The development of a questionnaire to assess the willingness of Chinese community health workers to implement advance care planning

The study was divided into three parts. The first part was to create the pool of items and generate the first draft of the questionnaire. The second part consisted of expert consultations to form the initial assessment questionnaire. The third part was to validate the initial measurement questionnaire (see Fig. 1).

Fig. 1figure 1

General flow chart of the study

Phase 1: A pool of items was created to generate a first draft of the questionnaire

The PubMed, Web of Science, Science Direct, China Knowledge Network, Wanfang, and other database resources were searched for keywords such as “advance care planning”, “living will”, “advancement directive”, “implementation intention”, “influence factors”, etc. Furthermore, important policy documents on ACP, hospice, and end-of-life care that have been issued by the relevant government departments of various countries were reviewed. These documents were studied and used as the theoretical framework for our study. Based on the literature review and the Chinese cultural context, we developed an interview outline based on TPB and conducted semi-structured interviews with CHWs.

Interview subject

A purposive sampling method was used to select health care workers from three community health service centers in Hangzhou. The inclusion criteria were community health service workers with one year or more of working experience who volunteered to participate in this study. The sample size was based on the principle of saturation of information [31].

Data collection

The interviews were conducted in the office of the community health service center and lasted 30–40 min. In view of the novelty of the ACP concept, an ACP leaflet was distributed to the interviewees before the interview to help them understand the ACP concept and inform them of the purpose of the study. In the process of browsing the leaflet, the interviewer should avoid imposing his or her own understanding and judgment on the other person and provide explanation to the interviewee in neutral and objective language that is easy to understand. The information is organized and analyzed on the day after the interview.

Analysis of interview results

By compiling and analyzing the interview data of 13 CHWs and combining the core concepts in TPB, the behavioral beliefs, normative beliefs, and control beliefs of CHWs about the implementation of ACP for patients were identified. These included 8 themes: positive evaluation of ACP, negative evaluation, support from patients themselves and their families, help from the community attorney team, assessment from psychiatric professionals, importance from community hospital leaders, facilitators, and hindrances (see Fig. 2).

Fig. 2figure 2

Results of interview themes and sub-themes based on TPB framework

Phase 2: Expert consultation to determine the initial assessment questionnaire

In the Delphi expert consultation phase, the data collected from two rounds of expert consultation were organized and analyzed using the expert positivity factor, the expert authority level, and the degree of concentration and correspondence of expert opinions. According to the inclusion criteria of the experts, 10 experts representing 6 different fields, including geriatric care, community management, community nursing, clinical psychology and hospice, were selected to provide consultation in two rounds (see Table 1).

Expert positive factor

In both rounds of expert consultations, 11 copies of the forms were distributed and recovered, with a 90.9% recovery rate in both rounds, which is well above 70% [32]. This indicates that the experts were very motivated to complete this study.

Expert authority level

The expert authority coefficient is defined by the arithmetic mean of the expert’s basis of judgment and familiarity with the content. The expert authority coefficient in both rounds was greater than 0.80, which suggests a high authority.

The degree of concentration of expert opinions

This metric is generally evaluated using the mean (Mj) and standard deviation (σ) of the importance scores of the items. In line with past studies [33], the screening criteria for questionnaire items were set to include responses that met both the coefficients of variation (CV) < 0.25 and Mj > 3.50. After the first round of correspondence, the Mj scores of the questionnaire dimensions ranged from 4.60 to 5.00, and the CV ranged from 0.00 to 0.11. According to the questionnaire modification criteria, the CV for items 8, 9, and 28 were 0.25, 0.25, and 0.38, respectively, and were removed. In the second round of correspondence, the importance scores of questionnaire dimensions showed Mj ranging from 4.20 to 4.90, with CV ranging from 0.07 to 0.22. The Mj of the importance scores of questionnaire entries of the second round of correspondence ranged from 3.70 to 5.00, with CV ranging from 0.00 to 0.26. In accordance with the questionnaire modification criteria, the CV for items 4 and 33 were 0.25 and 0.26, respectively, and were removed. Expert consultation was mainly conducted by email. After the first round of expert consultation, the experts’ opinions were summarized and collated. Statistical analysis of the ratings of the dimensions and entries filled out by the experts was performed, and the results were promptly discussed and communicated with the subject members to revise the entries in the questionnaire. Subsequently, the revised consultation form was sent to the experts for the second round of consultation. The experts were asked to rate the dimensions and entries of the questionnaire again and submit amendments in order to finalize each questionnaire dimension and entry.

