Cross-cultural adaptation and psychometric evaluation of the educational content validation instrument in health.

O iginal Resea ch A icle INQUIRY: The Jou nal o Heal h Ca e O ganiza ion, P o ision, and Financing Volume 59: 1–9 © The Au ho (s) 2022 A icle euse guidelines: sagepub.com/jou nals-pe missions DOI: 10.1177/00469580211060143 jou nals.sagepub.com/home/inq C oss-Cul u al Adap a ion and Psychome ic E alua ion o he Educa ional Con en Valida ion Ins umen in Heal h Se gio Cazo la-Calde ón, PhDc RN 1 , Jos´ e Manuel Rome o-S´ anchez, PhD RN 1,2 , Elena Fe n´ andez-Ga c´ ıa, PhD RN 3 , and Olga Paloma-Cas o, PhD RN 1,2  Abs ac Heal hca e p o essionals o en use mul imedia pa ien educa ion media, bu no all ha e he same con en quali y. This s udy aimed o c oss-cul u ally adap he Educa ional Con en Valida ion Ins umen in Heal h o he Spanish se ing and assess i s psychome ic p ope ies. A me hodological alida ion s udy was ca ied ou be ween Janua y and Sep embe 2020. Da a collec ion ook place om May o June 2020. A ansla ion, back ansla ion, commi ee e iew, and p e- es ing was ca ied ou . Subsequen ly, eliabili y (in e nal consis ency), and alidi y ( ac o ial and con e gen ) we e assessed by equi ing 210 Heal hca e P o essionals o comple e he ins umen based on ideo ma e ial. In addi ion, a efinemen o he ins umen was conduc ed based on he modifica ion indexes. The ins umen showed adequa e in e nal consis ency, al hough some edundancy in he i ems (α= .93). Ex- plo a o y ac o analysis sugges ed a uni ac o ial s uc u e ha explained an adequa e a iance (47.37%). Con e gen alidi y was poo ( = .11; P= .05). A e analysis, 6 i ems we e dele ed wi hou impai ing he alidi y esul s and elimina ing edundancy. The e o e, a 12-i em e sion o he ins umen was c ea ed. I can help o assess mo e objec i ely he con en s o he ma e ials p esc ibed, acili a ing he choice o hose o highe quali y and po en ially imp o ing hei pa ien s’heal h ou comes. Fu he s udies a e needed o confi m he p e ious esul s and eassess some o he sho comings. Keywo ds pa ien educa ion, pa ien educa ion handou , mul imedia, ins umen de elopmen , psychome ics, ques ionnai es, eliabili y and alidi y, Spain Wha Do We Al eady Know abou This Topic? Al hough se e al ins umen s ha e been de eloped in he o m o checklis s o assess a ious aspec s ela ed o he con en o PEM, none o hese ins umen s ound in a comp ehensi e li e a u e sea ch has been c oss-cul u ally adap ed and psychome ically es ed in he Spanish se ing. How Does You Resea ch Con ibu e o he Field? This s udy p o ides p elimina y e idence on he eliabili y and alidi y o a 12-i em c oss-cul u ally adap ed e sion o he Educa ional Con en Valida ion Ins umen in Heal h o heal h p o essionals o e alua e he con en o ideo-based PEM o i s use wi h pa ien s in he Spanish con ex . Wha a e You Resea ch’s Implica ions Towa d Theo y, P ac ice, o Policy? The a ailabili y o a 12-i em c oss-cul u ally adap ed o he Educa ional Con en Valida ion Ins umen in Heal h could be help ul o Spanish heal h p o essionals assis ing hem in selec ing he PEM wi h he bes possible con en o o e hei pa ien s. C ea i e Commons Non Comme cial CC BY-NC: This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-NonComme cial 4.0 License (h ps://c ea i ecommons.o g/licenses/by-nc/4.0/) which pe mi s non-comme cial use, ep oduc ion and dis ibu ion o he wo k wi hou u he pe mission p o ided he o iginal wo k is a ibu ed as specified on he SAGE and Open Access pages (h ps://us.sagepub.com/en-us/nam/open-access-a -sage). Main Tex In oduc ion Pa ien s ecei e la ge amoun s o new in o ma ion a a single consul a ion. 1 Heal hca e p o essionals (HCPs) cu en ly ely hea ily on e bal communica ion and assume ha pa ien s ha e unde s ood he in o ma ion hey p o ide ully. 2 How- e e , hey o en use echnical ja gon and p o ide pa ien s wi h e y complex in o ma ion in a sho ime, which makes i di ficul o unde s and and memo ize. 2 This si ua ion leads o 40-80% o e bal in o ma ion ecei ed a e a o mal con- sul a ion being immedia ely o go en, 3 and almos hal o he in o ma ion pa ien s ecall is inco ec . 