Turkish validity and reliability of children’s environmental health knowledge and skills questionnaires for nursing students

While our world is changing daily, many environmental changes seen on a global scale pose a challenge as well as a threat to human health [1]. Almost every child is exposed to environmental hazards at some point in their life [2]. These environmental exposures play a major role in children’s development [3, 4]. Children, including those in the foetal period, are at greater risk of environmental hazards than adults until adolescence. However, their exposure differs from that of adults [3]. Children are not small adults. Children, who have a special place in the global community and who will build our future, need healthy environments in which to grow, learn, and develop [3, 5]. Approximately 26% of the global population is younger than 15 years old, and this rate is higher in countries with low/middle income levels. In Türkiye, the population under the age of 15 is approximately 20% [5]. In 2016, approximately 1.6 million deaths among children under five years of age were environmentally friendly, almost two-thirds of which occurred in these countries [6]. The Sustainable Development Goals aim to eliminate preventable child mortality by 2030 [7]. If these targets are achieved, it is estimated that approximately 10 million lives under the age of 5 will be saved [8]. The environment, which is one of the basic concepts of the nursing profession, has an important role in child health [6, 9]. Nurses are conscious of the impacts of environmental degradation on health [10]. However, International Council of Nurses call for nurses to take action on local and global environmental health issues that affect health [11]. Recently, the issue of child environmental health has attracted increasing attention in nursing research [12, 13]. Reports published at the global level also justify the interest in this issue [14, 15]. The effects of many substances on health, whose use in daily life is constantly increasing or newly produced, are also a matter of curiosity [16]. “Child Environmental Health” is a scholarly field that “examines how environmental exposures (chemical, nutritional and social) early in life affect health and development during childhood and even throughout human life”. Its focus is the prevention, diagnosis and treatment of diseases in children related to environmentally detrimental exposures [17].

Notably, health workers can be strong advocates in addressing children’s environmental health [11, 18, 19]. To take action, they need to generate evidence and provide clear recommendations for remedial/preventive activities [20]. However, environmental health does not have the place it deserves in the routine practices of healthcare experts [21, 22]. These studies emphasize that environmental risk factors are not questioned, and the need for training healthcare workers on environmental history is emphasized [21‐23]. In addition, studies have shown that nurses feel uncomfortable at the point of discussing possible exposure sources related to the disease with the patient and family [22]. The reason for this discomfort can be considered insufficient knowledge and skills on the subject. However, American Nurses Associations (ANA) has set competences in the field of environmental health for undergraduate nurses. It states that they communicate with healthcare recipients, families, and the community to identify environmental health risks [20]. In the literature, the knowledge, skills, attitudes, and competency necessary to be possessed by undergraduate nurses in the fields of the environment and child health are summarized [18]. In our country, there are descriptions connected to the notion of the environment in ‘The Nursing Undergraduate Education Programme National Qualifications’ and the target learning outcomes [9]. All these can be seen as very good bases for equipping future nurses in this field. However, in the studies carried out, unfortunately, nursing education cannot educate students sufficiently on this subject, and deficiencies in terms of knowledge and skills connected to child environmental health are expressed [12, 21]. It is clear that future nurses need to be supported in this regard, and measurement tools are needed to determine whether educational goals are achieved. In the literature, tools for measuring nursing students’ knowledge and skills related to child health and the environment have been developed and these tools are valid and reliable in various countries [13, 24‐26]. ANA also recommends the use of assessment tools to identify environmental hazards [20]. However, when studies conducted with nursing students in Türkiye were examined, it was determined that there were no accessible measurement tools and study findings that simultaneously assessed multiple levels of knowledge about environmental risk factors (pesticides, mercury, lead, etc.) specifically for children. Besides that for undergraduate students in Türkiye, “creating a safe environment; participating in social responsibility projects related to the effects of the environment on human health” is listed as a basic skill at skill level 3 [9]. Qualitative study findings examine students’ self-perceptions of talent/skill during home visits conducted within the scope of public health nursing field practice in Türkiye [27, 28]. However, the lack of measurement tools that can be used in the measurement of these skills and knowledges especially in the field of paediatric environmental health, in the literature of Türkiye reveals the need to complete this field. The existence of structured measurement tools in the international literature that can simultaneously assess the knowledge and skills of nursing students regarding many environmental exposures related to child health and various environments (home, school, playground) can be considered an advantage [25, 26]. The study aimed to adapt the “Children’s Environmental Health Knowledge (ChEHK-Q) and Skills (ChEHS-Q) Questionnaires” into Turkish and to appraise its psychometric characteristics [25].