The degree of correspondence of expert opinions

The metric is predominantly expressed as a combination of CV and Kendall’s harmony coefficient (W). During both rounds of expert correspondence, the CV for each dimension were less than 0.20, and the experts’ opinions tended to be unified. The CV of items in both rounds of expert correspondence ranged from 0.00 to 0.38 and 0.00 to 0.26, indicating that some of the items in the questionnaire were agreed upon, while others were disputed. There was a positive correlation between the two rounds of correspondence between experts’ opinion dimensions with 0.269 and 0.305, and a negative correlation between the entries with 0.228 and 0.237, respectively, showing a statistically significant difference. This indicated that the experts’ evaluation of the questionnaire tended to be consistent and that the evaluation results were appropriate (see Additional file 1). After two rounds of expert consultation, a preliminary questionnaire was developed to measure the willingness of CHWs to implement ACP in four dimensions, covering the behavioral attitudes, subjective norms, perceived behavioral control, and behavioral intentions, with 33 items.

Table 1 Analysis of the importance rating of the first round of items by experts Phase 3: Validation the initial test assessment questionnaire

To validate the previously developed questionnaire used to assess CHWs’ willingness to adopt ACP, a pre-survey was conducted.

Research subject

Overall study: CHWs in Hangzhou, Zhejiang Province, China.

Inclusion criteria: People who have worked in community health services for one year or more and who are willing to participate in this study.

Exclusion criteria: CHWs whowere absent from their posts.

Research tool

General information questionnaire: There were 21 items in total, including age, gender, education, attitude toward death, and family physician services.

CHWs’ willingness to implement the ACP initial assessment questionnaire: The self-administered questionnaire included four dimensions, namely behavioral attitudes, subjective norms, perceived behavioral control, and behavioral willingness, which consisted of 33 items. Each item was scored from “strongly disagree” to “strongly agree” on a scale of one to five. Seven items were included in the behavioral attitude variables, of which six were positive and one was negative; the maximum score was 35 and the minimum was 7. A higher score indicates a more positive attitude toward ACP among CHWs and vice versa. There were nine subjective normative variables, all of which were positive, resulting in a maximum score of 45 and a minimum score of 9. Higher scores indicate that the support of significant others or groups or organizations has a greater impact on CHWs, and vice versa. Perceived behavioral control included 13 items, all of which were positive, with a maximum score of 65 and a minimum score of 13. Higher scores indicate that CHWs have more internal conditions and external resources to implement ACP, and vice versa. There were four positive entries assessing behavioral willingness; the maximum score was 20 and the minimum was 4. Higher scores indicate a greater behavioral willingness.

Data collection

A random sampling method was used between June and August 2021 to randomly select three urban areas (Gongshu District, Shangcheng District, and Xiacheng District) from the five main urban areas of Hangzhou and a questionnaire survey was conducted among CHWs in these three urban areas. Due to the novelty of the ACP concept, informative leaflets were distributed to the subjects before the survey for better understanding, and the questionnaires were collected and checked carefully after completion. If any items were missing, the CHWs were consulted or corrected as soon as possible. Each questionnaire was carefully checked and two researchers collected and entered the data. Questionnaires that had more than 20% of items missing and unclear handwriting were considered invalid and were excluded.

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