Validation of an instrument to evaluate health promotion at schools

Pinto, Raquel Oliveira; Pattussi, Marcos Pascoal; Fontoura, Larissa do Prado; Poletto, Simone; Grapiglia, Valenca Lemes; Balbinot, Alexandre Didó; Teixeira, Vanessa Andina; Horta, Rogério Lessa

doi:10.1590/S01518-8787.2016050005855

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Original Articles • Rev. Saúde Pública 50 • 2016 • https://doi.org/10.1590/S01518-8787.2016050005855 copy

Validation of an instrument to evaluate health promotion at schools

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To validate an instrument designed to assess health promotion in the school environment.

METHODS

A questionnaire, based on guidelines from the World Health Organization and in line with the Brazilian school health context, was developed to validate the research instrument. There were 60 items in the instrument that included 40 questions for the school manager and 20 items with direct observations made by the interviewer. The items’ content validation was performed using the Delphi technique, with the instrument being applied in 53 schools from two medium-sized cities in the South region of Brazil. Reliability (Cronbach’s alpha and split-half) and validity (principal component analysis) analyses were performed.

RESULTS

The final instrument remained composed of 28 items, distributed into three dimensions: pedagogical, structural and relational. The resulting components showed good factorial loads (> 0.4) and acceptable reliability (> 0.6) for most items. The pedagogical dimension identifies educational activities regarding drugs and sexuality, violence and prejudice, auto care and peace and quality of life. The structural dimension is comprised of access, sanitary structure, and conservation and equipment. The relational dimension includes relationships within the school and with the community.

CONCLUSIONS

The proposed instrument presents satisfactory validity and reliability values, which include aspects relevant to promote health in schools. Its use allows the description of the health promotion conditions to which students from each educational institution are exposed. Because this instrument includes items directly observed by the investigator, it should only be used during periods when there are full and regular activities at the school in question.

School Health; Health Promotion; Program Evaluation; Evaluation of Research Programs and Tools; Reproducibility of Results; Validation Studies

Theme	Item	h²	Factors

			1	2	3	4
Drugs and sexuality
	(Questioned) Educational activities at school that stimulate debate regarding the risks associated with the consumption of:
	alcoholic beverages	0.837	0.874	-	-	-
	tobacco (cigarettes, cigars)	0.867	0.868	-	-	-
	illicit drugs	0.904	0.858	0.393	-	-
	(Questioned) Educational activities that promote debate on sexual health, reproductive health and STDs (sexually transmitted diseases).	0.594	0.698	-	0.307	-
Violence and prejudice
	(Questioned) Educational activities to stimulate reflection and discussion on:
	bullying (hostility, coercion, constraint)	0.789	0.358	0.792	-	-
	discrimination and prejudice	0.784	0.382	0.751	-	-
	sexual diversity/homophobia	0.589	-	0.728	-	-
Self-care
	(Questioned) Educational activities regarding healthy eating in different areas of the school.	0.783	-	-	0.856	-
	(Questioned) Educational activities relating to personal skills such as empathy, interpersonal relations, decision-making, critical and creative thinking, pressure and/or stress management, self-understanding.	0.781	-	-	0.848	-
	(Questioned) Educational activities that address and stimulate personal hygiene at school.	0.709	-	-	0.713	0.437
Peace and quality of life
	(Questioned) Educational activities on a culture of peace and human rights.	0.698	-	-	0.338	0.739
	(Questioned) Educational activities relating to physical exercise at school, not considering those that are part of the Physical Education curriculum (e.g., games, contests, dances, bouts, running, gymnastics, team sports or other).	0.551	-	-	-	0.728
	(Questioned) Educational activities to stimulate reflection and discussion on violence (domestic, sexual and other).	0.728	-	0.54	-	0.657
General Cronbach's alpha of the dimension	0.843	Alpha	0.89	0.74	0.79	0.61
Split-half coefficient	0.856	Variance %	37.2	16.9	10.5	9.4
KMO	0.705	Cumulative %	37.2	54.1	64.5	73.9
Bartlett	< 0.001	-	-	-	-	-

Dimension	Questions
Structural	(Questioned) Do you consider that the Parent-Teacher Council at your school is an effective body?
	(Questioned) Does the school have any permanent project in which students have the opportunity to participate in educational/recreational activities outside the school environment?
	(Questioned) Does the school open up its space or offer access to the local community for educational and leisure activities at weekends? (e.g., open school)
	Answer if your school continuously and permanently develops the actions/programs presented below: (Projects in development, those not yet implemented, or those run for a period, but subsequently stopped, should not be considered!)
	(Questioned) Does the school have any partnerships with institutions/technical support from health professionals on health guidance in general.
	(Questioned) Are there appropriate facilities to provide a healthy diet (own dining hall with adequate space and structure)?
	(Questioned) Does the school develop sanitary practices to prevent the spread of disease at school and in the community such as controlling vectors such as rats and insects, and properly disposing garbage? (consider the whole school).
	Does the school have structural conditions that are compatible with:
	(Questioned) fire prevention (license issued by the local authority)
	Do you consider the physical structure of the classrooms adequate in terms of:
	(Questioned) accident prevention?
	(Questioned) climate control (temperature and humidity)?
	(Observed) Access to foods with a high content of fat, saturated fat, trans fat, sugar and salt (e.g., biscuits with fondant filling, fried foods, sweets in general, savory snacks).
	(Observed) Cafeteria properly structured in general terms of cleanliness and organization.
	(Observed) (Observed) Posters, flyers or any other form of information access for individuals frequenting the school regarding smoking, alcohol and drugs in general.
	(Observed) Presence of security cameras in internal or external common areas.
	(Observed) Recycle bins for proper disposal, with separation facilities for dry and organic waste.
	(Observed) Sports court or area for performing sports or physical activity, attached to the school, with covered and outdoor space.
	(Observed) Maximum of up to 35 students per class (5^th to 8^th grade).
Relational	(Questioned) Does the school have student body or any other social group in which all students have the opportunity to participate in the school’s decision-making process?
	(Questioned) Have there been any incidents of verbal abuse in the school environment between students and students over the last 30 school days?
	(Questioned) Have there been any physical conflicts between students and students in the school environment over the last 30 schooldays?
	(Questioned) Have there been any security-related issues involving weapons (firearms or blade weapons), theft and vandalism, regardless of whether or not police/municipal guards/security officers had been called, in the school environment over the last 30 schooldays?

