Psychometric properties of the Attitudes Scale facing Alcohol and Alcoholism in nursing students1 1 Paper extracted from Master's Thesis "Validation of the Scale of Attitudes towards Alcohol, alcoholism and the alcoholic fot nursing students", presented to Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.

Divane de Vargas Fernanda Mota Rocha About the authors

ABSTRACT

Objective:

to verify the psychometric properties of the Attitudes Scale facing Alcohol and Alcoholism (EAFAA) and people with disorders related to the use of alcohol in nursing students.

Method:

a convenience sample (n=420) completed the EAFAA, the data were submitted to Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Results:

the EFA resulted in an instrument composed of 48 items divided into four factors. The CFA has established the validity of the factorial structure. The internal consistency of the scale was considered adequate (α=0.85) presenting a sensitivity of 70% and specificity of 75%.

Conclusion:

the EAFAA constitutes a reliable instrument to identify the attitudes of nursing students towards alcohol, alcoholism and persons with disorders related to alcohol use.

Descriptors:
Scales; Students, Nursing; Validation Studies; Psychometrics

RESUMO

Objetivo:

verificar as propriedades psicométricas da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e as pessoas com transtornos relacionados ao uso do Álcool em estudantes de enfermagem.

Método:

uma amostra de conveniência (n=420) completou a EAFAA, os dados foram submetidos à Análise Fatorial Exploratória (AFE) e Análise Fatorial Confirmatória (AFC).

Resultados:

a AFE resultou em um instrumento composto por 48 itens divididos em quatro fatores. A AFC estabeleceu a validade da estrutura fatorial. A consistência interna da escala foi considerada adequada (α=0,85) apresentando sensibilidade de 70% e especificidade de 75%.

Conclusão:

a EAFAA constitui-se em um instrumento confiável para identificar as atitudes de estudantes de enfermagem frente ao álcool, ao alcoolismo e a pessoa com transtornos relacionados ao uso de álcool.

Descritores:
Escalas; Estudantes de Enfermagem; Estudos de Validação; Psicometria.

RESUMEN

Objetivo:

verificar las propiedades psicométricas de la escala de actitudes frente al alcohol, al alcoholismo y a las personas con trastornos por consumo de alcohol en estudiantes de enfermería.

Método:

una muestra por conveniencia (n=420) completó la EAFAA, cuyos datos se sometieron a un análisis factorial exploratorio (AFE) y un análisis factorial confirmatorio (AFC).

Resultados:

el AFE dio como resultado un instrumento compuesto por 48 ítems divididos en cuatro factores y estableció la validez de la estructura factorial. La coherencia interna de la escala se consideró adecuada (α=0,85) y presentó una sensibilidad y especificidad de 70% y 75%, respectivamente.

Conclusión:

la EAFAA representa un instrumento confiable para identificar las actitudes de estudiantes de enfermería frente al alcohol, al alcoholismo y a las personas con trastornos por consumo de alcohol.

Descriptores:
Escalas; Estudiantes de Enfermería; Estudios de Validación; Psicometría

Introduction

Classical theories of social psychology11. Rodrigues A. Psicologia social. 12ª ed. Petrópolis: Vozes; 1978. argue that attitudes are formed and developed from social relations, not limited only to the visible behavior but also to everything that can be logically inferred from the external behavior. Also according to these theories11. Rodrigues A. Psicologia social. 12ª ed. Petrópolis: Vozes; 1978. an attitude is an enduring organization of beliefs and general cognitions, endowed with emotional charge, for or against a defined social object, which predisposes to an action consistent with the cognitions and emotions related to this object, in the case of multidimensional constructs involving affective, cognitive and behavioral components.

Given the diversity of definitions of the term attitudes, at least three common elements can be found in most of them, namely: attitudes are conscious or unconscious mental state, a value, a belief or sentiment facing a particular object, a predisposition to a certain behavior and or action22. Altmann TK. Attitude: A concept analysis. Nurs Forum. [Internet] 2008. [Acesso 14 ago 2015];43(3):144-50. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1744-6198.2008.00106.x/epdf
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.

Regarding the attitudes of nurses towards alcohol and associated issues, according to scholars of the subject33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
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, these are influenced by the values and moral perceptions internalized during childhood and also in daily life. These values lead to conceiving persons with disorders related to alcohol use as without character, and guilty of their health problems, it also evokes fear in childhood, which is turned into rejection and avoidance in adulthood. Thus, the concepts and predispositions acquired in relation to those people in the social, emotional and intellectual development of the individual bring up other values, in the case of nurses, manifested through negative attitudes to people with disorders related to alcohol use33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
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.