4 Gi en he di ficul ies in he spoken communica ion o heal h in o ma ion, i is common o use pa ien educa ion media (PEM) o complemen i . Video-based PEM p o ides isual and audi o y in o ma ion and is easie o abso b o pa ien s han o he pa ien educa- ional me hods 2 and hus could o e come ba ie s ela ed o limi ed li e acy and hea ing impai men , espec i ely. 5 Thus, ideo-based PEM has become inc easingly commonly used among heal hca e p ac i ione s. 6 Howe e , i is logical o hink ha he con en o all o hem may no be o he same quali y. PEM should mee ele an aspec s o educa ional con en , which a e essen ial o ulfill he pu poses o hese ma e ials and p o ide educa ion as e ficien ly as possible. 7 Fo his, se e al ins umen s ha e been de eloped in he o m o checklis s o assess a ious aspec s ela ed o he con en s o PEM. 5,6,8,9 Among hese ools, The Pa ien Educa ion Ma e ials Assessmen Tool (PEMAT) 10 uses a sys ema ic me hod o e alua e and compa e he unde s andabili y and ac ionabili y o pa ien educa ion ma e ials, o he Sui abili y Assessmen o Ma e ials (SAM) ins umen o e s a sys ema ic me hod o objec i ely assess he sui abili y o heal h in o ma ion ma e ials. O he ins umen s we e de eloped o asse s PEM in a specific o ma , such as he Tool o E alua e Ma e ials Used in Pa ien Educa ion (TEMP Ed), es ablished o help HCPs e alua e and selec PEM in p in ed o ma bu no in mul imedia o ma . The Educa ional Con en Valida ion Ins umen in Heal h (ECVIH), a ool c ea ed by a g oup o B azilian esea che s o assis HCPs in assessing heal h educa ion con en in 3 con en - ela ed di- mensions: objec i es, s uc u e and p esen a ion and ele ance. 7 I is also an ins umen wi h ew i ems and a simple adminis- a ion and sco ing sys em. Howe e , none o he ins umen s lis ed abo e o o he s ound in he comp ehensi e li e a u e sea ch has been c oss-cul u ally adap ed and psychome ically es ed in he Spanish se ing. Gi en he cha ac e is ics o b e i y and ease o sco ing and applica ion o ECVIH, we belie e i would be help ul o Spanish heal h p o essionals adap he ins umen ha would assis hem in selec ing he PEM wi h he bes possible con en o o e hei pa ien s. The e o e, his s udy aimed o c oss-cul u ally adap he Educa ional Con en Valida ion Ins umen in Heal h o he Spanish se ing and assess i s psychome ic p ope ies. Me hods Design A me hodological alida ion s udy was ca ied ou . C oss-Cul u al Adap a ion The guidelines p oposed by Guillemin e al. 11 we e used, sligh ly modified o adap hem o he pu poses o he s udy o p ese e equi alence in he c oss-cul u al adap a ion o he ins umen . The ollowing phases we e included: (1) T ansla ion. Th ee independen ansla ions o Spanish we e made o he o iginal English ins umen pub- lished by Lei e e al. 7 Two ansla o s we e nu ses and we e wa ned o he objec i es and ela i e concep s o he ma e ial o be ansla ed. A hi d ansla o was a psychologis who was no wa ned o elici unexpec ed meanings om he o iginal ins umen . All o hem we e bilingual, English, and Spanish; hei mo he ongue is he la e . The ansla o s discussed he 3 e sions and s udied he disc epancies un il a consensus e sion was eached. (2) Re o- ansla ion. The consensus e sion was e o- ansla ed in o English by a p o essional ansla o wi h a s able esidence in Spain whose mo he ongue is English and un amilia wi h he ma e ial. (3) Re iew. A commi ee o expe s was se up o compa e he e o- ansla ion wi h he o iginal e sion o he ins umen . This commi ee consis ed o he p e ious ansla o s oge he wi h he p incipal au ho o he o iginal ins umen . The decen e ing echnique was used in which he i ems wi h p oblems we e loca ed, and he au ho p o ided a wo king e sion o hem, main aining he concep . On he o he hand, gi en ha he o iginal ool was designed o assess w i en PEM and his s udy sough o alida e i using he ma e ial in 1 Resea ch G oup PAIDI CTS-1019 “MELES - Nu sing Me hods and S anda d Languages”, Uni e sidad de C´ adiz, C´ adiz, Spain 2 Facul y o Nu sing and Physio he apy, Nu sing and Physio he apy Depa men , Uni e sidad de C´ adiz, C´ adiz, Spain. 