Development and validation of the HFAI was carried out in three phases following the assessment tool development process: (1) item generation; (2) construction of domains, subdomains, and items; and (3) validation with field testing. Statistical analyses for reliability and validity were conducted.
Phase I: Item Generation
For Phase 1, we organized lists of indicators relevant for company health-friendly activities, as well as for Corporate Social Responsibility (CSR) and Creating Shared Value (CSV) sectors that are associated with social contribution. We developed the list of indicators in tandem with our development of the Worksite Health Index.11 We first reviewed more than 20 published indexes, such as the FSG Measuring Shared Value,12 the B Corporation GIIRS Index,13,14 the Dow Jones Sustainability Index,15 the Health Impact Assessment,16 the Nestlé CSV Report,17 the British Government’s CSR Index,18,19 Creating Shared Value,20,21 Porter & Kramer Moore,19 the CDC Worksite Health Scorecard10,22, and CSR.2,4 We conducted semi-structured interviews with 24 health and CSV professionals (two family medicine doctors, one psychiatrist, four chief executive officers (CEOs), one consulting firm director, two non-profit organization security generals, two CSV experts, one economist, one nutritionist, three physical education experts, three psychologists, two CSR staff members, one Korea Occupational Health Agency assistant chief, and one occupational health nurse). We generated new assessment items for health-friendly activity to determine their contribution to consumers’ health. We summarized field experiences and insights and used them to construct the framework of HFAI.
We then generated six domains for a total of 125 items reflecting key issues as follows: (1) Governance and Infrastructure, (2) Needs Assessment, (3) Planning, (4) Implementation, (5) Monitoring and Feedback, and (6) Outcomes. The Governance and Infrastructure domain includes three subdomains: Philosophy, Policy, and Infrastructure of company. The Needs Assessment domain includes two subdomains: Needs Assessment and Actual Condition Investigation. The Planning domain includes three subdomains: Planning, Budget, and Participation and Cooperation. The Implementation domain includes eight subdomains: (1) Research & Development, (2) Purchase of Raw Material, (3) Product Production / Service Provision, (4) Promotion / Marketing, (5) Packing / Distribution, (6) Sales / Disposal / Post-marketing Management, (7) Information Disclosure, and (8) Creating Health Value for Products / Services. The Monitoring and Feedback domain includes three subdomains: Evaluation System, Monitoring, and Reflection on Post-plan. Finally, the Outcome domain includes no subdomain.
Phase Ii: Original Item Construction
The list was created using the Delphi method originally developed in 1967 by the RAND Corporation.23 A group of 28 experts anonymously checked the feasibility and reliability of each item based on a five-point Likert scale and subsequently provided feedback. This was repeated twice. Items remained on the list if four criteria were met: (1) relevance mean score ≥ 3.0, (2) feasibility mean score ≥ 2.5, (3) prevalence ratio of less than relevance mean score 3 ≤ 25%, and (4) prevalence ratio of less than feasibility mean score 3 ≤ 25%. Items that did not meet these four criteria were deleted. Utilizing this method, we deleted 20 items, and the first version of the HFAI was reduced to 105 items on the questionnaire. To rate the assessment tool for evaluation, we utilized a yes/no scale.
Phase Iii: Validation With Field Testing
The purpose of field testing is to test reliability and validity. Considering statistical power, thirty companies should participate in this study. For Group One, our goal was to include at least 30 companies representing 10 business sectors and 24 industry groups selected based on the Global Industry Classification Standard (GICS) 2014; we succeeded in including 31 companies. Two research assistants assessed Group One with a provisional HFAI based on their recent sustainability reports. Then the corresponding author assessed the reports independently with reference to their assessment. However, we did not evaluate the outcomes of HFAI in sustainability reports as the reports did not show the activity of measuring outcomes for health-friendly activities.
