|Year : 2021 | Volume
| Issue : 1 | Page : 39-44
Measuring medical graduate behavioral intention for administering on-site care to road traffic accident victims: Development and validation of a questionnaire
Neeti Rustagi1, Abhishek Jaiswal2, Dervla Kelly3, Naveen Dutt4, Arvind Sinha5, Pankaja Raghav6
1 Additional Professor, Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Senior Resident, Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Lecturer, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
4 Additional Professor, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
5 Professor and Head of Department, Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
6 Professor and Head of Department, Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Submission||03-Apr-2020|
|Date of Decision||03-Jul-2020|
|Date of Acceptance||12-Aug-2020|
|Date of Web Publication||20-Mar-2021|
Department of Community Medicine and Family Medicine, 2nd Floor, All India Institute of Medical Sciences, Basni Industrial Area, MIA, 2nd Phase, Basni, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Prehospital trauma care skills are often taught and assessed in undergraduate medical curricula but the intention to voluntarily offer these skills in out of hospital or primary care settings is poorly understood. Objectives: The objective is to develop and validate a questionnaire measuring behavioral intention among medical graduates for administering on-site care to road accident victims. Methods: A cross-sectional study was conducted from September 2018 to February 2019, among medical graduates of an academic institution in Jodhpur, Rajasthan. Items for “Measure of Intention to help road accident victim (MIHRAV) instrument” were framed as per the constructs of theory of planned behavior. A total of 150 candidates undergoing internship were approached for informed consent and a link for online questionnaire was shared. Statistical Analysis: Exploratory factor analysis (EFA) and tests for convergent, discriminant, and predictive validity was done using IBM SPSS version 23.0 for psychometric validation of scale. Results: Original version of MIHRAV included 29 items which were reduced to 18 items. EFA identified five factors which explained 72% of cumulative variance with high Cronbach's α (0.920). Discriminant validity showed adequate correlations ranging from 0.283 to 0.541. Predictive validity demonstrated that model was significantly able to predict “behavioural intention to help” (F (4128) = 24.139, P = 0.0001) and explained 43% of variance. Conclusion: The findings reveal that developed instrument “MIHRAV” is a reliable and valid scale for predicting behavioral intention among medical graduates for administering onsite care to road accident victims.
Keywords: “Intention,” “road traffic accidents,” “scale development”, “theory of planned behaviour,” “validation”
|How to cite this article:|
Rustagi N, Jaiswal A, Kelly D, Dutt N, Sinha A, Raghav P. Measuring medical graduate behavioral intention for administering on-site care to road traffic accident victims: Development and validation of a questionnaire. Indian J Public Health 2021;65:39-44
|How to cite this URL:|
Rustagi N, Jaiswal A, Kelly D, Dutt N, Sinha A, Raghav P. Measuring medical graduate behavioral intention for administering on-site care to road traffic accident victims: Development and validation of a questionnaire. Indian J Public Health [serial online] 2021 [cited 2021 Apr 10];65:39-44. Available from: https://www.ijph.in/text.asp?2021/65/1/39/311520
| Introduction|| |
Road traffic accidents (RTAs) have emerged as an important public health issue, with the greatest burden contributed by low-income and middle-income countries.
Deaths due to road injuries in India had shown increase of 58·7% from 1990 to 2017 as compared to global increase of 8%. Suchalarming rise in burden of RTAs in countries such as India with increasing urbanization and rising vehicular population is a cause of concern.
Quality prehospital trauma care is recognized as an essential link in continuum of care for road accident victims. The efficiency of emergency medical services (EMS) system depends on ability of bystanders to recognize emergency, to activate the EMS system and to provide direct care till the time of EMS arrival. However, inadequate prehospital and hospital-based trauma care for road accident victims has been reported, particularly in low- and middle-income countries., Lack of helping behavior during emergencies even with improved clinical competence and training has previously been reported and is ascribed to various factors as lack of confidence, fear of forgetting techniques or making mistakes and not receiving training.,, Latané and Darley explained a five-step decision-making model adopted by bystanders on facing situations of life-threatening emergencies. After the occurrence of potential emergency: (a) It first catches the attention of the bystanders, who (b) then weighs the emergency, (c) decides on his obligation, (d) his belief of competence, and then ultimately (e) makes the decision whether to help or not. The model predicts that factors interrupting this decision-making process at any step will inhibit any helping behavior or intervention.
