Development and Psychometric Evaluation of an Instrument for Preventing Occupational Neck Pain Behaviors in Teachers

Background: Development and psychometrics of a questionnaire for preventive occupational pain behaviors in teachers.Quantitative and qualitative research plan in tool development and validation. Method: A qualitative study was conducted in December 2020 with 25 participants to obtain the initial information of the questionnaire. Then content validity and face validity were performed. In the next stage, a questionnaire was distributed among the sample of teachers. In total, 146 teachers participated in this study (with a mean age 36.7; SD 8.92 years). Exploratory factor analysis was used to obtain the factor structure of the questionnaire. The correlation matrix in the case scale has been used to evaluate the validity of the structure. Internal stability (Cronbach's alpha) was calculated to assess reliability and internal correlation coecient to assess stability. Results: Based on analysis of the exploratory factor, 8 factors with 43 substances, that together accounted for 65,25% variances were obtained. Also, the correlation matrix in the case scale to establish the validity of the questionnaire showed satisfactory results. The results of face validity showed that 4 factors were not approved and were removed from the questionnaire. Reliability evaluation with internal consistency method (Cronbach's alpha) showed excellent compatibility (0.87). The Intraclass correlation reliability assessment showed that the questionnaire has satisfactory stability (ICC) (0.92). Conclusion: This study provides the reliability and validity of the Occupational Pain Neck Preventive Behaviors Questionnaire. This study provides an instrument for evaluating occupational neck pain prevention behaviors among teachers. The instrument is useful for teachers and staff of administrative units and healthcare settings to implement appropriate interventions. benets the benets of suggested behaviors to reduce the risk or worsening of a disease or harmful condition resulting from a particular behavior. Perceived severity as person's abstract belief about the actual and perceived costs of pursuing new behavior. Cues to action, the accelerating forces that make one feel

the need to perform a particular behavior, which can be of internal (perception of a physical state) or external (interpersonal interactions, media communication) and self-e cacy as ensuring that one has the ability to pursue a particular behavior [16,17].Based on the health belief model for adopting disease prevention behaviors, people must rst feel threatened by the problem (perceived sensitivity), then understand the depth of the danger and the severity of its effects (perceived severity) with the positive symptoms they receive from their environment (Cues to action), useful and capable believe in the implementation of preventive behaviors (perceived bene ts) And nd the factors that prevent this behavior from being less costly than its bene ts (perceived barriers) and also consider themselves capable of performing preventive behaviors (self-e cacy) to ultimately perform the correct function in preventing the disease [16]. Since, it seems that this model can be applied for designing a proper instrument to measure neck pain behavior, the purpose of this study is to develop and psychometric evaluation of an instrument for preventing occupational neck pain behaviors in teachers.

Aim
The purpose of this study is development and psychometric the questionnaire of preventive behaviors of occupational neck pain in teachers.

Design
This instrument was developed in a two-step study. In the rst stage, a qualitative study was used to produce items and in the second stage, a cross-sectional study was used to do psychometric approach. At the second stage, the validity and reliability of the instrument was done. The reliability assessment was done by internal consistency method (Cronbach's alpha) and intra class correlation coe cient (ICC) were examined.