Studies investigating the issue of training nursing students in the field of psychoactive substances have shown that most of them are often faced with people with disorders associated with the use of alcohol and other drugs, in various specialties during their training44. Rassool GH, Villar-Luis M, Carraro TE, Lopes G. Undergraduate nursing students' perceptions of substance use and misuse: a Brazilian position. J Psychiatr Ment Health Nurs. [Internet] 2006. [Acesso 1 dez 2015];13(1):85-9. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2006.00917.x/epdf
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. Students can reproduce the attitudes of practitioners facing this clientele, which have been described as negative and permeated by the moral connotations of the problem33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
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. This phenomenon is not clear, given the scarcity of national scientific literature seeking to identify the perceptions and attitudes of nursing students towards the patient with disorders related to alcohol use55. Vargas D. Nursing students' attitudes towards alcohol, alcoholism and alcoholics: a study of a Brazilian sample. J Nurs Educ Pract. [Internet] 2012. [Acesso 1 dez 2015]; 2(1):1-7. Disponível em: http://www.sciedu.ca/journal/index.php/jnep/article/view/296/319
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.

North American studies, mainly in the last three decades of the last century, provide evidence that interventions made with nursing students through training sessions are effective in increasing knowledge; however, changes in attitude occur less frequently, and when they occur, they linger for short periods of time66. Vargas D. The Impact of Clinical Experience With Alcoholics on Brazilian Nursing Students- Attitudes Toward Alcoholism and Associated Problems. J Addict Nurs. [Internet] 2013. [Acesso 21 set 2015]; 24:180-6. Disponível em: http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
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) ; there is also evidence that after appropriate training sessions nursing students feel safer and better prepared to intervene with alcoholic patients with more positive attitudes66. Vargas D. The Impact of Clinical Experience With Alcoholics on Brazilian Nursing Students- Attitudes Toward Alcoholism and Associated Problems. J Addict Nurs. [Internet] 2013. [Acesso 21 set 2015]; 24:180-6. Disponível em: http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
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. A more recent study77. Puskar K, Gotham HJ, Terhorst L, Hagle H, Mitchell AM, Braxter B, et al. Effects of Screening, Brief Intervention, and Referral to Treatment (SBIRT) Education and Training on Nursing Students' Attitudes Toward Working With Patients Who Use Alcohol and Drugs. Substance Abuse. [Internet]. 2013; [Acesso 15 mar 2015]; 34(2):122-8. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/23577905
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found that after a theoretical training on the approach towards patients with disorders related to alcohol use, improvement was observed in attitudes relating the perception of legitimacy and capacity to work with alcohol-related problems patients among students, however, they manifested less motivation to work with this clientele at the end of training.

In Latin America and specifically in Brazil, studies on the attitudes of nursing students regarding alcohol issues suggest positive that they have positive attitudes 44. Rassool GH, Villar-Luis M, Carraro TE, Lopes G. Undergraduate nursing students' perceptions of substance use and misuse: a Brazilian position. J Psychiatr Ment Health Nurs. [Internet] 2006. [Acesso 1 dez 2015];13(1):85-9. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2006.00917.x/epdf
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-55. Vargas D. Nursing students' attitudes towards alcohol, alcoholism and alcoholics: a study of a Brazilian sample. J Nurs Educ Pract. [Internet] 2012. [Acesso 1 dez 2015]; 2(1):1-7. Disponível em: http://www.sciedu.ca/journal/index.php/jnep/article/view/296/319
http://www.sciedu.ca/journal/index.php/j...
, even though they prefer not to deal with this kind of patient66. Vargas D. The Impact of Clinical Experience With Alcoholics on Brazilian Nursing Students- Attitudes Toward Alcoholism and Associated Problems. J Addict Nurs. [Internet] 2013. [Acesso 21 set 2015]; 24:180-6. Disponível em: http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
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. These difficulties have been attributed by the researchers of this phenomenon44. Rassool GH, Villar-Luis M, Carraro TE, Lopes G. Undergraduate nursing students' perceptions of substance use and misuse: a Brazilian position. J Psychiatr Ment Health Nurs. [Internet] 2006. [Acesso 1 dez 2015];13(1):85-9. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2006.00917.x/epdf
http://onlinelibrary.wiley.com/doi/10.11...