3 Facul y o Nu sing, Physio he apy and Podia y,. Nu sing Depa men , Uni e sidad de Se ila, Se illa, Spain. Co esponding Au ho : Jos´ e Manuel Rome o-S´ anchez, Uni e sidad de C´ adiz. Facul ad de En e me ´ ıa y Fisio e apia, A da. Ana de Viya, 52; 11009 C´ adiz (Spain). Email: [email p o ec ed] 2INQUIRY audio- isual o ma , i was ag eed wi h he au ho o eplace i em 15, “The ex size is adequa e”wi h “The na a i e/dialogues a e hea d clea ly.”Once he ex- pe s app o ed he back- ansla ion, he o iginal and he Spanish adap a ion we e gi en o 5 bilingual nu ses o de ec disc epancies. Pa icipan s The sample comp ised HCPs mee ing he ollowing inclusion c i e ia: (1) Hold a bachelo ’s deg ee in heal h science ha qualifies hem o p esc ibe PEM o pa ien s and (2) p ac ice o ha e p ac ised he p o ession o which hey a e qualified in Spain. Visual and/o audi o y impai men s ha p e en he iewing o mul imedia ma e ial we e only conside ed as an exclusion c i e ion. This con enience sample was selec ed h ough non- p obabilis ic ne wo k sampling 12 o ob ain subjec s wi h di e se p o essional p ofiles and se ings. The 10:1 a io ule, en pa icipan s pe i em, was adop ed o de e mine a su fi- cien sample size. 13–15 Conside ing ha he ins umen o be psychome ically es ed con ains 18 i ems, he sample size would be se a 180 subjec s. Howe e , cu en ends ec- ommend a sample size o a leas 200 cases, e en unde op imal condi ions o high communali ies and well-defined ac o s. 16 The e o e, an a emp was made o maximize he sample size and hus ob ain a highe numbe o subjec s han ini ially p oposed. A panel o expe s was also selec ed in en ionally o enable he assessmen o he con e gen alidi y o c i e ia. I consis ed o 9 people ollowing he ecommenda ion o Poli and Ta ano. 17 To belong o he panel, hey had o mee he eligibili y c i e ia o he abo e sample and ha e p o en expe ience, ha ing de eloped a leas 5 PEM in he las 2 yea s. Ins umen s The ollowing ins umen s we e used (1) Socio-demog aphic and p o essional da a ques- ionnai e. Consis ed o ques ions o assess he ol- lowing a iables: age (yea s), gende (male, emale), heal hca e p o essional p ofile (assis ance, eaching, and esea ch, managemen ), educa ional p ofile (nu se, physician, psychologis ), p o essional expe- ience (yea s), academic deg ee (diploma, bachelo o g adua e deg ee, o ficial mas e ’s deg ee, doc o a e). (2) Specific ques ions o expe ’s ques ionnai e. Applied o expe s only oge he wi h he o he ins umen s. I consis ed o ques ions o assess he ollowing a i- ables: o ma o he PE ma e ial c ea ed by hem (w i en, mul imedia), PEM c ea ed in he las 2 yea s in each o ma (numbe ), and assessmen o he con en s o he pa ien educa ion ma e ial shown assessed wi h a single ques ion o mula ed as, “Ra e he o e all con en o he ma e ial displayed o ed- uca e he pa ien on (subjec o he ideo, in his case, Basic li e suppo (BLS) om 0 o 10”and wi h a 10- poin Like - ype measu emen scale whe e 0 indi- ca es ha he o e all con en is “Ve y bad”and 10 “Ve y good.” (3) Spanish e sion o he Educa ional Con en Valida- ion Ins umen in Heal h (ECVIH-SV). De eloped o his s udy in he c oss-cul u al adap a ion p ocess desc ibed abo e. The o iginal ins umen was de- eloped based on a na a i e e iew o he li e a u e and expe consensus. 7 I has 18 i ems alloca ed heo e ically in o 3 domains: (1) objec i es (i ems 1- 5), ela ing o pu pose, goals, o a ge he use o educa ional ma e ials; (2) s uc u e and p esen a ion (i ems 6-15), ela ing o gene al o ganiza ion, s uc- u e, s a egy, consis ency, and su ficiency o he p esen a ions; and (3) ele ance (i ems 16-18), ela ing o he significance deg ee o he educa ional con en and i s abili y o cause impac , mo i a ion, and/o in e es . The i ems we e applied o he PEM o be assessed, using a h ee-poin Like esponse scale whe e 0 = disag ee, 1 = pa ially ag ee, and 2 = o ally ag ee. Acco ding o expe s, he i ems ob ained mo e han 80% ag eemen and good in e nal consis ency in hei domains in he con en alida ion. ECVIH i ems a e p esen ed in Online Appendix 1. Da a Collec ion The au ho s designed 2 non- alida ed anonymous elec onic su eys o collec he da a specified in he p e ious sec ion, one o he expe s’sample and he o he o he gene al sample. Pa icipan s o bo h expe s and gene al samples we e con ac ed by mail, gi ing in o ma ion abou he pu pose o he s udy, he iden i y o he in es iga o s, and he ime in- es men o he su ey. To fill in he su ey, access o he websi e was h ough a link o he su ey, passwo d-p o ec ed o p e en malicious access. Passwo