Research questions;

Using standard measurement tools at the global level provides many benefits in determining the situation and progress by ensuring a common language among healthcare professionals. It is important to measure the knowledge and skills of Turkish nursing students with respect to child environmental health, and studies conducted in various countries using samples of nursing students may facilitate comparisons [24‐26].

The validity and reliability of scales can be tested with different models. In the Rasch model, an attempt is made to estimate the probability of what an individual at a certain ability level can do against a task that is requested to be performed [41]. It assumes that “the probability of a person passing an item is related to the person’s ability and the difficulty of the item” [34, 36]. Research findings suggest that this analysis, which is commonly used in the life sciences, is less common in nursing and that its reporting should be more systematic. To increase the quality and transparency of reporting, it is important to follow the minimum standards recommended in reporting the analysis in this study in terms of contributing to the literature [42]. In this study, the data met the necessary conditions for Rash analysis [36, 37]. Only the fact that the person separation indices for both scales were very close to 2 can be considered a limitation. This finding was found to be one-to-one similar to the original scales, while the Portuguese version showed similarity only for the ChEHK-Q [24, 26]. This situation can be interpreted in the literature, as the tool may not be sensitive enough to separate high performers from low performers. More items may be needed at this point [35]. In China, these values were determined to be much higher than recommended [13].

The findings of this study support that both the ChEHK-Q and the ChEHS-Q have a unidimensional structure, as in the original and other cultures, and that factorial construct validity was achieved [13, 25, 26]. In the Portuguese version, it was suggested that the findings did not allow for explaining the construct validity for both scales, but they should be considered as one-dimensional [24]. When the model-data fit indices and error indices in CFA were considered together, the model-data fit of the tested data was good for both scales [43‐45].

Model fit parameters can be calculated via Rasch analysis. For a good item fit (infit-outfit), there must be closeness between the observed and expected data. In regard to items that are near the potential trait level of participants, anomalous response patterns can be found via infit, an adjusted statistic with weighted data. The participants’ latent trait is considerably less susceptible to things than the outfit trait, which is an adjustment statistic. With a center value of 1, the infit and outfit span from 0 to positive infinity, indicating that the model fully fits the real data [35]. In this study, the model infit and outfit values of both the ChEHK-Q and the ChEHS-Q were not greater than the maximum acceptability limits of 0.5–1.5, indicating that all the items fit the model well [35]. In the literature, there are differences in the limit values (Spain: 0.8–1.2; England/China/Portugal: 0.7–1.3) considered [13, 24‐26]. The infit and outfit values in this study did not exceed all these specified limits, similar to those in England, China, and Portugal [13, 24, 25].

Rasch analysis also determines each item’s difficulty. The average degree of item difficulty is 0, and difficulty is defined as “the value of the latent feature required for a participant to have a 50% likelihood of endorsing the item” [35]. In this study, the easiest item of the ChEHK-Q was determined to be “Item 1”, whereas the most difficult item was determined to be “Item 19”, which is the same as studies conducted in England and Spain [25, 26]. In studies conducted with community nurses in China and nursing students in Portugal, the easiest item was again “Item 1”, and the most difficult item was “Item 5” [13, 24]. It can be interpreted that these differences between countries may be due to differences in sample groups (nursing students, public health nurses) and curriculum differences. The easiest item to answer is that nursing education provides nursing students and therefore nurses with a perspective on the level of awareness related to children’s development and their sensitivity to environmental risks. However, when looking at difficult items, it is clear that they require a knowledge load related to environmental health to be answered. ANA also emphasized the necessity of environmental health concept knowledge for nursing practice, and it was determined that undergraduate nurses should be able to communicate about environmental health risks as a competency [20]. In Türkiye, under the leadership of public health nursing, joint curriculum recommendations can be made by identifying the missing points in the curriculum and holding sessions with the Delphi technique to complete them. The easiest item of the ChEHS-Q is “Item 6”, and the most difficult is “Item 3”. In studies conducted in China and England, the easiest item was “Item 8”, whereas the most difficult item was “Item 3”, which is consistent with the study findings [13, 25]. In Portugal, the easiest item was “Item 2” and the most difficult item was “Item 3” [24]. The change in the easy items in all studies can be attributed to the nursing education curricula (theoretical and practical) of the countries. However, it should be considered as a remarkable finding that the most difficult item in all studies was “Item 3” [13, 24, 25]. These results can be interpreted as nurses and nursing students being more familiar with and working on environmental risks in areas such as school or home environments. However, deficiencies in knowledge should be mentioned first when determining the environmental risks of neoplastic diseases. Since the literature also supports this interpretation, epidemiological studies provide important evidence on this subject, but this information is not included in the daily practices of clinicians who tend to affect children affected by this illness [22, 46]. A previous study revealed that nurses were more uncomfortable discussing sources of exposure to neoplastic diseases with patients and their families than physicians were [22]. To eliminate this discomfort, it is important for future nurses to enter the prepared workforce. Considering the most difficult and easiest items of both scales can provide an idea of which points need to be developed in the nursing education program. It may be recommended that revisions be made to the curriculum, taking into account the recommendations of leading organizations on child environmental health.