5. Vargas D. Nursing students' attitudes towards alcohol, alcoholism and alcoholics: a study of a Brazilian sample. J Nurs Educ Pract. [Internet] 2012. [Acesso 1 dez 2015]; 2(1):1-7. Disponível em: http://www.sciedu.ca/journal/index.php/jnep/article/view/296/319
http://www.sciedu.ca/journal/index.php/j...
-66. Vargas D. The Impact of Clinical Experience With Alcoholics on Brazilian Nursing Students- Attitudes Toward Alcoholism and Associated Problems. J Addict Nurs. [Internet] 2013. [Acesso 21 set 2015]; 24:180-6. Disponível em: http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
http://journals.lww.com/jan/toc/2013/060...
to the sparse attention given to the teaching of this subject in the curricula of Brazilian nursing schools.

It must be emphasized, however, that despite their significant contribution to the knowledge of this phenomenon in Brazil, national studies have obtained their results using instruments mostly not validated for use among nursing students, a fact that can contribute to biases in their findings.

Given the scarcity of Brazilian studies assessing the attitudes of nursing students to issues related to alcohol66. Vargas D. The Impact of Clinical Experience With Alcoholics on Brazilian Nursing Students- Attitudes Toward Alcoholism and Associated Problems. J Addict Nurs. [Internet] 2013. [Acesso 21 set 2015]; 24:180-6. Disponível em: http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
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, to the need to map the situation in geographic areas not yet explored, and also the importance of identifying the attitudes of this population to propose strategies to characterize the attitudes of future nurses. The availability of a robust and reliable instrument can be considered essential to systematically study the attitudes of nursing students when facing issues related to alcohol and alcoholism.

The scale of attitudes towards alcohol, alcoholism and people with disorders related to the use of alcohol (EAFAA), was developed and tested psychometrically to measure this construct among nurses and health practitioners33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
http://www.scielo.br/pdf/reeusp/v45n4/en...
,88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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, however, there are no studies of its psychometric properties among nursing students.

The EAFAA consists of 50 items divided into four (4) factors: Factor 1: The work and interpersonal relationships with patients with disorders related to alcohol use; Factor 2: The person with disorders related to alcohol use; Factor 3: The alcoholism (Etiology); Factor 4 - Alcoholic beverages and their use. This Likert scale has five points (1 being strongly disagree and 5 fully agree) showing reliability indices close or equal to 0.9033. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
http://www.scielo.br/pdf/reeusp/v45n4/en...
,88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
.

The positively oriented EAFAA items are usually ordered in a way to avoid the acquiescence in the style of responses, i.e., the tendency to constantly endorse "agree" or "disagree" in response to the items. The estimated time to complete the instrument is 15 minutes88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
.

Given that the estimates of the validity of instruments and its reliability depend mainly on the nature of the samples, and the fact that whenever an instrument is used in a new context or in different groups, it is necessary to re-establish its psychometric properties99. Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use. 3ª ed. New York: Oxford University Press; 2003.. It also needs to be considered that the psychometric studies published on EAFAA result of its application in health practitioners33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
http://www.scielo.br/pdf/reeusp/v45n4/en...
,88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
. This study aimed to study the psychometric qualities of EAFAA among nursing students.

Objective

Verify the psychometric properties of the Attitude Scale toward Alcohol, Alcoholism and people with disorders related to the use of alcohol, in nursing students.

Method

420 nursing students of the fourth and third year were recruited from three nursing schools (two private, one public) in São Paulo during the period of January 2011 to December 2012. Participants were randomly divided into two samples, one of them composed by 75% of participants (n=298) and the second consisting of the remaining 25% (n=122). In order to preserve the anonymity of the institutions, the schools are named as School A School B and School C. The collection instruments were constituted from the EAFAA composed of 50 items88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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and a sociodemographic questionnaire with information on age, gender and year (third or fourth) attended at the time of collection.

