Reliability and Validity of the Health Options Scale
in Community-Dwelling Parents and Children

Family health promotion is a process undertaken by the family to sustain or enhance the social, emotional, and physical well-being of the family system and its members. Developing knowledge of family health promotion is a priority for nursing research that has been hampered both by limited theorizing and, subsequently, lack of instrumentation at a family versus individual level. The concept of health work (Allen, 1986, 1994; Ford-Gilboe, 1997, 1998) offered a starting point for understanding the process of health promotion in families and provided the basis for developing a new instrument, the Health Options Scale, to measure family health promotion behaviour.

Study Purposes

1. To examine the reliability (internal consistency, test-retest) and construct validity of the a revised 38-item version of the Health Options Scale (HOS) in a community sample of adult parents (>18 years) and children (10-17 years).

2. to examine the comparability of two methods of administering the HOS (i.e. individual family member versus family consensus).

Conceptual Basis of the HOS

In the Developmental Health Model, health work is defined as a process of active involvement through which families learn ways of coping and developing that are conducive to healthy living over time. In essence, health work is reflected by the extent to which families are involved in two interrelated sets of activities:

1) Growth seeking/developmental activities that emphasis setting and achieving goals that foster healthy individual and family development, and
2) Problem-solving/ coping activities focused on managing health situations using a problem-solving approach in collaboration with professionals and others as needed

All families are engaged in some level of health work. Health work can be thought to exist on a continuum of extremes (low to high) with many variations in between these points. The health promotion behaviours of families who engage in the lowest levels of health work are characterized as follows: lack of attention to health matters, having few health goals, focussing on barriers to changing health practices, managing health situations by ignoring the problem (default), relying on experts to solve the problem, and/or engaging in limited problem-solving (eg. identifying few options, select options that can be implemented quickly and result in the least amount of change, brief try out period, little analysis of unsuccessful attempts). In contrast, higher levels of health work are associated with: active involvement in health matters, setting realistic health goals that fit with the family's sense of where it is going, actively working toward health goals, managing health situations by seeking information, discussing/analyzing the situation, identifying options, weighing pros and cons of each option including its fit with family lifestyle, trying out and evaluating health behaviours based upon goals (Allen, 1994, Ford-Gilboe, 1997,1998). This work is accomplished in collaboration with experts as necessary. Thus, health work can indicated by the number and quality of health-related problem-solving and growth-seeking activities demonstrated by a family at a particular point in time (Allen, 1994). Over time, the ways of coping and developing learned in response to particular situations become integrated into the family's way of living and are translated into new situations as they arise. When the health work of a family is examined across different situations, a general pattern or style emerges.

Initial Development and Testing of the HOS

The Health Options Scale (HOS) was developed to measure health work (Ford-Gilboe, 1994). It is a summated rating scale on which participants rate the extent to which their families engage in behaviours reflecting health work from `strongly disagree'(1) to `strongly agree' (4). Higher scores reflect higher degrees of health work. A balance of items representing both extremes of the health work continuum (i.e. lower and higher) have been included, and, therefore, some items are reverse scored. The reading level of the HOS, determined using the FOG formula (Lynn, 1989), is fifth to sixth grade.

An initial pool of 29 items was developed from an earlier conceptualization of health work. A content validity index of .97 was computed from ratings of item relevance provided by two nurses who have expertise in the subject matter. Based on an item analysis performed on pilot data from a sample of 35 mothers, the HOS was reduced to an internally consistent 25-item scale (a=.89).

Next, the HOS was tested with a larger, economically diverse, predominantly caucasian sample of 138 Canadian families. The mother and one child (10-14 years) from each family completed the HOS and several other measures of theoretically-related concepts. Evidence of construct validity was provided through a positive correlation between mothers' scores on the HOS and the Health Promoting Lifestyle Profile (HPLP)(r=.51,p<.01). These instruments measure similar phenomena (health promotion) from different perspectives (process versus lifestyle) and at different levels (family versus individual). Moderate positive correlations were also found between HOS scores and: the FACES III which measures family cohesion (emotional closeness), the General Self-Efficacy Scale, a measure of perceived confidence, and the PRQ85, a social support measure. Within the Developmental Health Model, health potential (the strengths, motivation and resources of the family and its members), positively influences health work.

Results of an item analysis were used to delete four items with item-correlations of <.30 from the scale. Exploratory factor analysis using Principal axis factoring (PAF), performed separately for mothers' and childrens' data, provided support for a single factor that explained 33% of the variance in health work for mothers and 31% for children. Three additional items with low factor loadings (<.30) were deleted from the scale. Alpha reliability coefficients for the revised 18-item scale were .91 for both mothers and children.

These promising results justified additional validation studies of the HOS with a larger, more diverse sample so that more definitive evidence of reliability and validity could be obtained and the applicability of the HOS for other populations (eg. males, adolescents) could be determined. During this time, a more complex conceptualization of health work was developed. Each of the 18 HOS items was consistent with this enhanced concept; however, 20 new items were generated to reflect aspects of health work not tapped by the original instrument.

Methodology

A methodological study was undertaken to examine the reliability and validity of the revised 38-item Health Options Scale (HOS) in a community sample of parents and children (10-17 years) recruited from a mid-size city in Ontario, Canada. Data from four subsamples were used to assess: a) test-retest reliability and internal consistency, b) construct validity, including dimensional structure, and c) the comparability of two methods of administration (i.e. individual family member versus family consensus).