d was sen oge he wi h he in i a ion email. The elec onic su ey sys em p e en ed mul iple en ies om he same indi idual h ough email add esses. The anonymi y o he esponses was ensu ed. No ad e ising was used. Bo h su eys we e designed using he comme cial web su ey p o ide www.su eymonkey.com. The accoun was only accessible o he leading in es iga o o da a p o ec ion pu poses. The web su ey was es ed be o e he s a o he s udy by colleagues. Ques ions asked o all pa icipan s we e manda o y (an au oma ic op ion in he su ey p og am). Responden s could e iew and change exis ing answe s un il he su ey was finished h ough a “back bu on.” PEM o be assessed is needed o apply he ins umen . In his case, 3 PEM we e included in he su eys, p ecisely 3 di e en ideos on he same opic, “how o pe o m Basic Li e Suppo wi h an au oma ic defib illa o ,”aimed a he Cazo la-Calde ón e al. 3 gene al public. These ideos we e p e-selec ed by he e- sea ch eam based on hei opinion and ega ding hei quali y, looking o di e ences be ween hem. The au ho s o he ideos ha we e no classified as ee use we e asked o au ho iza ion. Each pa icipan in he gene al sample was equi ed o use he ECVIH ins umen o assess he con en o only one o hese ideos assigned andomly by he Web applica ion. Video 1 was assessed by 83 pa icipan s (39.5%), ideo 2 by 70 (33.3%), and ideo 3 by 57 (27.1%). In con as , expe s assessed all 3 ideos since hei assessmen was necessa y o assess con e gen alidi y. The ideos we e shown o expe s in andom o de o p e en he lea ning e ec in he applica ion o he ins umen om cons i u ing a bias in he sco es. Da a collec ion was conduc ed om May o June 2020. E hical Conside a ions This s udy is pa o a la ge p ojec app o ed by he An- dalusian Coo dina ing Commi ee on E hics in Biomedical Resea ch (PI-0019-2017). Pa icipa ion was olun a y, and he anonymi y o he pa icipan s was gua an eed, so he web applica ion did no eco d any da a ha could be used o iden i y hem. The pa icipan s we e in o med o he pu pose o he s udy and he p ocessing o he da a. They also signed a w i en consen o m be o e filling he su ey. W i en pe - mission was ob ained om he au ho s o he ins umen o i s c oss-cul u al adap a ion and alida ion. Da a Analysis The no mali y o he a iables was checked using he Kolmogo o -Smi no -Lillie o s es . 18 Da a ela ing o he dis ibu ion sco es and he sample cha ac e is ics we e summa ized using he desc ip i e s a is ics, he mean and s anda d de ia ion o he quan i a i e a iables, while e- quency and pe cen age we e used o he ca ego ical ones. The eliabili y assessmen included es s o in e nal con- sis ency: (a) C onbach’salpha(α) o he comple e ins umen and when each i em was emo ed. A alue o αo .70-.90 was conside ed app op ia e and ha he e we e no subs an ial changes in alue when he i em was excluded; (b) i em- o al co ela ion co ec ed using he Pea son co ela ion coe ficien . An i em- o al co ela ion o ≥.40 was conside ed app op ia e. 19 The con e gen alidi y o he ins umen was assessed using he assessmen o he o e all con en s o he PEM by he expe s. Gi en ha no ins umen alida ed in Spain ha measu es he same cons uc was ound in he li e a u e sea ch, an ad hoc ques ion was used o assess he con en in gene al e ms. The o al sco es on he ins umen we e co ela ed wi h he a e ages ob ained in he p e ious ques ion in each o he 3 ideos shown o he expe s h ough Pea son’s es . A co ela ion coe ficien anging om .30-.40 indica es a high con e gen alidi y. 13 The cons uc alidi y was assessedin e mso ac o ial alidi y h ough explo a o y ac o analysis (EFA) using p in- cipal componen analysis (PCA). An EFA was ca ied ou using he main componen s analysis me hod. As well as concep ual in e p e abili y, he ollowing c i e ia we e used o iden i y he op imal numbe o ac o s: (a) Sc ee plo 20 de e mined he poin whe e he slope o he cu e is le eling o ; 21 (b) explained a iance o a leas 40% 22 and ha each ac o con ains a leas 3 i ems. 23 The ac o ial ma ix was examined, ex ac ing hose i ems ha load unambiguously on heex ac ed ac o s,con- side ing hose wi h ac o loading >.50 on exac ly 1 ac o and <.40 on all o he ac o s. 24 Da a we e checked be o ehand o sui abili y o ac o analysis by examining Kaise –Meye – Olkin (KMO) indices es o sampling adequacy and Ba le ’s es o sphe ici y (BTS). A alue o KMO <.50 and a BTS significance le el o P< .05 was being conside ed app op ia e. 25 Once he op imal ac o solu ion acco ding o he EFA was ob ained, a confi ma o y ac o analysis (CFA) was ca ied ou o de e mine whe he he da a fi he p oposed model. The ollowing adjus men indices we e used: (a) Significance o chi-squa e (χ2), being desi able a χ2 no significan o he model; 26 (b) compa a i e fi index (CFI) and Tucke –Lewis Index (TLI) o which alues g ea e han .90 indica e a good fi , while alues g ea e han .95 indica e an excellen fi 27,28 and (c) oo mean squa e e o o app oxima ion (RMSEA) o which alues below .08 indica e an accep able model fi and .06 an excellen fi , such as a i s uppe limi o he 90% confidence in e al. 29 I he model did no fi he da a ob- ained in he sample, efining he ins umen by s udying he disc epancies be ween he model and he da a h ough he modifica ion indexes (MIs) was conside ed. 30 The MIs in- dica e he amoun o dec ease in he χ2 o he model wi h a deg ee o eedom. A high MI alue indica es ha he ele an fixed-pa ame e should be eleased o imp o e he model fi . 26 To ee i , i was decided o elimina e he specificele- men s wi h highe MIs, which mean an imp o emen in he model fi , wi h a dec ease o χ2 and a subs an ial imp o emen o he o he adjus men indices. 31 The elimina ion was ca ied ou one by one, s a ing wi h he one wi h he highes MI and so on successi ely since changing a single pa ame e in a model could a ec o he pa s o he solu ion. 32 A e each elimi- na ion, he CFA was epea ed on he emaining elemen s, assessing he specific adjus men a es. These s eps we e e- pea ed p og essi ely un il he indices showed a good model fi acco ding o he c i e ia specified in he p e ious pa ag aph. Once he i ems ha comp ised he defini i e model we e e ained, he eliabili y and con e gen alidi y es s we e epea ed o check i hey also ob ained simila o be e psychome ic p ope ies in addi ion o hei dimensionali y. The esul s we e conside ed s a is ically significan i he P- alues we e <.05. Da a we e analyzed using IBM SPSS S a is ics o Windows, e sion 25, and IBM AMOS, e sion 23 (IBM Co p, A monk, NY, USA). 4INQUIRY Resul s C oss-Cul u ally Adap ed Ins umen The ansla ions made independen ly by he ansla o s ob- ained comple e coincidence in 3 i ems, pa ial coincidence in 4, and disc epancy in ele en. Pa ial coincidences we e sol ed by choosing he ansla ion o he 3 ha bes ep e- sen ed he i em, wi h each o ing o he 1 ha seemed co ec . T ansla ions o dissen ing i ems we e esol ed by join discussion, ob aining a consensus ansla ion o each i em. The e o- ansla ion was e ised by he ansla o s and one o he au ho s o he o iginal ins umen . She only ad- jus ed 3 i ems. The ansla ions o hese we e modified conce ning hei con ibu ions and sen back o compa ison, a e which he ansla ion was app o ed. The bilingual nu ses who e iewed he Spanish and he o iginal ins umen s endo sed he equi alence o bo h e sions. The Spanish e sion o he ECVIH is gi en in Online Appendix 1. Desc ip ion o he Pa icipan s O he 600 ques ionnai es sen ou , 222 we e e u ned co ec ly filled in, implying a esponse a e o 37%. O hese, 12 we e elimina ed as hey did no mee he inclusion c i e ia (8 we e non- uni e si y senio heal hca e echnicians, and 4 we e non-g adua e nu sing s uden s). The e o e, he final sample consis ed o 210 pa icipan s, mos o whom we e women (55.5%) wi h an a e age age o 40.8 yea s (SD = 10.41). Mos o he sample we e nu ses (79%), wo king mainly in he heal hca e field (80%) wi h an accumula ed p o essional expe ience o 16.53 yea s (SD = 9.95). Conce ning aining, 52.6% o he pa icipan s had some pos - g adua e uni e si y educa ion. The pa icipan s’demog aphic and p o essional p ope ies a e shown in de ail in Table 1. Rega ding he expe s, 8 we e nu ses (88.9%) and 1 was a physician. 