The voluntary nature of offering help to an accident victim and the perceived self-efficacy can be preferably explained by socio-behavioral public health approach as per the constructs of theory of planned behavior where the intention to help an accident victim is believed to be influenced by learner's attitudes toward the deliberate action of helping an accident victim, the learner's perceptions of social expectation, understanding of normative behaviors, and the confidence of the learner, i.e., perceived self-efficacy to successfully enact the helping behaviors.,
Prehospital skills, including ensuring airway patency, relieving respiratory distress, adequate hemorrhage control and required spinal care are often taught and assessed in medical curricula. The understanding about the requirements for voluntarily offering these skills in an “out of hospital” or primary care settings is poor. Given the rising fatalities due to RTAs, we propose a mandatory inclusion and integration of prehospital skill's in the undergraduate medical curricula.
In conjunction with adequate training, the self-efficacy of medical graduates in administering these skills at the site of incident need to be emphasized. Bandura's self-efficacy theory has provided a theoretical basis and methodology to explore an individual's social skills, sense of control in negotiating situations and beliefs about personal ability in areas of condom use, smoking, weight control, alcohol abuse, and exercise. Self-efficacy is defined as expectation's about one's ability to perform a specific behavior and is considered as an essential mediator between knowledge and action. No researcher has till date addressed self-efficacy and helping behavior of medical graduates or other health personnel towards accident victims at the site of incident or in resource constrained settings. No self-efficacy scale for pro-social behavior currently exists and without such a measure, it is impossible to apply the self-efficacy models to predict behavioral intention among medical graduates towards accident victims in administering on-site trauma care.
Miller and Pellegrino have emphasized that likelihood of using the knowledge and skills to help a victim in an emergency situation is associated with affective domain which influences the person's intention or motivation to help. Unlike the knowledge and skills which can be objectively assessed, the measures of affective component especially in case of emergencies is less widely studied or known. Assessment of affective domain by theory of planned behavior (TPB) construct along with knowledge (cognitive domain) and skills (psychomotor domain) may be better at predicting the enactment of target behavior of “helpinga road accident victim.” Further, understanding influence of affective domain in context of emergencies can provide evidence for innovations in curriculum for enhancing learner's intent to help and may contribute in improving survival rate among road accident victims.
Given a lack of comprehensive, reliable, and valid questionnaire, the present study attempted to develop and validate a questionnaire to measure behavioral intention among medical graduates for administering on site care to RTA victims.
| Materials and Methods|| |
Study deign and setting
This cross-sectional study was conducted over a period of 6 months, from September 2018 to February 2019 among medical graduates of an academic institution in Jodhpur, Rajasthan.
Phases of the study
This study consisted of two phases: Phase 1-Questionnaire (instrument) design (through items development and an expert panel review) and Phase 2-Questionnaire (instrument) evaluation.
Phase 1-instrument design
A literature search was conducted to identify instruments that may be related to factors influencing bystander's intention and helping behavior toward RTA victims. The search was guided using combination of different keywords including helping behavior, accidents, traffic accidents, bystanders, and theory of planned behavior. The search engines included PubMed, Science Direct and Google Scholar. As research team was unable to identify any questionnaire related to measure of intention among medical graduates as bystanders, items for new instrument was framed through literature review as per the constructs of theory of planned behavior. Items and scoring were formulated in accordance with the paper by Francis et al. For initial content validity, the peer review was solicited by experts in field of emergency and trauma care and edits were made based on provided feedback.
Phase 2-administration and instrument evaluation
The final version of the instrument - Measure of Intention to help road accident victim (MIHRAV) questionnaire composed of 29 items and six subscales (attitude toward road accident victim, subjective norm, perceived competency in managing an accident victim, intention and past experience of managing an accident victim, perceived competence for learning prehospital trauma care skills and perceived competence for helping a road side accident victim). The survey instrument included 29 items, all measured on a 7-point Likert scale (1 = Disagree/unlikely/unpleasant, 4 = Moderately, and 7 = Agree/likely/pleasant).
Assessment of validity of the instrument
The investigator distributed the prefinal version of the questionnaire to the target population for face value evaluation. During this phase, ten medical graduates were cognitively debriefed. Ten respondents are deemed to be sufficient using an interview type of pilot testing (Eremenco, 2005). The respondents were interviewed and asked to identify words or sentences that they did not understand. The respondents were encouraged to suggest an alternate suitable words with which they were familiar. The feedback of participants was discussed with other investigators in the research team, and the final version of questionnaire was decided.
Application of the questionnaire Participants and data collection
The sample size was estimated on the basis of planned procedure for factor analysis. Thus, as recommended to ensure a conceptually clear factor structure for analysis, a sample of minimum 5 participants per item was considered. Thus, the required minimum sample size was estimated to be 150 (29 items were in the questionnaire).