Theme	Item	h²	Factors

			1	2	3
Access
	(Questioned) Does the school have structural conditions that are compatible with accessibility (physical environment that enables students with special needs to access the same educational activities that are provided to others)?	0.820	0.898	-	-
	(Observed) Accessibility (physical environment which permits persons with disabilities access to all activities, such as ramps, floors and rooms that are suitable for wheelchairs)?	0.775	0.805	-	0.334
	(Observed) Access to the only point leading to the inside of the school (or similar) permanently monitored by porter or security guard.	0.44	0.626	-	-
Structure conservation and equipment
	(Observed) Evidence of problems to conserve the structure, such as broken chairs being used, holes, leaks, broken tiles, risk of falling due to floor conditions or other.	0.674	-	0.819	-
	(Observed) Library occupying an exclusive room, reading tables, chairs, bookshelves, windows with protection from the sun, and a minimum of seats equivalent to at least 50.0% of the school’s students who attend the study time with the most students.	0.658	-	0.786	-
	(Questioned) Does the school have structural conditions that are consistent with environmental preservation (sustainable energy use, tree planting, recycling)?	0.508	-	0.505	0.414
Sanitary conditions
	(Observed) Covered and outdoor physical space/recreation area in conditions suitable for recreational activities, not counting the areas reserved for sports, with an area equivalent to at least 1/3 of the total area occupied by classrooms (not including the common areas).	0.698	-	-	0.818
	(Questioned) Does the school have its own health team or the support of a local health service team that performs periodic health evaluations and provides guidance to its students?	0.596	-	-	0.726
	(Observed) Bathrooms in working order, properly preserved equipment (clean flushable toilets with adequate water, access to sinks for washing hands and general cleaning) and brushodrome or suitable structures to allow children, including the smallest ones, to brush their teeth.	0.552	-	0.508	0.519
General Cronbach’s alpha of the dimension	0.737	Alpha	0.72	0.63	0.58
Split-half coefficient	0.805	Variance %	33.1	16.1	14.4
KMO	0.639	Cumulative %	33.1	49.2	63.5
Bartlett	< 0.001	-	-	-	-

Theme	Items	h²	Factors

			1	2
Community relations
	(Observed) Generally, the school’s surrounding area can be considered pleasant and suitable for children and adolescents to frequent.	0.634	0.794	-
	(Observed) Evidence of physical damage to the school, such as graffiti, vandalism or other signs of vandalism against the property.	0.584	0.754	-
	(Questioned) Does your school participate in organizations or have any partnerships of interest with the local community, involving councils, authorities, NGO’s, local leaders, social or any other groups?	0.405	0.589	-
Relationships at school
	(Questioned) in the last 30 days there have been episodes of school fights/arguments between people from the local community and school representatives?	0.756	-	0.869
	(Questioned) Have there been any incidents of verbal abuse in the school environment between teachers and teachers over the last 30 school days?	0.529	0.402	0.606
	(Questioned) Have there been any incidents of verbal abuse in the school environment between students and teachers over the last 30 school days?	0.339	-	0.613
General Cronbach's Alpha of the dimension	0.642	Alpha	0.58	0.49
Split-half coefficient	0.642	Variance %	38.1	17.1
KMO	0.681	Cumulative %	38.1	55.1
Bartlett	< 0.001	-	-	-

Dimension	Questions
Pedagogical	Answer if your school continuously and permanently develops the actions/programs presented below: (Projects in development, those not yet implemented, or those run for a period, but subsequently stopped, should not be considered!):
Pedagogical	(Questioned) Are school meals offered and/or food and healthy meals (e.g., fruits, natural juices, snacks or meals low in sugar, salt and fats) for sale at school?
Structural	(Questioned) Are the bathrooms connected to the sewage network.
	Do you consider the physical structure of the classrooms adequate in terms of:
	(Questioned) Natural lighting (including protection against direct sunlight)?
	(Questioned) Ventilation?
	(Observed) Access to food and healthy meals (e.g., fruits, natural juices, snacks or meals low in sugar, salt and fats).
	(Observed) Posters, flyers or any other form of information access for individuals frequenting the school regarding sexual and reproductive health.
	(Observed) Ventilated rooms, with adequate and direct aeration.
	(Observed) Adequate lighting in classrooms along with protection against direct sunlight.
	(Observed) Minimum of 1.20 m² of space per pupil in each room (mean room size in m²/mean number of students per room).
Relational	(Observed) Does the school have rules (clearly defined standards) regarding rights and duties at school?
	(Observed) Have there been any physical conflicts between students and teachers in the school environment over the last 30 schooldays
	(Observed) Have there been any physical conflicts between teachers and teachers in the school environment over the last 30 schooldays?

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[1] Correspondence
: Rogério Lessa Horta. Rua Jari, 671 apto 703 Passo D’Areia. 91350-170 Porto Alegre, RS, Brasil. E-mail: rogeriohortamed@gmail.com