For data collection, the questionnaires were distributed in the classroom in envelopes to be deposited in an urn in the back. The participants who agreed to participate in the research deposited the answered instruments without identification. The Research Ethics Committee of the institution of the main researchers approved the proposal prior to its beginning. Of the respondents, the majority, 61%, were from School A. Table 1 shows the demographic data of the participants according to the Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Table 1
Factorial matrix of the EAFA. São Paulo, SP, Brazil, 2015

Given that it was an instrument already validated in populations of nurses and other health professionals, the data were submitted to a Confirmatory Factor Analysis (CFA) in a first step, obtaining a poor adjustment of the model. In view of this result, the data were submitted to an Exploratory Factor Analysis (EFA) after verifying whether the data met the criteria of normality and sphericity through the Kaiser-Meyer-Olkin test and Bartlett's test of sphericity. The data of sample 1 (n=298) underwent Exploratory Factor Analysis (EFA) with main axis extraction and Oblimin rotation .

The criteria adopted for the composition of the factors and for keeping items in the model were the same used in validating the original version of EAFAA88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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. This standard has also been followed to determine the reliability of the scale, using the Cronbach's alpha for the instrument in its entirety and for each of the extracted factors. The Pearson correlation coefficient was used to verify the correlation between the variables of EAFAA, and between the scores obtained by the sample in the instrument before and after the changes brought about by the AFE.

The cutoff of the EAFAA nursing students version, was identified from the analysis of the ROC technique (receiver operating characteristic), and defined as the one that maximized the Youden index1010. Alderson M. An Introduction to Epidemiology. London: Macmillan; 1976..

The best model identified by the AFE was the result of the extraction of 4 factors (after exclusion of items with no significant factor load and with double factor load) this model was subsequently selected for the Confirmatory Factor Analysis using the second sample (n=122). The CFA was conducted using the Analysis of Moment Structures method (AMOS) version 22, and the following indexes adjustments were examined: Tucker-Lewis index (TLI), Comparative Fit Index (CFI) and the Root Mean Square Error of Approximation (RMSEA). We also assessed the parsimony of the model through the parsimony comparative fit index (PCFI) and the parsimony normed fit index (PNFI).

Results

The criteria of normality and sphericity checked by the Kaiser-Meyer-Olkin and Bartlett's sphericity tests were attended presenting respective values of (0.85) and significance of (<.0001). The model consists of 50 items distributed in 4 factors and it was the best solution for this version of the scale. The model was submitted for consideration, with the exclusion of 2 items that made up the initial version of the instrument88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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(F233 -I consider the patient with disorders related to alcohol use as a lost cause & F327 - Dissatisfied people abuse of alcohol) because they have a factor load below the determined cut-off point to stay in the instrument (0.40), and because they have shown significant factor load on more than one factor at the end of the rotation.

Excluding these two items from the EAFA for nursing students did not cause damage to the reliability coefficients of the respective factors and the EAFAA. The observed result was consistent with the results of the factor analysis of the original scale88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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, keeping 48 items distributed in 4 factors (Table 1).

The reliability coefficients measured by Cronbach's alpha for the scale in full (α=0.85) and also for each of the 4 individual factors were considered satisfactory in both cases (Table 2), with a significant correlation between the factors and between these and the full version of the scale (Tabela 2). As expected, a significant correlation was found (r=0.90, p<000.1) between the scores obtained by the sample in EAFAA88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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and in the version modified by the EFA, supporting the validity criteria of the EAFAA for nursing students.

Table 2
Description of the correlations between the factors that make up the EAFAA and psychometric characteristics resulting from the Exploratory Factor Analysis and Confirmatory Factor Analysis. São Paulo, SP, Brazil, 2015.

The analysis for the selection of the cut-off point of the EAFAA adopted from the ROC curves technique pointed out as optimal for nursing students the 3.29 score presenting a sensitivity of 70% and specificity of 75%.

The model with four factors resulting from the EFA, was assessed in the second sample of participants (n = 122) using the CFA for this purpose. The results of this analysis showed reasonable fit of the model as suggested by the indexes (Table 2). The reduced model is shown in Figure 1. All four factors presented inter-correlation among them (Table 2).

Figure 1
Resulting path diagram of the Confirmatory Factor Analysis. São Paulo, SP, Brazil, 2015

Discussion

The results of this study provide evidence to support the validity of the EAFAA for use among nursing students, the factorial structure of the resulting scale of the AFE is consistent with that obtained in the original version88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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. Although composed of 48 items, two less than in the previous version88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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, the EAFAA maintained unchanged the composition of the four factors; Factor 1: Work and interpersonal relationships with patients with disorders related to alcohol use; Factor 2: The person with disorders related to alcohol use; Factor 3: O alcoholism-(Etiology); Factor 4 - Alcohol and its use, observing a significant correlation coefficient with the scores observed in the health practitioners' version88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
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.

