 0.88 0.92 0.78 0.92 53 0.51 0.64 0.66 0.80 0.62 0.84 0.83 0.72 0.86

  0.26 0.40 0.43 0.64 0.38 0.71 0.69 0.51 0.74

meaning, and how he or she imagines and explains things (Creswell, 2013). It was designed to measure not only wellness but also the distinctive and holistic spirit of the individual (Corbin & Pangrazi, 2001).

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6  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX Table 2.  Homogeneity Reliability (Cronbach’s α) and Stability Reliability (ICC), n = 214 Life Context/Comprehensive Index and Constituents Work Life Context Index   My workplace cares about me   I adapt to workplace needs and demands   I feel balance and harmony in my work   I thrive with my work colleagues   I thrive with my managers   I thrive in my work role   I feel meaningful in my workplace   I contribute to the development of my workplace   I feel appreciated and receive the salary and benefits that I deserve Family Life Context Index   My family cares about me   I adapt to my family’s needs and demands   I feel balance and harmony in my family   I thrive with my family   I thrive in my home   I thrive in my family role   I feel meaningful to my family   I contribute to the development of my family   I feel appreciated and receive love and friendship in return for the contributions that I make Spare Time Life Context Index   My friends and relatives care about me   I adapt to my friends’ and relatives’ needs and demands   I feel balance and harmony in my social life   I thrive among my friends and relatives   I thrive during my spare time   I thrive among my friends and relatives in my spare time role   I feel meaningful to my friends and relatives   I contribute to the development of my friends and relatives   I feel appreciated and receive love and friendship in return for the contributions that I make Ethos Brief Index   I am satisfied with my work   I am satisfied with my family   I am satisfied with my housing   I am satisfied with my social life   I am satisfied with my financial situation   I am satisfied with my leisure time   I am satisfied with my living habits/lifestyle   I am satisfied with my health   I am satisfied with my overall life situation

ICC

95% CI

.78 .63 .79 .74 .86 .78 .77 .80 .77

[.71, [.52, [.72, [.66, [.82, [.71, [.70, [.74, [.70,

.83] .72] .84] .80] .90] .83] .83] .85] .82]

.82 .71 .83 .83 .71 .77 .80 .74 .77

[.76, [.62, [.77, [.77, [.63, [.70, [.71, [.66, [.70,

.86] .77] .87] .87] .78] .82] .83] .80] .82]

.81 .62 .81 .79 0.74 0.83 .81 .78 .81

[.75, [.50, [.74, [.72, [.65, [.77, [.75, [.72, [.76,

.85] .71] .85] .84] .80] .87] .85] .86] .86]

.77 .77 .72 .82 .86 .77 .80 .80 .80

[.70, [.70, [.63, [.76, [.82, [.70, [.74, [.75, [.73,

.83] .83] .78] .86] .89] .83] .85] .85] .84]

Cronbach’s α, First Occasion

Cronbach’s α, Second Occasion, After 4 Weeks

.94

.92                  

.92

.93                  

.94

.96                  

.88

.89                  

Note: ICC = intraclass correlation coefficient; CI = confidence interval.

Furthermore, the PWP has been tested only once for psychometric properties in a small sample of African American female college students (Brown et  al., 2008), while the EtWeQ has been tested on both

sexes in a healthy middle-aged Swedish population (Fridlund & Baigi, 2014). The replication of the validation procedure in a Norwegian population was logical as the Swedish and Norwegian cultural contexts

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Psychometric Properties of the EtWeQ / Fridlund et al.   7

are quite similar. It was no surprise to find that the Norwegian figures corresponded well with those from the Swedish sample (http://dytt.no/). A multiprofessional expert panel considered that the original Swedish version had content validity. This was confirmed in the present study by a pilot test focusing on context and readability, response alternatives, constituents, and indexes. The same six indexes (i.e., Healthiness, Unhealthiness, Work Life Context, Family Life Context, Spare Time Life Context, and the comprehensive Ethos Brief Index) were identified in both the Norwegian and the Swedish context. The latter four indexes comprising constituents at ordinal scale level were used in a factor analysis and found to have good to excellent communalities (>0.30), factor loadings (>0.30), and factors (>50%) in the present Norwegian population. A minor limitation in terms of construct validity (Rattray & Jones, 2007) was the fact that one of the communalities of the Ethos Brief Index was somewhat low, 0.26. However, this was found to be acceptable when establishing a new instrument. As validity and reliability are linked, it is likely that the reliability figures are sufficient. Accordingly, both the homogeneity and the stability showed good to excellent relationships in the Norwegian context. On both occasions, with a 4-week interval, the homogeneity was excellent (Rattray & Jones, 2007), and logically the figures were somewhat higher after 4 weeks. With regard to 4-week stability, the figures were also good to excellent. However, according to Cohen, Cohen, West, and Aiken (2003), two items, one in the Work Life Context index (0.63) and the other in the Spare Time Life Context (0.62) index, exhibited a moderate to good relationship (0.50-0.75).