Item generation
Due to the pandemic of the Corona virus, it was not possible to interview the participants in person. For this reason, a qualitative study was conducted in December 2020 by main researcher through making telephone calls to 30 participants, based on the structures of the HBM to prepare questionnaire items. Participants were asked questions about the existence of occupational neck pain , the factors causing neck pain based on HBM and methods to prevent occupational neck pain. Based on the information obtained from the participants and the studies conducted, the initial questionnaire was designed with 77 items. Then, the questionnaire which was prepared by the research team (Moradi and et al.) was evaluated, in which 26 items were removed from the questionnaire. A total of 51 items remained at this stage.
Developing a preliminary questionnaire At this stage, the questionnaire was subject to content validity and face validity. To determine the content validity of the questionnaire , the 15 specialists in the majors of health education and health promotion, ergonomics, physiotherapy and occupational health evaluated the items of the instrument through correcting grammar, use of appropriate words, item allocation and appropriate scoring and scaling and responding to cases of being essential, useful but unnecessary and useless items [18][19][20]. The responses were calculated based on the formula and matched to the Law she's table (Lawshe, 1975) to estimate the content validity ratio (CVR) [21]. Experts were asked to evaluate each questionnaire in terms of three criteria: relevancy, simplicity and clarity to calculate the content validity index _ CVI [22,23].
The CVR for the questionnaire was (0.85) and the CVI for the questionnaire was (0.92) that were higher than the recommended values. However, 26 items were removed at this stage. Then, to assess face validity, a questionnaire was sent to 30 teachers to examine the items based on simplicity, importance, relevancy and clarity. Obtained data were analyzed by which the impact score for each item was calculated above 1.5 for all items and there was no change in the number of items. Therefore, at this stage, a preliminary questionnaire with 51 items was prepared.
Validity, reliability, and rigor A cross-sectional study was performed to evaluate the psychometric properties of the questionnaire.

Sample, participants
The samples were teachers working in junior high schools, district 19 of Tehran , Iran. The selection of participants was based on the purpose of the study. A total of 30 participants were interviewed by telephone in order to obtain information about the existence of occupational neck pain and methods to prevent occupational neck pain. A cross-sectional study was done by 146 teachers. Initially, a list of all schools in district 19 was prepared and due to lack of cooperation, all non-pro t schools were removed from the list. Therefore, only public schools were selected to estimate the sample size. The names of all schools were identi ed by code. The codes were then poured into a bag and randomly divided into two groups. Informed consent was obtained from all participants. (Table 1) shows the characteristics of the study participants.

Data collection
The questionnaire was sent to the participants which completed by them and returned to the main investigator (Moradi).

Scoring
All items in the questionnaire (perceived sensitivity, perceived severity, perceived barriers, perceived bene ts, self-e cacy, Cues to action and behavior) were ranked on a 5-point Likert scale. In the eld of knowledge, the correct answers were formulated in two options (true, wrong). Any teacher who scores higher in the eld of knowledge has a higher level of knowledge to perform the recommended behaviors. The average rating on the knowledge items by the study sample are shown in (Table 2).

Data analysis
To evaluate the construct validity, exploratory factor analysis (EFA) and scale correlation matrix were employed. The Kaiser_ Meyer_ Olkin (KMO) Index and Bartlett's test sphericity were used to evaluation [24]. The factor structure of the questionnaire was extracted using Varimax rotation. The presence of a case in a factor of approximately 0.4 was determined based on the recommendation (Bernstein & Nunnally, 1994) [25], For the correlation matrix in the case scale, Pearson correlation coe cient was used and values of coe cient 0.4 or above were considered acceptable. For KMO, the value of 0.5 is unacceptable factor analysis, 0.5 to 0.7 is moderate factor analysis 0.7 to 0.8 is balanced factor analysis and 0.8 to 0.9 is desirable and greater than 0.9 results i excellent factor analysis. In this study, the KMO value was 0.833, which shows a favorable factor analysis for the data (Table3). Reliability evaluation with internal consistency method (Cronbach's alpha) showed excellent compatibility (0.87).