The internal consistency of the EAFAA for nursing students, as established by Cronbach's Alpha, showed adequate levels of reliability for the full version as well as for each one of its four factors1111. Gliem JA, Gliem RR. Calculating, interpreting and reporting Cronbach´s alpha reliability coefficient for Likert-type scales. Midwest Research- to-Practice Conference in Adult, Continuing and Community Education. [Internet]. 2003 [Acesso 4 ago 2016];82-8. Available from: http://www.ssnpstudents.com/wp/wp-content/uploads/2015/02/Gliem-Gliem.pdf
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. The factors 1, 2 and 3 showed excellent, good and adequate indexes respectively of reliability1111. Gliem JA, Gliem RR. Calculating, interpreting and reporting Cronbach´s alpha reliability coefficient for Likert-type scales. Midwest Research- to-Practice Conference in Adult, Continuing and Community Education. [Internet]. 2003 [Acesso 4 ago 2016];82-8. Available from: http://www.ssnpstudents.com/wp/wp-content/uploads/2015/02/Gliem-Gliem.pdf
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, the factor 4 showed acceptable reliability index (α=0.60)1111. Gliem JA, Gliem RR. Calculating, interpreting and reporting Cronbach´s alpha reliability coefficient for Likert-type scales. Midwest Research- to-Practice Conference in Adult, Continuing and Community Education. [Internet]. 2003 [Acesso 4 ago 2016];82-8. Available from: http://www.ssnpstudents.com/wp/wp-content/uploads/2015/02/Gliem-Gliem.pdf
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, consistent with previous studies that evaluated the psychometric properties of the EAFAA in different populations33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
http://www.scielo.br/pdf/reeusp/v45n4/en...
,88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
. It was also noted a low correlation of this fact with the EAFAA and the other factors of the scale, a result also observed in previous studies88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...

Among the reasons for this result, we can highlight the low variability in factor 4 in this version of the EAFAA (4%), providing additional evidence to the idea that this factor might be measuring another construct88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
. This can only be established more positively through studies aimed to test this hypothesis88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
.

The results suggest that the EAFAA has a satisfactory structural validity, since it presented 40% of the total variance of the data, concentrating over 20% of it in the first factor1212. Nunally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw Hill; 1994., matching consistently with what was observed in the original version88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
i.e. the one-dimensional characteristic of the scale1212. Nunally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw Hill; 1994.-1313. Roberts JS, Donoghue JR, Laughlin JE. A general item response theory model for unfolding unidimensional polytomous responses. Appl Psychol Meas. [Internet] 2000. [Acesso 1 dez 2015];24:3-32. Disponível em: http://apm.sagepub.com/content/24/1/3.full.pdf+html
http://apm.sagepub.com/content/24/1/3.fu...
.

The analysis of sensitivity and specificity of the EAFA showed that it has 70% (p < .000) of probability of identifying individuals who score above 3.29 on the scale and that actually have a positive attitude towards alcohol, alcoholism and people with disorders related to alcohol use. This cutoff point is slightly higher than that observed in the version for use among health professionals (3.15)88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
.

The hypothesis that the four correlated factors retained by the AFE are reliable and valid was confirmed by the AFC by the setting rates and parsimony, with values close to the cutoff point suggested by the literature which are, in the case of absolute fit indices: Comparative Fit Index (CFI) >0.851414. Balbinotti MAA, Barbosa MLL, Saldanha RP, Balbinotti CAA. Factor and internal consistency studies of the Balbinotti Motives to Competitiveness in Sports Scale. Motriz. Rev Ed Fis. [Internet] 2011. [Acesso 1 dez 2015];17(2):318-27. Disponível em: http://www.scielo.br/scielo.php?pid=S1980-65742011000200011&script=sci_arttext
http://www.scielo.br/scielo.php?pid=S198...
; Tucker- Levis Index (TLI) >0.901515. Vieira PRC, Ribas JR. Análise Multivariada com uso do SPSS. Rio de Janeiro: Ciência Moderna; 2011. and the Root Mean Square Error of Approximation (RMSEA) < 0.08. Although the absolute fit indices have been performing below the cutoff point established by some authors, we need to consider that there is no ideal index representing a definitive criterion for testing a structural model1616. Raykov T, Marcoulides GAA. First course in Structural Equation Modeling. New Jersey: Lawrence Erbaum; 2000.. Therefore it is recommended that the results are assessed in a selected set of fit adequacy ratios, even if there is no consensus among all1717. Kline RB. Principles and pratices of structural equation modeling. New York: The Guilford Press; 2005.. Based on these assumptions, it can be said that evaluating together the results of CFA, they reject the null model, suggesting satisfactory fit of the model, since it is a parsimonious model presenting PCFI and PNFI ≥ 0.601616. Raykov T, Marcoulides GAA. First course in Structural Equation Modeling. New Jersey: Lawrence Erbaum; 2000., and RMSEA <0.08.