77.8% had pos g adua e aining. Mos o hem had heal hca e unc ions (88.9%) and an accumula ed p o essional expe ience o 18 yea s (SD = 6.46). Mos o hem had ex- pe ience in c ea ing pa ien educa ion ma e ials in bo h w i en and mul imedia o ma s (77.8%), he es in w i en o ma only, wi h an a e age o 19.44 ma e ials in w i en o ma (SD = 19.70) and 22.00 in mul imedia o ma (SD = 29.26). Sco e Dis ibu ion The a e age scale sco e o he sample was 29.88 (SD = 2.77) ou o a maximum o 36 poin s. The i ems had a e age sco es in he ange o 1.33-1.87. The means and s anda d de ia ions o each i em a e shown in Table 2. Reliabili y In e nal consis ency. The α alue o he ins umen was .93. No i em significan ly inc eased o dec eased he αwhen i was emo ed. All i ems eached good i em- o al co ela ions (.41-.76), excep i em 14, which ob ained a low co ela ion (.28). These esul s a e shown in de ail in Table 2. Validi y Con e gen alidi y. A poo , hough significan , co ela ion ( = .11; P= .05) was ound be ween he o al ins umen sco es and he a e age o he sco es gi en by he expe s o each ideo. Fac o ial cons uc alidi y. The Ba le sphe ici y es (χ 2 = 2125.66; d = 153; P< .001) eached s a is ical significance, and he KMO alue was adequa e (KMO = .92). The p e- limina y PCA e ealed he p esence o 3 componen s wi h eigen alues g ea e han 1, which explained he 47.37%, 7.30%, and 5.99% o he a iance, espec i ely. Howe e , an inspec ion o he sc ee plo indica ed a significan slope a e he fi s componen , ollowed by a clea pla eau. The ac o ial ma ix was examined, de e mining ha all bu 3 i ems had high ac o ial loadings in he fi s componen (.45-.86) and low ones in he es (<.40).I ems16and18loadabo e.40onbo h hefi s and second componen s, al hough he loadings on he fi s we e significan ly highe han on he second (i em 16: .69 s .44; i em 18: .71 s .41). I em 14 loads high on he second (.58) and hi d componen (.53). Conside ing he sc ee plo , he high ac o loading o almos all i ems on he fi s componen , he accep able a iance explained by i , and ha he o he 2 componen s did no sa is y he condi ion, a leas 3 i ems load he highes on ha ac o . I was decided o ca y ou a new PCA by o cing he Table 1. Pa icipan s’Demog aphic and P o essional Cha ac e is ics. N% MSD Sex Women 116 55.5% Men 91 43.5% N/A 2 1% Age (yea s) 40.8 10.41 Field o wo k Heal h ca e 168 80% Managing 13 6.2% P o esso and/o esea che 29 13.8% Occupa ion Nu se 166 79% Physician 37 17.6% Psychologis 5 2.4% O he 2 1% P o essional expe ience (yea s) 16.53 9.95 Academic deg ee Bachelo 99 47.4% Mas e 87 41.6% PhD 23 11% M, mean; SD, s anda d de ia ion. Cazo la-Calde ón e al. 5 ex ac ion o a single componen ha explained a a iance o 47.37%, wi h all i ems wi h high loadings on i (.46-.81) excep i em 14 ha has a sligh ly lowe loading on he componen (.32) (Table 2). The e o e, he esul s o his second analysis suppo he one-dimensionali y o he ins umen . The CFA ca ied ou , assuming a one- ac o model as ex ac ed om he EFA, de e mined ha his model did no fi well wi h he da a ob ained wi h poo adjus men indices: X 2 = 474.89 (P< .0001); CFI = .83; TLI = .81; RMSEA =.11 (90% CI:0.10-.12). Ins umen Refinemen Based on hese esul s, i was decided o efine he ool by e- es ima ing and eassessing i mul iple imes o adjus he da a o he chosen model by s udying he MIs changes by pai s o i ems. I ems 6, 18, 5, 3, 10, and 14 we e p og essi ely elimina ed un il an app op ia e fi o he da a o he model was achie ed, ob aining excellen fi indices wi h he emaining 12 i ems excep o he χ2(χ 2 =101.21(P< .0001); CFI = .96; TLI =.95;RMSEA =.06(90%CI:0.04-.08). Figu e 1 shows he selec ed final model wi h i s ac o loadings. As can be seen, all he i ems ha e loadings highe han .50 excep i em 15, which loadings abo e .40. A 12-i ems ECVIH was ob ained om his efinemen p ocess (Online Appendix 2). Once he ins umen had been efined, he es o he psychome ic p ope ies we e eassessed conside ing only he 12 i ems e ained, wi h he ollowing esul s. Rega ding eli- abili y in e ms o in e nal consis ency, he α o he 12-i ems ins umen was .89. No i em significan ly inc eased o de- c eased he αwhen i was emo ed (.88-.90). Rega ding he con e gen alidi y, a poo co ela ion was again ound be- ween he o al sco e o he 12-i ems ins umen and he a e age o he sco es gi en by he expe s o each ideo, al hough mo e significan han o he 18-i ems ECVIH ( = .14; P=.04). Discussion This s udy aimed o c oss-cul u ally adap and alida e he Educa ional Con en Valida ion Ins umen in Heal h (EC- VIH). I is he fi s assessmen o he psychome ic p ope ies o ECVIH on a sample o HCPs. The ins umen , de eloped o he B azilian con ex , was only p e iously assessed o con en alidi y by expe s in he same s udy ha de eloped i . 