Translation and validation of the Hungarian Version of the infection control standardized questionnaire: a cross-sectional study

Infection prevention and control (IPC) is one of the most cost-effective interventions to prevent the transmission of healthcare-associated infections (HAIs) [1] and disease outbreaks and to ensure the safety of healthcare workers (HCWs) [2]. The proper implementation of IPC measures may result in a 70% reduction in HAIs [3]. IPC practices have been present in different forms for decades. Universal precautions (UPs) were first introduced by the Centers for Disease Control and Prevention in the early 1980s after the identification of acquired immunodeficiency syndrome as a means of ensuring HCW safety. In 1996, UPs were replaced by standard precautions (SPs) after being revised. Later, IPC guidelines were updated several times as a result of several disease outbreaks [4]. For instance, respiratory hygiene/cough etiquette was added after the emergence of the severe acute respiratory syndrome epidemic in 2003. Furthermore, safe injection practices were included after the continued outbreaks of hepatitis B and C [4]. Afterward, the guidelines were further updated after the 2014 Ebola virus disease outbreak in West Africa [5].

Implementing IPC measures is a mandatory requirement in all healthcare institutions, yet despite policies and procedures to impose their practice, HCWs’ compliance with IPC remains substandard [4]. Poor knowledge of IPC is the main reason for the low adherence of HCWs to IPC practices. Other common reasons are organizational barriers, insufficient supplies, time limits, poor experience, inadequate training, and poor self-efficacy [4, 6‐9]. Attempts should be continued to enhance the knowledge of HCWs on IPC to ensure higher compliance with IPC practices. Efforts should focus on nurses, who play a vital role in controlling and preventing the transmission of HAIs [9], which have detrimental effects on patient safety [10].

A recent systematic review on nurses’ knowledge and practice of IPC measures reported a lack of investigation of the validity and reliability in most of the included studies [11]. Given this premise, a valid and reliable tool is required to assess nurses’ knowledge about IPC measures. The infection control standardized questionnaire (ICSQ) is an instrument that was developed by Tavolacci et al. [12] to measure IPC knowledge among HCWs, including nurses. The ICSQ assesses knowledge about SPs, including their indications, and the use of personal protective equipment (PPE) (gloves, masks, gowns), as well as knowledge about hand hygiene (HH) and alcohol-based hand rub (ABHR) indications and HAIs. Unlike other instruments that were used in former related studies that utilized the concept of UPs in measuring knowledge about the present IPC practices [2, 13], the ICSQ is more specific in assessing the knowledge of HCWs about SPs and other IPC practices [12]. Additionally, the ICSQ has been used in several studies, including developed [14‐17] and developing countries [18‐20], given its international applicability because of its original English language form and its global relevance. However, to our knowledge, neither study provided any psychometric properties beyond Cronbach’s alpha.

In Hungary, two recent studies have employed a Hungarian version of the ICSQ (ICSQ-H) to assess IPC knowledge among nurses [21, 22]. However, only internal consistency was reported as a measure of psychometric properties. It is important, therefore, to establish a validated Hungarian version of the tool to facilitate a more comprehensive and precise measurement of knowledge about IPC among nurses in Hungary, given that Hungarian is the official language in Hungary. Furthermore, this tool may act as a basis for planning and performing interventions to enhance IPC knowledge. It will also ease more research concerning IPC knowledge to be conducted in Hungary, especially because, to our knowledge, there are no validated Hungarian tools to assess HCWs’ knowledge about IPC practices. Thus, the aim of this study was to assess the validity and reliability of the ICSQ-H in Hungarian nurses.

This study aimed to evaluate the validity and reliability of the ICSQ-H. After translating the questionnaire to Hungarian, content validity was attained after removing two items. Then, the structural validity of the tool including 23 items was assessed using PCA and CFA. The final results of the PCA suggested a five-factor model with 17 items. Afterward, the CFA confirmed a four-factor model with 10 items. The original structure of the ICSQ (23 items) and the five-factor model suggested by the PCA did not meet the goodness of fit model requirements when tested for CFA. However, the final four-factor model (10 items) showed a good model fit where all the fit indices passed the requirements. The four factors of our suggested model were GLVS, PPE, ABHR, and HAIs. Furthermore, the convergent and discriminate validity of the instrument were tested and met for all factors except for the ABHR factor, where the convergent validity was slightly below the acceptable level. Additionally, the internal consistency of the factors was acceptable except for the ABHR factor.

Our findings did not support the original three-factor structure of the ICSQ. However, it should be clarified that the three factors (HAIs, HH, and SPs) that the original ICSQ evaluates are measured in our proposed Hungarian model (ICSQ-H) but with fewer items. For instance, the SP factor, including 12 items in the original ICSQ, was grouped into two factors in our model: the use of PPE and the use of GLVS, which measure the same parameter in the original questionnaire but with fewer items. Similarly, the HH factor, including eight items in the original ICSQ, can be found in our model as ABHR indications with two items, while another HH question was grouped with the GLVS factor, as it states the application of HH after removing gloves. Finally, in the original ICSQ, the HAI factor included five questions, while in our suggested model, it had only one item. We believe that failing to support the original structure of the ICSQ in our study could be due to the cultural and language differences between the French and Hungarian populations of nurses, as well as the difference in the policies and guidelines applied in the hospitals of the two countries, in addition to the differences in the educational systems and the curricula of nursing degrees that might affect the level of nurses’ IPC knowledge.