All factors presented correlation among each other, the positive correlations observed between factors 1 and 2 suggest that the scores of these two factors are positively correlated which may imply that the scores on the factor that measures attitudes towards work and interpersonal relationships with people with disorders related to alcohol use is correlated with the score obtained related to people with disorders related to alcohol use. This means that subjects who get high scores on factor 1 tend to also score high in factor 2, being the opposite also true88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
.

Consistent with previous studies33. Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
http://www.scielo.br/pdf/reeusp/v45n4/en...
,88. Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
http://www.scielo.br/scielo.php?pid=S010...
the EAFAA for nursing students is also positively oriented, which means that with the exception of items F117, F141, F303, F307, F311, F315, F319, F323, F327, F331, F339, F404, F408, F412, F416, F420, F428, F436, F117, F303 , F311, F319, F323, F335, F339, F404 , F408, F412, F420, F428, F436 the answers to all others must be calculated with inverted values, thus the scores should be calculated as follows: (1=5), ( 2=4), ( 3=3), (4=2),(5=1).

This study provides important contributions to nursing. Within the scope of research, it provides the scientific community with a psychometrically tested instrument for use among nursing students, filling a gap in this area. The availability of this version of EAFAA can also contribute to the increase of research on this subject in the country, and it can also be the subject of further research aiming to validate it in other cultural contexts. It may facilitate to identify common and divergent aspects in the attitudes of nursing students in different settings and cultures.

Among the implications for the nursing practice, the EAFAA can be used to assist teachers in identifying the attitudes of future professionals, thus enabling them to direct their actions in order to change them, in cases where the results of its application reveal negative attitudes. The EAFAA can even be used for the identification of the effects of proposed strategies to change the attitudes of students, comparing different groups and interventions.

Having certainty that the EAFAA has adequate levels of reliability and validity, it is suggested that the scale presents robust indexes of validity for use in nursing students' samples and their results may provide subsidies for research and the practice of nursing. This study should be interpreted within the framework of several limitations, namely, the specific time when data was collected and the convenience samples that even coming from institutions with different characteristics, their origin is the same region of the country. For those reasons it is advisable to enlarge the research using EAFAA through the inclusion of the regional differences in the country.

Moreover, the fact that the sample was predominantly composed of females may have influenced the external validity of the results and future studies should include more male students. Additional psychometric studies obtained with other samples are desirable in order to test the construct validity demonstrated here.

Conclusion

The psychometric properties of EAFAA suggests that it is in a reliable instrument to identify the attitudes of nursing students towards alcohol, alcoholism and the person with disorders related to alcohol use. The results are the basis for the advancement of science by offering an instrument with reliable psychometric properties to measure the attitudes of this population towards the theme alcohol and alcoholism with accuracy. It is suggested that its psychometric qualities are tested in different populations and in other contexts and situations.

