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Assessing the Construct Validity and Reliability of School Health Records of the ‘Health Dialogue Questionnaire,’ in 7th Grade in Compulsory School

HDQ: Health Dialogue Questionnaire; PedsQLTM: Paediatric Quality of Life Inventory; LUPP®: Local Monitoring of Youth Policy Questionnaire; HBSC: Health Behaviour in Swedish School-Aged Children; RMSEA: Root Mean Square Error of Approximation; TLI: Tucker-Lewis Index; CFI: Comparative-Fit-Index; GFI: Goodnessof-Fit Index; ITC: Item-Total-Correlation; M: Mean Value; SD: Standard Deviation; SMC: Squared Multiple Correlation


Introduction
In a WHO study including 40 countries, Sweden was identified as one of the countries where the majority of children live healthy and safe lives, eat healthy foods regularly, are physically active and play and go to school in a safe environment [1]. Schoolchildren's Health in Sweden has improved for many years, with increasing life expectancy and decreasing health problems. This increased health can be linked to increased financial resources, enhanced level of education and better health care and knowledge of how to promote health and prevent illness [2]. Children's health is a broad concept, incorporating much more than a simplistic freedom from medical illness. In this study the World Health Organizations [3] definition is used. Time trends from 1985/86 to 2005/06 among Swedish boys and girls; show that the risk of mental health problems such as nervousness, feeling low and sleeping difficulties has increased steadily [1,4,5]. Childhood health and development is affected by the environment and the of the HDQ 7 th grade in compulsory school through comparison of the HDQ with Paediatric Quality Of Life Inventory (PedsQL TM ), Local monitoring of youth policy questionnaire (LUPP ® ) and Health behaviour in Swedish school-aged children (HBSC).

Research Context
The data originate from the school nurses HDQ in 7 th in compulsory school in the county of Vasternorrland. Each year registers about 8,000health consultations in the county. The countycontains of seven municipals, and the region is characterized by large rural areas and few cities approximately 250,000 inhabitants located in the middle/north of Sweden. Furthermore the county has lower middle income, education level and proportion of residents with foreign background compared with the national average. The county's school students have slightly lower average level of grades compared with the national average [11].

Sample
The validity and reliability calculation were investigated based on the data from the HDQ in 7 th grade in compulsory school (n= 2008), the HBSC questionnaires (n=1500), the "LUPP ® "questionnaires (n=2648) and the PedsQL TM (n=477), in the academic year 2009/2010. The sample size for HDQ corresponded to 77 % girls and 79 % boys of all 7 th grades school girls and boys in the county [11].

Data Collected
The text regarding the used instruments was presented as follows: i.

Name
ii.
History, Background and Responsibility for the instrument iii.
Which dimensions and numbers of dimensions included iv.
Numbers of items and how these are sorted in to dimensions v.

How the questionnaire was distributed and handled
The health dialogue questionnaire, the HDQ: The County Council and the seven municipalities reached consensus on a systematically structured approach to the collection of school children's health data. The HD represents a cross-sectional image of the child's SRH regarding physical, mental and social health. The HDQ was offered to all school children at four occasions: in preschool, in fourth grade, in seventh grade, the first year of high school, and follows the child's development and growth from 6 to 16 years old and therefore repeat the content with age appropriate questions [12][13][14]. The HDQ consisted of a structured questionnaire covering three dimensions of health physical, mental and social. The physical dimension included six questions/items. The mental dimension included five questions/ items, while, the third dimension was social and included four questions/items. The school nurses who conduct the HDQ was situated at the school and shared the school environment with the school children at a daily base and were responsible for the data collection at each separate school i.e. distribution of written as well as oral information to all children and parents regarding voluntary participation and the registration of each HDQ. The school nurses were also responsible for the individual feedback to the students.