Limitations The selection of the population is always crucial. The present sample was a self-selected group of middle-aged, well-educated, and mostly female Norwegian participants with an apparent interest in their health and ethos. This must be taken into consideration when generalizing the outcomes but is of less importance when testing the psychometric properties of the EtWeQ. Furthermore, as the questionnaire is based on self-reported information, it may well be that the participants were reluctant to disclose sensitive data that they deemed too private. This must be taken into account as it often occurs in

studies that employ patient-related outcomes measures (Magasi et al., 2012). The attempt to grasp the whole often implies a huge battery of instruments, and 74 items may be an overly large number. However, this number is quite relevant from the humanistic perspective of understanding an individual’s wellness and ethos (Creswell, 2013; Saylor, 2004). A further limitation is the fact that concurrent validity could not be controlled for (Rattray & Jones, 2007) due to the absence of a previously validated comprehensive questionnaire based on both philosophical and empirical foundations.

Conclusions and Implications In the replication and establishment process of one of the few questionnaires that “grasp the big picture” of human beings, based on both philosophical reasoning and empirical recommendations about wellness, it was found that the EtWeQ is a valid and reliable measure for screening or follow-up of healthy people in a Norwegian cultural context. The EtWeQ can provide researchers and clinicians with a standardized and inexpensive resource for computergenerated information, such as comprehensive individualized descriptions or summary reports at group level in different settings, which can be used for guidance to achieve wellness and improved ethos. Recommendations for future research include replication of this study in various ethnic and age groups, as well as in patients with a range of diagnoses in other European countries.

References Antonovsky, A. (1979). Health, stress and coping. San Francisco, CA: Jossey-Bass. Brown, S. C., Geiselman, P. J., Copeland, A. L., Gordon, C., & Richard-Eaglin, A. (2008). Reliability and validity of the Personal Wellness Profile (PWP) questionnaire in African American college women. Journal of Cultural Diversity, 15, 163-167. Cohen, J., Cohen, P., West, S. G., & Aiken, L. (2003). Applied multiple regression/correlation analysis for the behavioral science (3rd ed.). Mahwah, NJ: Lawrence Erlbaum. Corbin, C. B., & Pangrazi, R. P. (2001). Toward a uniform definition of wellness. Research Digest, 3, 1-8. Creswell, J. W. (2013). Qualitative enquiry and research design: Choosing among five traditions. London, England: Sage.

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8  Journal of Holistic Nursing / Vol. XX, No. X, Month XXXX Dziak, E., Janzen, B. L., & Muhajarine, N. (2010). Inequalities in the psychological wellbeing of employed, single and partnered mothers: The role of psychosocial work quality and work-family conflict. International Journal for Equity in Health, 9, 6. Fridlund, B., & Baigi, A. (2014). Developing and establishing the psychometric properties of an Ethos Towards Wellness Questionnaire (EtWeQ). Open Journal of Nursing, 5, 1-10. House, J. S. (1981). Work stress and social support. Reading, MA: Addison-Wesley. Magasi, S., Ryan, G., Revicki, D., Lenderking, W., Hays, R. D., Brod, M., . . . Cella, D. (2012). Content validity of patient-reported outcome measures: Perspectives from a PROMIS meeting. Quality of Life Research, 21, 739-746. Miller, G., & Foster, L. T. (2010). Critical synthesis of wellness literature. Victoria, British Columbia, Canada: University of Victoria, Faculty of Human and Social Development. Niedhammer, I., Chastang, J. F., Sultan-Taïeb, H., Vermeylen, G., & Parent-Thirion, A. (2013). Psychosocial work factors and sickness in 31 countries in Europe. European Journal of Public Health, 23(4), 22-29. Nordlund, S., Reuterwall, C., Höög, J., Lindahl, B., Janlert, U., & Birgander, L. S. (2010). Burnout, working conditions and gender: Results from the northern Sweden MONICA Study. BMC Public Health, 10, 326. Rattray, J., & Jones, M. C. (2007). Essential elements of questionnaire design and development. Journal of Clinical Nursing, 16, 234-243.

Repetti, R. L., Wang, S., & Saxbe, D. E. (2011). Adult health in the context of every family life. Annals of Behavioral Medicine, 42, 285-293. Roscoe, L. J. (2009). Wellness: A review of theory and measurements for counselors. Journal of Counseling & Development, 87, 216-226. Saylor, C. (2004). The circle of health: A health definition model. Journal of Holistic Nursing, 22, 97-115. Sperlich, S., Arnhold-Kerri, S., & Geyer, S. (2011). What accounts for depressive symptoms among mothers? The impact of socioeconomic status, family structure and psychosocial stress. International Journal of Public Health, 56, 385-396. Bengt Fridlund, RNT, BScEd, PhD, FESC, is a Professor and Research Director at the School of Health Sciences, Jönköping University, Jönköping Sweden, and a Professor at the Faculty of Health and Social Sciences, Bergen University College, Bergen Norway. Jan Mårtensson, RN, PhD, FESC, is a Professor at the School of Health Sciences, Jönköping University, Jönköping Sweden, and a Professor at the Faculty of Health and Social Sciences, Bergen University College, Bergen Norway. Amir Baigi, PhD, is a Statistician and Epidemiologist at the Region of Halland, Halmstad, and an Associate Professor at the Sahlgrenska Academy, Göteborg University, Göteborg Sweden. Anders Broström, RN, PhD, is a Professor at the School of Health Sciences, Jönköping University, Sweden, and a Professor at the Faculty of Health and Social Sciences, Bergen University College, Bergen Norway.

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Establishing the Psychometric Properties of the Comprehensive Ethos Towards Wellness Questionnaire in a Norwegian Population.

to replicate and establish the psychometric properties of the 74-item comprehensive Ethos Towards Wellness Questionnaire in a healthy Norwegian popula...
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