To assess the functioning of the items in Rash analysis, item maps are considered. The participants’ latent characteristics (θ) are compared with the item difficulty level (β). The closer the distribution of item difficulties is to the persons’ latent trait distributions, the higher the test’s accuracy is considered [35]. In this study, the majority of the students and the majority of the items on the item map were located in the central area. This implies that the variety of test items given to students was suitable for this response group. There was at least one item that could be measured at each ability level for both scales. The findings of this study align with the literature [13, 24, 25].

Rasch analysis calculates the item threshold or the distance between each item’s neighboring choices. The thresholds for ChEHS-Q must shift from negative to positive, and a shift in this sequence could mean that the response categories are not operating as they should [47]. The threshold values increased simultaneously as the ability level increased in the response categories of the ChEHS-Q items from the lowest to the highest. In accordance with the literature, the five response options of the Likert-type scale worked correctly [13, 24, 25].

In the nursing education curriculum in Türkiye, especially the public health nursing and child health nursing courses should be strengthened by taking into account the child health-environment interaction. Topics on the effects of the environment on health can be integrated into the curriculum to increase students’ knowledge of child environmental health. More opportunities can be provided for the transfer of theoretical knowledge to the clinic. For this purpose, case discussions can be held that include different application environments (school, home, playground), and students can be included in field studies to gain practical knowledge. the ChEHK-Q and the ChEHS-Q, measure student nurses’ knowledge and skills in identifying, assessing, and managing environmental health risks to children. Case studies, simulations, and practical training can be organized in training programs to help students gain this knowledge and skills. While doing all of this, it may be recommended to use educational technologies (online education, video, etc.) and encourage students to do research on this subject.

According to the research results, the Turkish versions of both the ChEHK-Q and the ChEHS-Q met the necessary assumptions for the Rasch Model (fit, unidimensionality, local independence required by the Rasch model), and none of the items contained DIF. Reliability (item/person) levels were high on an item basis and close to the limit on a person basis; the scales were reliable and had internal construct validity. The structure of the ChECK-Q, which consists of 26 items, and the ChEHS-Q, which consists of 11 items, were validated. Turkish versions of the ChEHK-Q and ChEHS-Q can be used to define the current knowledge and skills of nursing students and primary health care workers (nurses, midwives) on this subject. Scales can be tested on different samples (pediatric nurses and midwives) serving in the field of child health. If Pediatric Environmental Health Specialty Units are established in Türkiye, it may be recommended to improve the scale by adding “Item 12” to the Turkish version of ChEHS-Q. In addition to this, it may be recommended that the exposures of vulnerable groups, especially children, be clearly defined under the heading of “environment” in the updating stages of national nursing curricula. Also, the effects of lessons/planned and structured training about children and the environment on the formation of knowledge and skills can be evaluated.

This study has several limitations. Because participation was voluntary, the study results may be prone to self-selection bias. This may imply that participants may have been those most interested in environmental issues, for example, compromising the generalizability of the findings. Additionally, the use of self-administered surveys may increase the risk of desirability bias (e.g., respondents responding to provide a positive impression of themselves) or other response biases (e.g., demand attributes). Online data collection may cause participants to reflect personal or socially accepted truthful views. They may give answers that are more acceptable in an online environment. However, since the data were collected online, test‒retest evaluation could not be performed.