Participants and data collection
Complete enumeration of medical graduates of two consecutive years undergoing internship training program (in total 150 interns) in an academic medical institute was done. All efforts were taken to preserve anonymity and confidentiality of the participants. The participants were informed about the aim of the study and were asked to complete an online self-administered questionnaire. Information on age and gender was collected to describe the participant characteristics. Of the total 150 interns who consented for the study, 133 completed the online survey. Each participant was approached a minimum of three times to return the completed response to questionnaire.
This study was part of an Indian Council of Medical Research project and ethical clearance for performing this study was obtained from the Institutional Ethics Committee (AIIMS/IEC/2018/1188, dated 02.05.2018). All the eligible participants were informed about the purpose of the study, and were assured regarding the confidentiality of the information obtained. Written informed consent for participating in the study was obtained from all of them.
The demographic data were analyzed by descriptive statistics using IBM SPSS version 23.0. To analyze the psychometric properties, descriptive statistics were used for all items, followed by an exploratory factor analysis (EFA) and reliability analysis.
The reliability of the questionnaire was determined by internal consistency (Cronbach's alpha) coefficient for each dimension of scale. A Cronbach's alpha coefficient >0.70 and <0.90 was considered an indicator of reliable scale.
EFA and reliability analysis was performed using SPSS Version 23 (IBM, Chicago, IL, USA, 2015). The EFA was performed using principal component analysis with oblique rotation (Promax) since underlying components were expected to be correlated. To determine the suitability of the data for factor analysis, the Kaiser-Meyer-Olkin (KMO) measure of sampling and Bartlett's test of sphericity (Williams and Brown, 2010) were performed. The KMO measure was >0.5 (0.86), and Bartlett's test of sphericity was significant (P < 0.001). Loading values <0.40 were excluded from the EFA analysis for the final instrument.
| Results|| |
The majority of the sample were male participants (69.2%) and average age was 23.9 (0.3 S. E.) years. Only few participants (18%) reported any previous experience of helping a RTA victim in the past 3 months.
Exploratory factor analysis and reliability analysis
A total of 4% responses were having missing values which were then imputed using mean item values (after applying Missing Completely at Random test). Prior to factor structure analysis, the scale was refined to reduce item redundancy. The communalities (extraction) of all items were satisfied [>0.5; [Table 1]]. A low communality indicates that the low variation in an item is explained by the construct.
|Table 1: Communalities for factors extracted as per Principal Component Analysis for “Measure of intention to help road accident victim” instrument|
Click here to view
For the factor extraction, scree plot and Kaiser Criteria with an eigenvalue of more than one showed that the instrument contained five factors which represented 72% of cumulative variance. The item designation criteria were utilized to reduce the instrument to a simple factor structure. The selected designation rule requires that an item have a factor loading of 0.5 or higher on the designated factor and a loading of <0.35 on all other factors.
The pattern matrix shows factor loading of each item in its construct where all items with factor loading >0.40 were retained. The five dimensions were labeled as “Behavioural Intention to help;” “Self-efficacy in providing on site care to RTA victim;” “Enabling attitude;” “Societal responsibility;” and “Supporting environment.” Of 29 original items, 18 items were included in final version of instrument. [Table 2] shows the five dimensions (subscales) with their respective related items and the factor loading per item.
|Table 2: Principal component and reliability analysis of “Measure of intention to help road accident victim” instrument|
Click here to view
The dimension of “behavioural intention to help” include items reflecting intention of participant to help the accident victim and perceived ability in arranging help. The dimension of “self-efficacy in providing on site care to RTA victim” included items about competence of participant to administer on site trauma care to an accident victim and learning the required skills. The dimension of “enabling attitude” include items reflecting the attitude of participants and their associates (friends and colleagues) for administering on site care to accident victim; the dimension of “societal responsibility” included items about possible role of bystanders at an accident site and “supportive environment” included items facilitating on site trauma care to an accident victim.