Our χ2/df was less than three with an insignificant p-value, which indicates a good model fit. However, there are some limitations for χ2/df model use. The main limitation is having a small sample size where χ2/df lacks power and might not be able to distinguish between good fitting models and poor fitting models [31, 38]. When having a large sample size, the χ2/df model is exact, which is our case [38]. Our results showed that GFI, CFI, and TLI values were above 0.95. Given the detrimental effect of the sample size on the GFI index, it is recommended to be used along with other indices that we took into account when conducting our study [31]. For instance, CFI is one of the most used and recommended fit indices since it is among the measures least affected by sample size. Similarly, TLI is a fit index that is less affected by sample size. In this study, the values of both CFI and TLI indicated a good model fit [31]. RMSEA has recently been suggested as one of the most informative fit indices since it is affected by the total count of the estimated parameters in the model. Until the early 1990s, a value between 0.05 and 1 was considered to reflect a fair model fit [31, 39]; however, in the late 1990s, a value less than 0.06 was recommended [31, 40]. Our model showed a much lower RMSEA, which indicates the goodness of fit of the model. Additionally, SRMR is recommended for use since it is easier to interpret than other fit indices because of its standardized nature. Values closer to zero show a better fit, which is the case for our model [31].

Convergent validity was met for the GLVS and PPE factors, which indicates a satisfactory level of correlation of multiple items of the same factor [34]. However, the AVE of the ABHR factor was slightly below 0.5, which could still be considered acceptable. The weak correlations between the four factors proved the discriminant validity of each. This means that the measures of distinct factors share a little common variance and support the uniqueness of the items and the factor [33]. Furthermore, it indicates that the latent factors used for measuring the causal relationships in our model are actually different from each other and do not measure the same thing that could lead to multicollinearity [34].

Concerning the interitem correlations and the corrected item-total correlations, they were acceptable for all factors. Furthermore, the internal consistency of the ABHR factor was below 0.6; however, its interitem correlations and the corrected item-total correlations were acceptable. This could be due to the low number of items in this factor (two items) [41].

Finally, the removal of 15 items during the different stages of this study (two items during content validity assessment, six items during PCA, and seven items during CFA) might considerably modify the original factor structure of the ICSQ, bearing in mind that they could hold valuable and important factors in IPC. Nevertheless, these findings further suggest the existence of repetitions of similar items measuring similar factors that compromise the construct validity of the original ICSQ [42]. However, the concise methodology that we have used allows for an adequate start to develop a Hungarian tool to assess IPC knowledge among the Hungarian population.

Few studies have been conducted to test the psychometric properties of some IPC questionnaires that are used to assess HCWs’ knowledge about IPC measures. For instance, Duarte Valim et al. [43] validated the Knowledge Questionnaire regarding Standard Precautions Measures (QCSP) for Brazilian nurses. Convergent validity was tested using known-group methods. Reliability was tested by calculating the intraclass correlation coefficient (ICC) by applying the test–retest method. The Kappa index was used for the purpose of agreement. The Portuguese QCSP showed satisfactory ICC and Kappa. However, validation by discriminant groups did not reveal a statistically significant difference between the two groups. Similarly, the infection control evaluation tool was developed by Wu et al. [2] to assess nursing students’ knowledge about standard and additional IPC precautions. The tool was a modified version derived from two previously developed tools including 15 questions. Content validity was assessed by six experts using the CVI, where an acceptable degree of validity was found, with 68% agreement. KR-20 was used to test the internal consistency, which revealed a satisfactory value of 0.76. It is worth mentioning that this tool was based on two previously developed tools, mainly Chan et al. [13], who employed the concept of UPs in measuring knowledge. Another tool was developed by Chan et al. [44] in 2008 to examine nurses’ knowledge of SPs and transmission-based precautions using four multiple-choice questions. Content validity was assessed by two experts with a CVI = 0.97. Structural validity was assessed using EFA. One factor was found to include four items with factor loadings ranging from 0.76 to 0.86. The scale reliability was assessed via test–retest. Cronbach’s alpha showed an acceptable value (0.79). Finally, we noticed that only one study assessed the structural validity of the scale using EFA [44], while neither study performed CFA, which suggests that further research is needed to test the structural validity of these scales using EFA and CFA.

This study did not support the original three-factor structure of the ICSQ tool. However, the ICSQ-H based on the four-factor structure revealed by PCA and CFA demonstrated an adequate degree of good fit and was found to be reliable. The ICSQ-H could contribute to conducting more research on the development of Hungarian tools that assess nurses’ IPC knowledge among the Hungarian population. Further research is needed to test the psychometric properties of the ICSQ across different countries and languages.