Each participant independently completed a questionnaire containing the HOS, a demographic profile and several instruments measuring concepts that are theoretically-related to health work (Table 1). Subsample 1 participants (prenatal program participants) completed the HOS twice, two weeks apart. Subsample 2 participants, parents of school-aged children were recruited from community programs/centers where their children were engaged in some activity (eg. soccer, swimming lessons, arts and crafts, etc). Subsample 3 participants, children between the ages of 10 and 17, were recruited from two sources: community centers and public schools. Subsample 4, families of school-aged children, were recruited using advertisements in placed in community settings (recreation centers, libraries, etc) and newspapers. These families completed an additional version of the HOS by reaching consensus among family members after having completed individual questionnaires.

All of the measures used to examine construct validity of the HOS are summated rating scales with established reliability and validity. Higher scores reflect higher degrees of the attributes being measured on all but one of these scales, the PSI. Internal consistency of each of these scales was acceptable.

Table 1. Data Collection Approach

- Family Hardiness Index; FACES III - Family Cohesion and Adaptability Evaluation Scales; PSI - Problem-Solving Inventory; APGAR- Family Apgar

FHI - Family Hardiness Index (McCubbin, McCubbin & Thompson, 1987). A 20-item self-report measure of family hardiness, a basic strength containing both cognitive and behavioural components used by families to manage difficult transitions and challenges.There is some overlap between the behavioral components of hardiness and health work. A moderate, positive correlation between the FHI and HOS was hypothesized.

FACES III - Family Cohesion and Adaptability Evaluation Scales ((Olson, McCubbin, Barnes, Larsen, Muxem & Wilson, 1985). Self-report instrument containing two scales of ten items each - one for cohesion (emotional closeness) and one for adaptability (flexibility). Cohesion and adaptability are proposed to be family strengths. According to the Developmental Health Model, family strengths positively influence participation in health work. Therefore, a moderate positive correlation between the FACES III and HOS would provide evidence of construct validity of the HOS.

PSI - Problem-Solving Inventory (Heppner, 1988). A 32-item self-report measure of individual problem-solving style containing three subscales: problem-solving confidence, approach-avoidance style, and personal control. Lower scores on the PSI indicate appraisals of more successful problem-solving. A moderate, negative correlation was expected between the PSI and HOS as these scales measure similar concepts (problem-solving) from different reference points (individual versus family).

APGAR- Family Apgar (Smilkstein, 1978). A 5-item measure of satisfaction with family functioning in the areas of: adaptation (family resources), partnership (shared problem-solving and decision-making), growth (support for change), Affection (expression of feelings) and resolve (time spent together). Theoretically, satisfaction with family functioning is proposed to be an outcome of in health work. Therefore, a positive correlation between the Family APGAR and HOS was expected.

Summary of Main Results

Construct Validity
Factor analysis was used to examine the dimensional structure of the HOS using data provided by 325 adult participants (subsamples 1 and 2). Prior to the factor analysis, 11 items having item-total correlations of <.30 were deleted from the scale. Using confirmatory factor analysis, a 3 factor solution containing 21 items was found to fit the data (GFI = .89) and account for 98% of item variance. The subscales were labelled as follows: 1) Attending, which reflects active involvement in health matters (8 items), 2) Goal Attainment, the family's efforts in identifying and working toward goals aimed at improving family health (6 items), and, 3) Experimenting, which reflects openness to new ideas and risking of old ways of living; mobilizing resources and working through health situations using a problem-solving approach (7 items). Conceptually, the subscales overlap as each contains aspects of both the developmental and problem-solving components of health work. Correlations between the subscales range from .42-.61 and the subscales are highly correlated with the total score (r=.77=.91).

As further evidence of construct validity, moderate correlations were found between scores on the HOS and several measures of theoretically-related concepts: the FACES III cohesion scale (r=.36), Family Hardiness Index (r=.30), family APGAR (r=.29), and the Problem-Solving Inventory (r=-.35). Among the PSI subscales, HOS scores were most strongly correlated with approach avoidance scale; this subscale, which taps a person's tendency to actively work toward solving a problem rather than avoiding it, has the most conceptual overlap with health work.

Reliability
Internal consistency estimates were: .88 for the total score, .82 for Attending, .74 for Goal Attainment and .72 for Experimenting. Test-retest reliability over a 2-week interval was .61, indicating moderate stability over a short period of time but lower than anticipated. The data used in the test-retest analysis were obtained from 34 expectant men and women who were in nearing the end of the last trimester of pregnancy, most of whom were having their first child. In this situation, health work may be quite changeable as these families learn to respond to the demands of preparing for labour and parenting. The small sample and timing of the second data collection period around the expected time of birth may have also affected the stability of participants' responses.

Reliability and Validity with Children
Analysis of children's data is in progress.

Sample Items

Higher degrees of health work:

We pay attention to our health practices on a daily basis.
Before we make decisions that will affect our health, we look at all of our options.
We are trying to make healthy changes in areas that are important to us.
We talk about how new ways of staying healthy fit with our lifestyle before deciding to try them.
When a solution to a health problem is not successful, we examine why it didn't work.

Lower degrees of health work (items are reverse scored):

We do not have any special health goals.
Making plans to improve health doesn't work because we live from day to day.
If we try to make changes in our health practices, we quickly return to our usual routine.
We don't have a clear idea about what we want for our family in the future.

Subsequent Use of the HOS
The Health Options Scale is a core measure used in studies conducted within the Family Health Promotion Research Program. The 21-item HOS has been used in graduate student research involving families of preschool children (Monteith, 1997), families with a member with chronic inflammatory bowel disease (Moore-Hepburn, 1997), Latin American Mennonite families (Burrill, 1998) and single-parent families who have children with chronic health problems (Chambers, 2000) as well as in a recently completed study of influences and outcomes of health work in a community sample of 236 single-parent families (Ford-Gilboe, Laschinger, Berman and Laforet-Fleisser, 2000). Reliability and validity estimates for the HOS in each of these samples are comparable with the estimates reported earlier. Several additional studies are in progress.