Health behavior in Swedish school-aged children (HBSC):
The HBSC was a part of the WHO global survey and since 1985/1986 this study has taken place around the world every four years, most recently in over 40 different countries. The international standard questionnaire enables the collection of common data across participating countries and thus enabled the quantification of patterns of key health behaviours, health indicators and contextual variables. School children aged 11, 13 and 15 were asked to answer different health questions during their ordinary school classes and give a cross-sectional image of school children's health [15]. The HBSC consisted of a structured questionnaire with 82 questions covering four dimensions of health behaviour among school aged children. The dimensions were 'Self-rated health and general well-being', 'Lifestyle', 'Social relationships' and 'School'.
The sampling method for participating school children was carried out in a two-step cluster design. First, a national representative cluster of schools was randomly selected. Second, a selection of schools or classes in each grade was included in the study, with at least 1500 school children in each grade; data consisted of school children 13 years old from the academic year 2009/2010. The cluster of schools differs for each occasion the HBSC is conducted. Furthermore the HBSC was a schoolbased survey with data collected through self-completion questionnaires administered in the classroom by teachers. The HBSC did not include individual contact, dialogue or feedback concerning the questionnaires with the school children. The teacher is responsible for distribution of information concerning the study, such as parental agreement and school children´s voluntary participation.

Pediatric Quality of Life Inventory (PedsQL TM ):
The PedsQL TM was a modular approach to measuring health-related quality of life in children and adolescents. The PedsQL TM consisted of brief, practical, generic core scales suitable for use with healthy school and community populations. Accordingly, the PedsQL TM consisted of developmentally appropriate forms for children ages 2-4, 5-7, 8-12 and 13-18 years. Paediatric selfreport was measured in children and adolescents ages 5-18 years. The PedsQL TM was not used on a regular base in school environment, but mostly used in the research context [16]. The PedsQL TM encompassed the essential core domains for paediatric health related quality of life measurement: i.
'School Functioning' (5 items) [17] The questionnaires were distributed by the school nurses in one of the municipalities in the county, in addition to the HDQ to the same individuals.
Knowledge about young people -LUPP ® : The LUPP ® (a local follow-up of youth policy) was a cross-sectional survey that enabled municipalities to gather knowledge on the living situation of young people, as well as information on their experiences and opinions, since 2001. The Swedish Agency for Youth and Civil Society has developed the LUPP ® survey in consultation with municipal representatives and researchers. The survey was adapted for different age groups: young people at compulsory school aged 13-15; young people at upper secondary school aged 16-18; and young adults 19-25 years old. The LUPP ® survey contains approximately 80 questions was divided into different modules with questions concerning the perception of influence and democracy, wellbeing school, leisure activities, work, health and future plans. The survey was mainly intended to be conducted electronically in school. In order to reach young people outside school it could be supplemented with a mail survey, in either electronic or paper form.
The LUPP ® survey could be carried out electronically or on paper, by the latter age group, a web-based survey, while the younger age group typically use questionnaires implemented during a lesson hours in school by teachers. Distribution was like the HBSC. LUPP ® survey was analysed and reported at a municipal and national level and used in the research context.

Statistical Analyses
Assessing the usefulness of school health records demands a structured approach to validity. A schematic picture of the construct validity 1 model was used as the analysing structure could be seen in Figure 1. A variety of ways exists to evaluate the construct validity and in general the order of analysis follows chronologically 1 to 3 ( Figure 1). Construct validity consisted of Translational validity 4 , though in the model not analysed and henceforward not mentioned, while Criterion validity 2 consisted of concurrent 3 (Table 1), predictive 3 , convergent 3 and/ or discriminant 3 ( Table 2) validity.
Related items defined a part of a construct and were grouped and modelled together as a factor/s or a latent construct/s. A structural equation model approach was used to develop and test the factor models. In the first structure analyses models, all the items were modelled as indicators of the intended underlying latent constructs. A two-step structural equation model procedure was applied. In the first step, an exploratory factor analysis was conducted to determine a model where the constructs measured the underlying latent variables. The factor analysis assumed each manifest variable/item to be a distinct indicator of an underlying latent construct, whereby different constructs were permitted to be inter correlated. In the second step a Mann Whitney U test was carried out to determine if the latent variables were acceptable as independent constructs that could be sufficiently distinguished from each other. Significant Mann-Whitney test values indicate discriminate validity. The appropriateness of a specific factor analysis model was assessed by measures of global and local fit. Global fit indicated whether the empirical associations among the

Ethics
This study followed the ethical principles recommended by the Research Council and was approved by the Ethics Committee at the Medical Faculty, Umea University, to be evaluated the (Dnr 2008-122M).