Convergent validity and construct reliability
Five items loaded on to factor “behavioural intention to help” and “self-efficacy in providing on site care to RTA victim” with acceptable reliability of 0.840 and 0.889. Four items loaded for factor “enablingattitude” with a Cronbach's alpha of 0.825. Two items loaded each for factor “societal responsibility,” and “supporting environment” with Cronbach alpha of 0.767, and 0.785. Thus, Cronbach's alpha, which provides an estimate of the reliability based on the inter-correlations of the observed indicator variables was more than threshold (0.5) for all the factors. Composite reliability was 0.71–0.85 and average variance extracted for all the subscales was above 0.5 [Table 3]. Thus, the results proved that convergent validity and construct reliability existed for the constructs of this study.
|Table 3: Convergent validity of “Measure of intention to help road accident victim” instrument|
Click here to view
The Pearson correlation coefficients® between dimensions were calculated using summated respondent scores on the individual scale components. The proportion of linearly explained variance (r2) between dimensions was also estimated [Table 4]. The associations between all the five factors were considered substantial (with proportions of explained variance >0.20) indicating that “behavioural intention to help” an accident victim is likely influenced by “self-efficacy in providing on site care to RTA victim;” “enablingattitude;” “societal responsibility;” and “supporting environment.”
|Table 4: Scale component correlations (r) and linearly explained variance (r2) between components of “Measure of intention to help road accident victim” instrument|
Click here to view
A multiple regression was carried out to investigate whether our model could significantly predict an “intention to help a road accident victim” among medical graduates. The result of the regression indicated that the model explained 43% of the variance and that the model was a significant predictor of behavioral intention to help a road accident victim (F (4128) = 24.139, P = 0.0001). The factors which were found to predict the intention to help a road accident victim included “self-efficacy in providing on site care to RTA victim” (β = 0.362, P < 0.05); “enabling attitude” (β = 0.261, P < 0.001), and “societal responsibility” (β = 0.213, P < 0.006) but “supporting environment” (B = 0.023, P = 0.7) was not observed to be a significant predictor.
| Discussion|| |
Results from this study indicate that the MIHRAV instrument is a reliable and valid instrument for predicting perceived competence of medical graduates in administering onsite care to an accident victim. The study indicates that intention to help an accident victim at the site of incident is influenced by many different factors and the ability of the instrument to explain 70% of variance signifies emphasizing on related domains during training of medical students in prehospital trauma care. This is especially useful in countries with evolving trauma care systems.
Medical graduates in low income countries such as India, are likely to come across RTAs, and are expected to take a leadership role in providing essential care to victim. Currently, the medical curriculum focuses on the knowledge and skills required by medical graduates in such settings. However, acquiring knowledge and skills alone are not found to correlate with actual helping behavior., This absence of helping behavior in emergencies is termed as the “bystander's effect” and was previously reported by Darley and Latane. An inhibition of helping act in case of an emergency situation is often attributed to a feeling of decreased responsibility in the presence of others (diffusion of responsibility), fear of unfavorable public response (evaluation apprehension), and acting as per the behavior of others around (pluralistic ignorance).
To date, this study is first of its kind to explore the factors predicting behavioral intention of medical graduates in Indian setting on providing on site care to an accident victim. We propose an educational approach which assesses and addresses these psychological and motivational factors will be helpful in overcoming inhibitory behavior of trained health workers during such situations.
MIHRAV scale is suitable for assessing affective domain of medical students towards an accident victim. This is essential as a measure of affective domain along with knowledge and skills and will create evidence to innovate and improve the medical curriculum and may prove useful to update educational approaches for learners cues, enhance learner's intent to help, and hopefully will improve survival rates among accident victim.
This study contributes toward developing a valid and reliable method for predicting psychological aspects as experienced by medical graduate while managing RTAs in out of hospital settings. This instrument will be useful (a) to understand emotional/psychological components influencing a trained candidate's decision to help an accident victim, (b) to study in detail the process and sequence of behavior toward victim at accident site, (c) to develop appropriate interventions and to introduce policy measures to strengthen prehospital trauma care system, and (d) to introduce essential curricular reforms to strengthen efficacy of medical graduates in contributing in out of hospital settings in low resource situations.
The study presents a novel tool for measuring self-efficacy of medical graduates and their intention towards administering care to RTAs. Present study being done in single institute with a small sample size may affect the generalizability of these results and must be applied with caution to a larger population of medical graduates. In addition, there may be social desirability bias which was addressed in part by keeping the participation anonymous and administering online questionnaire. This instrument need to be validated in different parts of country to reflect the applicability of instrument among medical graduates trained in varied settings. Future studies are also required to test the validity of MIHRAV questionnaire in different populations, (e.g., health-care professionals with varied levels of experience, and training in handling RTA victims) against behavioral measures such as self-regulation and motivation, and also on outcomes, for example, provision of care at RTA sites. Further, it is necessary to explore MIHRAV predictive validity and responsiveness to change using longitudinal data.
| Conclusion|| |
The findings reveal that MIHRAV is a reliable and a valid instrument to predict intention to help a RTA victim among medical graduates. The use of this instrument while training medical undergraduates can enable educators to include activities toward enhancing self-efficacy of students in handling accident patients and acquiring leadership roles especially in resource poor settings.