Results
The sample characteristics In all, 146 teachers agreed to participate in the study (mean age 36.7 years and SD 8.92). Of these, 119 (81.51%) were female and 27 (18.49%) were male. The average work experience of the participants was 12.04,(6.2 SD) years.
Factor structure After con rming the adequacy of the sample based on KMO and Bartlett sphericity test (KMO = 0.833 and χ2 = 5030.743, p < .001), exploratory factor analysis was performed and 12 factors were obtained, (Fig. 1). Based on the dimensions of the health belief model and considering the factor load, factors with a coe cient value greater than 0.4 were acceptable and factor load less than 0.4 were eliminated. Therefore, factors 11 and 12 were removed. Also, at this stage, 8 items including (items 1,3,6,6,7,10 of knowledge) (item 7 of behavior) (item 2 of self-e cacy) and (item 1 of cues to action) that had low factor load were removed from the questionnaire. After factor analysis of the remaining items, 10 factors were obtained. Due to the fact that the coe cient of factors 9 and 10 was less than 0.4, these two factors were also removed. Therefore, the number of factors was reduced to 8 factors with 43 items. Table 4 shows the changes expressed by the factor analysis model for the 8 factors extracted. This criterion can be used to evaluate the adequacy of the model. Moreover, downloaded items include: knowledge (5 items), perceived sensitivity (6 items), perceived severity (5 items), perceived bene ts (5 items), perceived barriers (4 items), Cues to action (3 items), self-e cacy (6 items) and behavior (9 items) The results of nal questionnaire and scoring manual are shown in (Table 5).  Item-scale correlation matrix The correlation between its items and subscales is shown in (Table 6). The lowest amount of subscription for item 3 of the knowledge scale with a value of 0.549 and the highest amount of subscription for the item 21 is the perceived bene t scale with a value of 0.841.

Discussion
The purpose of this study was to design and evaluate reliability and validity, of an instrument for evaluating effective factors associated with neck pain prevention behaviors among teachers. The initial items of the questionnaire were obtained based on the data of a qualitative study and quantitative studies and overview of neck pain in teachers. Also, in the production of items, psychological, social, economic factors related to neck pain in teachers were used [3,5,26,27]. In the health belief model, there are four concepts, perceived sensitivity, intensity, practice guide and self-e cacy. That these concepts with environmental, social and psychological factors can play a role in the formation of a health behavior or health threatening behavior. The two concepts of perceived sensitivity and perceived intensity are considered to be a perceived threat that this concept with educational resources, environmental support, internal and external motives (Cues to action), skill and self-e cacy can lead to change behavior [16,28,29]. The results show that this questionnaire is appropriate in terms of validity and reliability. In addition to assessing knowledge, it also measures other dimensions, including attitude and self-e cacy. In fact, this questionnaire can measure knowledge, attitude, perceived sensitivity, perceived intensity, perceived bene ts, perceived resources, self-e cacy, and behaviors that are all modeloriented constructs. In general, the effective factors causing neck pain include: personal and demographic factors, psychological and occupational factors, perceived sensitivity, perceived severity, perceived bene ts, perceived barriers, Cues to action and selfe cacy in performing neck pain prevention behaviors [1]. Therefore, the various causes and complex nature of neck pain necessitate the use of a multidimensional instrument to assess neck pain. In fact, the Occupational Neck Prevention Behavior Questionnaire is a multidimensional instrument that includes structures that together can indicate reasons for performing or not performing occupational neck pain prevention behaviors. These reasons are very important in improving the health of occupational groups, especially teachers. Without understanding such reasons, the development of educational interventions is almost impossible.

Limitations
Although this study had several strengths, there were some limitations. The most important limitations were the outbreak of the coronavirus and the closure of schools, where teachers had to answer the questionnaire online, so it may affect their response.
Also, due to the unavailability of teachers and their busy schedule, it was possible for someone else to respond instead of the actual respondent. In fact, the researcher called the participants and asked them to complete the questionnaire themselves.
Therefore, conditions are provided for lifting the restriction. In addition, all data were self-reported and collected in Tehran. Therefore, care should be taken in generalizing the ndings. Despite all the limitations, this instrument is statistically very valuable in assessing and measuring the factors associated with occupational neck pain among teachers.

Conclusion
The Occupational Pain Neck Prevention Behavior Questionnaire is a reliable instrument among teachers and can be used in future studies in different populations and environments. The model used in this instrument includes different structures that are: awareness, perceived sensitivity, perceived intensity, perceived barriers, perceived bene ts, Cues to action, self-e cacy and behavior. Figure 1 The scree plot obtained from exploratory factor analysis for the questionnaire