For Group Two, we recruited a sample of 19 worksites to participate in this study. To test reliability and concurrent validity, enrolled worksites were asked to have two knowledgeable employees complete the provisional HFAI and Contribution Assessment Tool for Consumer’s Health (CATCH).3 With the CATCH, participants rated how products or services of their company contribute to the physical, mental, social, and spiritual health status of consumers (0 = not at all helpful, 10 = very helpful) (Table 1). We also collected information about worksite demographics, such as number of employees, business type, and industry. The survey was conducted online.
Table 1
Contribution Assessment Tool for Consumer’s Health
Company’s health-friendly activities that make an important contribution to consumers' physical health |
| Reflecting physical health status during product / service development / improvement |
| Reflecting the enhancement of physical health activities when developing / improving products / services |
| Quality control for raw materials |
| Minimization of harmful elements of production / service process |
| Active compensation for health-related accidents |
Company’s health-friendly activities that make an important contribution to consumers' mental health |
| Reflecting mental health status during product / service development / improvement |
| Reflecting the promotion of mental health activities when developing / improving products / services |
| Customer friendly service |
| Actively coping with customer complaints |
| Building confidence in corporation-made products / services |
Company’s health-friendly activities that make an important contribution to consumers' social health |
| Reflecting social health status during product / service development / improvement |
| Reflecting on social health activity promotion when developing / improving products / services |
| Constantly building relationships with customers |
| Respecting customers without discrimination |
| Contributing to improvement of family / relationship with others |
Company’s health-friendly activities that make an important contribution to consumers' spiritual health |
| Reflecting spiritual health status during product / service development / improvement |
| Reflecting on spiritual health activity promotion when developing / improving products / services |
| Providing products / services that respect the person as a human being |
| Providing products /services make a person feel worthy and valuable |
| Providing products / services that help improve life satisfaction |
(0 = not at all helpful, 10 = very helpful) |
Additional evaluation
In addition, from March to May 2018 we conducted another survey of the general Korean population, including people 20–70 years old residing across 17 major cities and local districts. In each major city and local district, all participants were recruited using two strata (age and sex) following the guidelines of the 2016 census of Korea. We used a probability-proportional-to-size technique for sample selection to represent a nationwide sample.24 Approximately 4,000 people were contacted over the 17 major cities and local districts. The World Research Co., Ltd., conducted the survey, and 1,200 individuals were included in the final sample (the response rate was 30%). Using the CATCH, participants were asked to rate how a company’s product or service helped their physical, mental, social, and spiritual health status (Table 1). For the total 100 companies evaluated, 400 people rated 33 companies, another 400 people rated 33 different companies, and the final 400 people rated 34 companies. The 31 companies of Group One were included in the 100 companies evaluated. The Cronbach’s α of the CATCH for the 31 companies of Group One suggested high reliability with good internal consistency (Appendix 1).
Our study developing and validating the HFAI was reviewed and approved by the Institutional Review Board (IRB) of the Seoul National University Hospital (SNUH) (IRB No. 1904-082-1026) as an IRB Review Exemption study. Ethics approval was obtained from the IRB of the SNUH for participants’ self-reported questionnaire of the general population as an IRB Review Exemption study. (IRB No. 1804-024-934)
Reliability and validity test
To estimate the reliability of all five HFAI domains and subdomains for Group One and all six HFAI domains and subdomains for Group Two, Cronbach’s α coefficients were used. To assess the concurrent validity of the HFAI domains, we investigated the correlation of HFAI domains with consumers' evaluation of each company’s health-friendly activities that made an important contribution to their health (CATCH) in the general population. To establish the validity of the HFAI scale, the Spearman correlation was constructed to determine meaningful associations between the HFAI score and scores of contributions to the health status of general population. In addition, for the 19 companies in Group Two, the Spearman correlation was constructed to determine meaningful associations between their self-rated HFAI score and scores of their contributions to consumers’ health status.
All calculated p-values were two-sided with the significance level set at p < 0.05. SAS statistical package version 9.3 (SAS Institute, Cary, NC, 1990) and R 3.5.1 were used for all analyses.