References

  • 1
    Rodrigues A. Psicologia social. 12ª ed. Petrópolis: Vozes; 1978.
  • 2
    Altmann TK. Attitude: A concept analysis. Nurs Forum. [Internet] 2008. [Acesso 14 ago 2015];43(3):144-50. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1744-6198.2008.00106.x/epdf
    » http://onlinelibrary.wiley.com/doi/10.1111/j.1744-6198.2008.00106.x/epdf
  • 3
    Vargas D. Reduced version of the scale of attitudes towards alcohol, alcoholism, and alcoholics: primary results. Rev Esc Enferm USP. 2011. [Acesso 13 jun 2015];45(4):918-25. Disponível em: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
    » http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a18.pdf
  • 4
    Rassool GH, Villar-Luis M, Carraro TE, Lopes G. Undergraduate nursing students' perceptions of substance use and misuse: a Brazilian position. J Psychiatr Ment Health Nurs. [Internet] 2006. [Acesso 1 dez 2015];13(1):85-9. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2006.00917.x/epdf
    » http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2850.2006.00917.x/epdf
  • 5
    Vargas D. Nursing students' attitudes towards alcohol, alcoholism and alcoholics: a study of a Brazilian sample. J Nurs Educ Pract. [Internet] 2012. [Acesso 1 dez 2015]; 2(1):1-7. Disponível em: http://www.sciedu.ca/journal/index.php/jnep/article/view/296/319
    » http://www.sciedu.ca/journal/index.php/jnep/article/view/296/319
  • 6
    Vargas D. The Impact of Clinical Experience With Alcoholics on Brazilian Nursing Students- Attitudes Toward Alcoholism and Associated Problems. J Addict Nurs. [Internet] 2013. [Acesso 21 set 2015]; 24:180-6. Disponível em: http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
    » http://journals.lww.com/jan/toc/2013/06000/doi 10.1097/JAN.0b013e3182a4cc43
  • 7
    Puskar K, Gotham HJ, Terhorst L, Hagle H, Mitchell AM, Braxter B, et al. Effects of Screening, Brief Intervention, and Referral to Treatment (SBIRT) Education and Training on Nursing Students' Attitudes Toward Working With Patients Who Use Alcohol and Drugs. Substance Abuse. [Internet]. 2013; [Acesso 15 mar 2015]; 34(2):122-8. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/23577905
    » http://www.ncbi.nlm.nih.gov/pubmed/23577905
  • 8
    Vargas D. Validação de Construto da Escala de Atitudes Frente ao Álcool, ao Alcoolismo e a Pessoas com Transtornos Relacionados ao Uso do Álcool. Rev Psiq Clín. [Internet] 2014. [Acesso 1 dez 2015];41(4):105-10. Disponível em: http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
    » http://www.scielo.br/scielo.php?pid=S0101-60832014000400106&script=sci_arttext&tlng=pt
  • 9
    Streiner DL, Norman GR. Health measurement scales: a practical guide to their development and use. 3ª ed. New York: Oxford University Press; 2003.
  • 10
    Alderson M. An Introduction to Epidemiology. London: Macmillan; 1976.
  • 11
    Gliem JA, Gliem RR. Calculating, interpreting and reporting Cronbach´s alpha reliability coefficient for Likert-type scales. Midwest Research- to-Practice Conference in Adult, Continuing and Community Education. [Internet]. 2003 [Acesso 4 ago 2016];82-8. Available from: http://www.ssnpstudents.com/wp/wp-content/uploads/2015/02/Gliem-Gliem.pdf
    » http://www.ssnpstudents.com/wp/wp-content/uploads/2015/02/Gliem-Gliem.pdf
  • 12
    Nunally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw Hill; 1994.
  • 13
    Roberts JS, Donoghue JR, Laughlin JE. A general item response theory model for unfolding unidimensional polytomous responses. Appl Psychol Meas. [Internet] 2000. [Acesso 1 dez 2015];24:3-32. Disponível em: http://apm.sagepub.com/content/24/1/3.full.pdf+html
    » http://apm.sagepub.com/content/24/1/3.full.pdf+html
  • 14
    Balbinotti MAA, Barbosa MLL, Saldanha RP, Balbinotti CAA. Factor and internal consistency studies of the Balbinotti Motives to Competitiveness in Sports Scale. Motriz. Rev Ed Fis. [Internet] 2011. [Acesso 1 dez 2015];17(2):318-27. Disponível em: http://www.scielo.br/scielo.php?pid=S1980-65742011000200011&script=sci_arttext
    » http://www.scielo.br/scielo.php?pid=S1980-65742011000200011&script=sci_arttext
  • 15
    Vieira PRC, Ribas JR. Análise Multivariada com uso do SPSS. Rio de Janeiro: Ciência Moderna; 2011.
  • 16
    Raykov T, Marcoulides GAA. First course in Structural Equation Modeling. New Jersey: Lawrence Erbaum; 2000.
  • 17
    Kline RB. Principles and pratices of structural equation modeling. New York: The Guilford Press; 2005.

  • 1
    Paper extracted from Master's Thesis "Validation of the Scale of Attitudes towards Alcohol, alcoholism and the alcoholic fot nursing students", presented to Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil.

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    09 Mar 2015
  • Accepted
    07 July 2016
Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br