7 This s udy, he e o e, p o ides e idence o he in e nal p ope ies o ECVIH when applied by HCPs on PEM, en- do sing i s use wi h a mo e excellen scien ific basis. The esul s endo se he eliabili y o he 18-i ems in- s umen in e ms o in e nal consis ency wi h an adequa e psychome ic pe o mance o mos i ems; howe e , he α alue abo e .90 o he en i e ins umen exceeds he alues Table 2. I em Sco es, Reliabili y Resul s, and Fac o Loadings o ECVIH. I ems I em Sco e To al Sco e i I em Dele ed, M Co ec ed I em-To al Co ela ion C onbach’s Alpha i I em Dele ed Fac o LoadingsMSD 1. Con empla es he p oposed heme 1.84 0.41 28.05 0.54 0.93 0.59 2. Sui s he eaching-lea ning p ocess 1.59 0.57 28.30 0.70 0.93 0.74 3. Cla ifies doub s on he add essed heme 1.42 0.65 28.47 0.61 0.93 0.66 4. P o ides eflec ion on he heme 1.56 0.65 28.32 0.67 0.93 0.72 5. Encou ages beha io change 1.57 0.64 28.31 0.69 0.93 0.74 6. Language app op ia e o he a ge audience 1.66 0.58 28.23 0.74 0.92 0.78 7. Language app op ia e o he educa ional ma e ial 1.70 0.56 28.19 0.71 0.93 0.76 8. In e ac i e language, enabling ac i e in ol emen in he educa ional p ocess 1.33 0.74 28.55 0.60 0.93 0.64 9. Co ec in o ma ion 1.59 0.61 28.30 0.63 0.93 0.68 10. Objec i e in o ma ion 1.72 0.54 28.17 0.69 0.93 0.74 11. Enligh ening in o ma ion 1.52 0.63 28.36 0.74 0.92 0.78 12. Necessa y in o ma ion 1.87 0.39 28.02 0.61 0.93 0.67 13. Logical sequence o ideas 1.71 0.55 28.17 0.69 0.93 0.73 14. Cu en heme 1.86 0.40 28.02 0.28 0.93 0.32 15. App op ia e ex size 1.78 0.46 28.11 0.41 0.93 0.46 16. Encou ages lea ning 1.70 0.50 28.18 0.65 0.93 0.69 17. Con ibu es o knowledge in he a ea 1.77 0.46 28.11 0.76 0.93 0.81 18. A ouses in e es in he heme 1.70 0.52 28.19 0.67 0.93 0.71 M, mean; SD, s anda d de ia ion. 6INQUIRY se as accep able. Ex emely high alpha alues sugges e- dundancy be ween some o he i ems; 33 some i ems measu e he same aspec o he cons uc . 34 In his case, i is usual o elimina e he edundancy by elimina ing i em. 17 In his s udy, i ems we e elimina ed based on he ac o abili y o he in- s umen . Howe e , e en hough he efinemen was ca ied ou based on a alidi y p ope y, he e-assessmen unde aken o he eliabili y o he 12-i em ECVIH, all i ems e ained o imp o ed pe o mance, and he alue o alpha o he en i e ins umen dec eased o op imal alues, hus elimina ing edundancy. Al hough he i ems we e alloca ed in o 3 dimensions heo e ically o s uc u e he ins umen in i s c ea ion, 7 a he empi ical le el, he scale seems o espond o a one- ac o s uc u e sugges ed by he EFA esul s, which accumula ed adequa e a iance and ac o loadings on he app op ia e ac o excep o 1 i em in he 18-i ems o iginal ins umen . No good fi was ob ained when he one- ac o s uc u e was es ed h ough a CFA on he da a o he 18 i ems. In he con ex o s uc u al equa ion models, MIs a e a measu e o en used o educe disc epancies be ween model and da a, 30 soi wasdecided ouse hem o efine he ins umen . Based on hese, a model 1 showing an excellen fi o all he calcula ed indices was ob ained, excep o he χ2, which is a pa ame e ha is ex emely sensi i e o he sample size. 35 A educed o m was ob ained om he p ocess wi h a clea s uc u e consis ing o 1 ac o and be e eliabili y o he 12 i ems e ained. I also educed he ins umen applica ion imes. None o he e sions, he o iginal 18 o he efined 12- i ems e sion, ga e good esul s o con e gen alidi y. Among he easons behind hese nega i e findings is ha he expe s’opinion was collec ed wi h a single ques ion de- eloped ad hoc, which may no cap u e he en i e cons uc . The e a e a ious po en ial limi a ions o he s udy ha need o be discussed. The in e en ion o a single ansla o in he back- ansla ion p ocess o he ins umen made i im- possible o implemen a double-check mechanism. The use o a con enience sample limi s he gene aliza ion o he esul s. No all aspec s o eliabili y o alidi y we e assessed. Sensi i i y o change was also no e alua ed, a p ope y ha mus be known i he ins umen is o be used as a ool by he c ea o s o heal h educa ion ma e ial o assess imp o emen s in ha ma e ial’s con en . Mo eo