We would like to acknowledge the medical graduates for participating in this study. We also acknowledge ICMR for funding this study.
Financial support and sponsorship
This study was supported by the Indian Council for Medical Research (ICMR) funded (2016-0274).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Soori H, Khorasani-Zavareh D. Road traffic injuries measures in the eastern mediterranean region: Findings from the global status report on road safety-2015. J Inj Violence Res 2019;11:149-58.
India State-Level Disease Burden Initiative Road Injury Collaborators. Mortality due to road injuries in the states of India: The global burden of disease study 1990-2017. Lancet Public Health 2020;5:e86-98.
Mohan D, Tiwari G, Bhalla K. Road Safety in India Status Report, 2015. Transportation Research & Injury Prevention Programme; 2017. p. 93.
Wesson HKH, Kwong M. Trauma care in India: A review of the literature. Surgery 2017;162:S85-106.
World Health Organization, Sasser S. Prehospital trauma care systems. World Health Organization; 2005.
Graham R, McCoy MA, Schultz AM, editors. Strategies to Improve Cardiac Arrest Survival: A Time to Act. Washington, DC: National Academies Press; 2015.
Bouland AJ, Halliday MH, Comer AC, Levy MJ, Seaman KG, Lawner BJ. Evaluating barriers to bystander CPR among laypersons before and after compression-only CPR training. Prehosp Emerg Care 2017;21:662-9.
Shotland RL, Heinold WD. Bystander response to arterial bleeding: Helping skills, the decision-making process, and differentiating the helping response. J Pers Soc Psychol 1985;49:347-56.
Latané B, Darley, JM. The unresponsive bystander: Why doesn't he help? New York: Appleton-Century-Crofts; 1970.
Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes 1991;50:179-211.
Panchal AR, Fishman J, Camp Rogers T, Starodub R, Merchant RM. An “Intention-Focused” paradigm for improving bystander CPR performance. Resuscitation 2015;88:48-51.
Bandura A. Self-efficacy mechanism in physiological activation and health-promoting behavior. In: Madden J, editors. Neurobiology of learning, emotion and affect. 4th
ed. New York: Raven Press; 1991. p. 229-69.
Miller B, Pellegrino JL. Measuring intent to aid of lay responders: Survey development and validation. Health Educ Behav 2018;45:730-40.
Bloom BS. Taxonomy of Educational Objectives. Vol. 1. Cognitive domain. New York: McKay; 1956. p. 20, 24.
Glanz K, Rime BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 4th
ed. San Francisco: John Wiley & Sons; 2008.
Francis J, Eccles MP, Johnston M, Walker AE, Grimshaw JM, Foy R, et al
. Constructing questionnaires based on the theory of planned behaviour. Newcastle Upon Tyne, United Kingdom: Centre for Health Services Research; 2004.
Eremenco SL, Cella D, Arnold BJ. A comprehensive method for the translation and cross cultural validation of health status questionnaires. Eval Health Prof 2005;28:212-32.
Kim KH. The relation among fit indexes, power, and sample size in structural equation modeling. Struct Equ Modeling 2005;12:368-90.
van Leeuwen R, Tiesinga LJ, Middel B, Post D, Jochemsen H. The validity and reliability of an instrument to assess nursing competencies in spiritual care. J Clin Nurs 2009;18:2857-69.
Williams B, Brown T, Onsman, A. Exploratory factor analysis: A five-step guide for novices. Australasian J Paramedicine 2010;8:1-13. Available from: http://ro.ecu.edu.au/jephc/vol8/iss3/1
. [Last cited on 2019 Nov 12].
Child D. The essentials of factor analysis. 2nd
ed. London: Cassel Educational Limited; 1990.
Hair JF, Anderson RE, Tatham RL, Black WC. Multivariate data analysis. In: Hu Q, Huang CD, editors, Using the Balanced scorecard to achieve sustained IT business alignment: A case study. Communications of the Association for Information Systems. Vol. 17. New Jersey: Prentice Hall; 1998. p. 181-204.
Kanstad BK, Nilsen SA, Fredriksen K. CPR knowledge and attitude to performing bystander CPR among secondary school students in Norway. Resuscitation 2011;82:1053-9.
Kuramoto N, Morimoto T, Kubota Y, Maeda Y, Seki S, Takada K, et al
. Public perception of and willingness to perform bystander CPR in Japan. Resuscitation 2008;79:475-81.
Piliavin IM, Rodin J. Good samaritanism: An underground phenomenon? J Pers Soc Psychol 1969;13:289-99.
[Table 1], [Table 2], [Table 3], [Table 4]