Results
The HDQ was salutogenic and the percentages of positive answers are presented in Table 1. Measuring the concurrent validity are done by comparing the percentages emanating from the HDQ with similar questions from different but resembling questionnaires HBSC, PedsQL TM and LUPP ® . Describing and analysing the percentages in Table 1, the percentages were averagely underestimated 9 percentages (Table 1); the items "daily physical activity", "eating breakfast every school day", and "sleep" differ mostly between HDQ and the population proxies.
In the girl's model (Figure 2), items 1 (psych 1) and item 2 (psych 2) showed content overlap. Item 4 (psych 4) and item 6 (psych 6) also appeared to overlap as well as item 1 (psych 1) and item 5 (psych 5). Each manifest item was mutually correlated >0.50. Error covariance parameters were included in the model to manage the item content overlaps in the girl model. In the boy's model (Figure 3), items 1 (psych1) and item 2 (psych 2) also showed content overlap. Item 16 (phys 7), item 19 (phys 9) and item 13 (phys 1) and item 15 (phys 4) correlated >0.40. Alas to modify the model, error covariance parameters were added in the boy model. Turning to the unstandardized model estimates, all were significant in both models as could be seen in Table 3 (Figures 1 & 3).
All results significant with P<.001 otherwise stated as (n.s.)      The item total correlations between the manifest item and their latent variable (factor) were generally high for both girls and boys. One item (psych 3) though, in the boy model only managed to reach 0.14 ( Table 5). All the other values, at least indicated good discrimination (0.2>=ITC<=0.39), with a majority of the values (90%) 0.4 and above indicating a very good discrimination (Tables 5 & 6) [18,19]. Furthermore, indices of local-fit proved that each latent construct was agreeably reliably measured by its indicators/items 0.42 % of the manifest items in the girl model and 17% in the boy model was measured acceptably by its underlying construct (indicator reliability, >=0.40) (SMC R 2 in Tables 5 & 6) [18,19].

Assessing the Construct Validity and Reliability of School Health Records of the 'Health Dialogue Questionnaire,' in 7 th Grade in Compulsory School
A confirmatory factor analysis confirmed a five factor model for the girls and a four factor model for the boys in school (7 th grade) using the items from HDQ (construct validity). The analyses resulted in two finals Table structures (girls and boys) that were tested and confirmed on another HDQ seven graders sample (academic year 2010/2011, n=1979). The five factor girl's model resulted in a 63% cumulative variance explained and the four factor boy's model in 58% cumulative variance explained (principal axis factoring with varimax rotation). In Table 2, the bivariate correlations of all scales from the exploratory factor analyses models (Figures 2 & 3)

Discussion and Conclusions
The aim was to psychometrically test HDQ for measuring the self-reported health in 7 th graders in compulsory school. The major finding was that it was possible to adequately model five (girls) respectively four (boys) hypothetical dimensions of the health In girls health these were psychological, environmental, physical, behavioral, and working environment (work) and the four hypothetical dimensions in boys health were psychological, environmental, physical and behavioral (Figures 2 & 3). A confirmatory factor analysis confirmed that it was possible to adequately model girls and boys health (construct validity) in 7 th grade using the items from HDQ. The analyses resulted in two finals  was analysed whenthe HDQ was compared with answers from three other questionnaires similar questions and similar sample (for HDQ and PedsQL TM actually identical). Ambiguous questions showed less criterion related validity, but most of the questions in the HDQ related highly with their proxy counterparts.
Convergent and discriminant validity was examined using the newly produced scales from the structural equation modelling factor analysis and correlating the scales resulted in understandable and expected associations. To further strengthen the validity of the HDQ would be to test the questionnaire in a highly different sample. The fact that we analyzed a regional cohort composed of mostly white children, living predominantly rural, with low or middle class parents mean that the population was well-defined. The questionnaire results might not be generalizable, for instance, to a more heterogenic urban area.

Methodological Considerations
Since all results were assessed using self-reports, results may have been biased by common method variance. The common method variance may state a real bias in survey-type of studies and enhance the observed correlation between variables [21]. Despite the above mentioned, the overall findings suggests that structured validation studies helps developing sound and usable questionnaires.

Conclusion
Children "learn health" through role models (mainly parents but also other adults close to the children) [22]. Therefore, the school is an important arena for health promotion, as all children attend school and all adults within a school have an opportunity to serve as role models [23,24]. A health promoting school strengthens children's self-esteem and school performance [25] and learning and health are known to be generated by the same factors [26,27]. The questionnaire may be used in health promoting practices in school, serving as a feedback instrument for assessing the health of school children in 7 th grade.