e , in his s udy, he CFA was ca ied ou on he same da a as he EFA, as was he de e mina ion o p ope ies o he efined e sion o 12 i ems. Fo all he abo e easons, i would be necessa y o ca y ou u u e s udies wi h mo e significan and ep esen a i e samples, i possible, o mi - iga e hese deficien aspec s. Simila ly, i would be neces- sa y o de e mine whe he he sou ce e sion and o he c oss-cul u al adap a ions o o he in e na ional con ex s p o ide simila psychome ic esul s. Finally, he educa- ional ma e ial on which he alida ion was ca ied ou was only o a mul imedia ype, and i would be necessa y o assess he ool’s pe o mance on he ma e ial in w i en o ma i i is o be used on i . Conclusion The esul s o his s udy p o ide p elimina y e idence on he eliabili y and alidi y o ECVIH o heal h p o essionals o e alua e he con en o ideo-based PEM o i s use wi h pa ien s in he Spanish con ex . A efined e sion o 12 i ems is p oposed, which, in addi ion o imp o ing he ac o abili y o he o iginal ins umen , allows i o be comple ed in less ime, imp o ing o main aining he psychome ic p ope ies o he o iginal 18-i ems e sion. The a ailabili y o an in- s umen makes i easie o HCPs o assess he con en s o he educa ional ma e ial hey p esc ibe o pa ien s wi h g ea e objec i i y, acili a ing he choice o he highes quali y ones and po en ially imp o ing hei pa ien s’heal h ou comes. I Figu e 1. I ems s uc u e. Cazo la-Calde ón e al. 7 also allows he c ea o s o PEM o assess he con en o he ma e ial, allowing o imp o emen in hose a eas whe e HCPs pe cei e deficiencies. Acknowledgmen s The au ho s g a e ully hank he au ho s o he o iginal ins umen , D . Lei e and he colleagues, o accep ing ou eques o c oss- cul u ally adap and alida ion he ECVIH as well hei suppo in his s udy. A special hanks o Ca olina C´ ano as Ma ´ ınez (RN) and Jos´ e Manuel Salas Rod ´ ıguez (MD) ounde s o Jacin o & iends’ P ojec (www. hinking-heal h.com) o allow us o use one hei ideos o ou s udy. We exp ess ou g a i ude o e e yone who pa icipa ed by p o iding expe ise and all he esponden s o making possible he s udy epo ed in his pape . Au ho Con ibu ions Se gio Cazo la-Calde on: Concep ualiza ion, in es iga ion, e- sou ces, w i ing—o iginal d a . Jose Manuel Rome o-Sanchez: Me hodology, o mal analysis, da a cu a ion, w i ing—o iginal d a . Olga Paloma-Cas o: Concep ualiza ion, esou ces, w i ing— e iew and edi ing, p ojec adminis a ion, unding acquisi ion. Elena Fe nandez-Ga cia: In es iga ion, w i ing— e iew and edi ing. Decla a ion o Conflic ing In e es s The au ho (s) decla ed no po en ial conflic s o in e es wi h espec o he esea ch, au ho ship, and/o publica ion o his a icle. Funding The au ho (s) disclosed eceip o he ollowing financial suppo o he esea ch, au ho ship, and/o publica ion o his a icle: This pape is pa o he fieldwo k o he p ojec en i led “E ec i eness o Mul imedia Con en Exposu e in Imp o ing he Expe ience and Repo ed Pa ien Ou comes in Pa ien s Su e ing om AMI Du ing he T ans e o Hospi al: a Clinical T ial.”(PI-0019-2017), unded by Heal h Depa men o he Andalusian Go e nmen , Spain, in he ‘2017 ITI Call o Funding o Heal h Sciences & Biomedical Resea ch G an s’a e a igo ously pee - e iewed unding p ocess. ORCID iDs Se gio Cazo la-Calde ón h ps://o cid.o g/0000-0003-4965-6011 Jos´ e Manuel Rome o-S´ anchez h ps://o cid.o g/0000-0001-8227-9161 Elena Fe n´ andez-Ga c´ ıah ps://o cid.o g/0000-0002-7922-2663 Supplemen al Ma e ial Supplemen al ma e ial o his a icle is a ailable online. Re e ences 1. Selic P, S ab I, Repolusk M, Gucek NK. Wha ac o s a ec pa ien s’ ecall o gene al p ac i ione s’ad ice? BMC Fam P ac . 2011;12(1):141. doi:10.1186/1471-2296-12-141. 2. Abu Abed M, Himmel W, Vo m elde S, Koschack J. Video- assis ed pa ien educa ion o modi y beha io : A sys ema ic e iew. Pa ien Educ Counsel. 2014;97(1):16-22. doi:10.1016/ j.pec.2014.06.015 3. Kessels RPC. Pa ien s’memo y o medical in o ma ion. JR Soc Med. 2003;96(5):219-222. doi:10.1258/j sm.96.5.219. 4. Jansen J, an Wee J, an de Meulen N, an Dulmen S, Hee en T, Bensing J. Recall in olde cance pa ien s: Measu ing memo y o medical in o ma ion. Ge on ol. 2008;48(2): 149-157. doi:10.1093/ge on /48.2.149. 5. 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