Psychometric Properties of ‘Attitudes to Health Professionals Questionnaire’ (AHPQ) in Iranian Context

Background: The professional life has been frequently made by social interactions in which different forms of professional collaboration appear. Everybody has different attitudes through his/her life that could inuence on choosing profession and probably the approach towards inter professional work. In order to study the current attitude towards planning educational courses and assess eciency of the ongoing educational courses, the present study has normalized the Persian version of the ‘Attitudes to Health Professionals Questionnaire’ (AHPQ). Method: After permission from questionnaire developers, in order to conrm face and content validity, the process of translation and back translation was performed. Then it was sent to ten scholars (Delphi Technique) and their comments were considered for providing the nal copy. The questionnaire was back translation from Persian into English. The nal version was compared with the original questionnaire in terms of concepts. Reliability conrm by test-retest and internal consistency (intra class correlation and Cronbach alpha coecient).The construct validity was conrmed by exploratory factor analysis. Results: According to the rst phase (67 participants), wide range has caused unnecessary variations in answers; so reliability has been conrmed in larger sample size (104 participants) after decreasing the extent of scale from 10 to 5 points. Exploratory factor analysis was used by main construct and rotation of maximum variance. Final reliability was conrmed by Cronbach alpha as 0. 899. Three underlying constructs of professional ethics, professional autonomy and patient-centered care had been revealed in the questionnaire. Conclusion: In addition to conrmation of AHPQ construct validity, reveals that such a tool is able to specify the attitude of health team members based on their perceived importance towards the basis of inter professional collaboration. Thus, recognizing and directing priorities of health care team in inter professional collaboration enables us to manage establishment, integrity, sustainability and coordination of group activities.

specify the attitude of health team members based on their perceived importance towards the basis of inter professional collaboration. Thus, recognizing and directing priorities of health care team in inter professional collaboration enables us to manage establishment, integrity, sustainability and coordination of group activities.

Background
Our professional life frequently has been made by social interactions with other which appear in different forms of communication and collaboration. It conveys the meaning of sharing, when a group tries to achieve a common goal with spirit of coordination and trust, particularly in the eld of professional health. (1) It also causes decrease in hospital costs and patients' mortality (2), promotion of health care and improvement quality of care. (3,4,5) Such e cient communication brings about success for physicians and nurses (6), increases productivity, improves patients' conditions (7), and reduces length of hospital stay and medical costs of patients. (8) On the other hand, faulty communication results in making incorrect diagnosis, decreasing patients' participation in their therapeutic programs as well as weakening process of patient instruction. (9) Attitude has been de ned as an indicator of how people feel about their experience. (10) Everybody has different attitudes through his/her life that could in uence on choosing profession and probably the approach towards inter professional work. (11) A wide range of educational curricula are being implemented throughout the world in order to develop inter professional skills. (12)(13)(14)(15) Similar curricula are being planned and implemented in Iran as well. (16,17) In order to study the current attitude towards planning educational courses and assess e ciency of the ongoing educational courses, an instrument is necessary to measure inter professional attitude. (11) Several tools have been developed for this purpose (18)(19)(20)(21)  the respondent was asked to mark the place of an imaginary member of a health team on a 10-poin visual analogue scale. The internal consistency for the nal copy of AHPQ questionnaire was 0.87 for all 20 items. The exploratory factor analysis speci ed two categories of caring and service as the underlying constructs of the questionnaire; however, the two items of high-income/ low-income and aggressive/ nonaggressive have been kept in the questionnaire as the separate items. (11) The valid and reliable version of the questionnaire was not available in Iranian context. The present study has normalized the Persian version of questionnaire.

Methods
In present research, validity and reliability of Persian version of AHPQ have been studied. It has conducted on senior medical and nursing students of Tehran University of Medical Sciences.
AHPQ has been developed in order to assess level of inter professional attitude by Lindquist et.al. In 2005. It has 20 bipolar statements with score between 0-10. The higher mean score means higher capability of inter professional skills. The higher score in each sub scale also indicates to higher competence in the related eld. (11) First Phase After permission from questionnaire developers, in order to con rm face and content, based on modi ed Toolkit on Translating and Adapting Instruments, the process of translation was performed. (20) Two independent language expert who were familiar with health profession terminology, translated the questionnaire. Then it was sent to ten scholars including psychologists, medical educationists and clinicians (Delphi Technique) and their comments were considered for providing the nal copy.
Afterwards, the questionnaire was back translation from Persian into English by two other English translators. The nal version was compared with the original questionnaire in terms of concepts. The construct validity was con rmed by statistical methods.
Random strati ed sampling was used in this research. The samples were 34 senior medical students and 34 senior nursing students. Ethical considerations were followed: Tehran University of Medical Science's Ethics committee approval letter was taken (code: 92-01-61-20964). The related letters for conducting study in hospitals were also prepared. After explaining the research objectives, the informed consent was taken from participants. They were also assured that their data were kept con dential.
In order to con rming reliability by test-retest, the questionnaire was lled by participants two times. Since the recommended interval between conducting retest must be long enough to avoid recall bias and the appropriate time interval to conduct the rst test and retest must be 1 to 2 weeks (22), they were reprovided with the questionnaire after a week. Internal consistency was con rmed by calculating Cronbach alpha coe cient. Test-retest reliability was evaluated with intra class correlation coe cient. Based on Nunnally's theory, correlation coe cient equal or higher than 0.7 is acceptable. (23) Data were analyzed using SPSS: 16.

Second Phase
Based on the analysis of the rst phase, wide range has caused unnecessary variations in answers; besides, larger sample size is necessary. Therefore, a ve-point Likert scale (1)(2)(3)(4)(5) was applied in the second phase. In order to con rm construct validity, exploratory factor analysis was used by main construct and rotation of maximum variance. The sample size was calculated as 100 based on standards of psychometric studies, i.e. at least 5 participants for each item (24). Regarding the dropout, 104 were recruited. 52 senior medical students and 52 senior nursing students were introduced in the study through accessible sampling method. All participants returned their questionnaires (response rate=100%) The condition for factor analysis was also con rmed including sample su ciency by KMO= 0.844 method and Bartlett's test. Factor analysis was performed at 95% con dence level using SPSS: 16.

Results
Participants were senior students of medicine (6th and 7th year) and nursing (4th year). In the rst step, 67 students attended of which 33(49.3%) were nursing student and the rest were medical. 22 students (32.8%) were male and 45(67.2%) were female). In the second step, 104 participants attended in study of which 52(50%) were nursing student and the rest were medical. 37(35.6%) were male and 67(64.4%) were female.
In order to con rm content and face validity, ten experts were asked to read questionnaire, then their comments were considered for preparing nal version. The reliability was con rmed by Cronbach alpha as 0.882 in the rst phase and 0.899 in the second. ICC was also calculated as 0.882 resulted from the rst phase. The con rmation of the conditions under which the factor analysis has been performed including sample su ciency through KMO method and Bartlett's test were signi cant. The second phase factor analysis interpretation through underlying constructs and maximum difference in rotation, has identi ed three underlying constructs for questionnaire (Tables 1 and 2), which on the whole, revealed 58% variance. These three constructs were classi ed in order based on the highest percentage of dispersion as follows:  1. Inter professional collaboration based on "professional ethics" with 37.83% dispersion 2. Inter professional collaboration based on "professional autonomy" with 13.65% dispersion, and 3. "Patient-centered" inter professional collaboration with 6.53% dispersion.
Reliability of questionnaire in second step was calculated as 0.899, on the other hand, reliability of main construct and maximum difference methods for the rst second and third subscales were 0.833, 0.934 and 0.893 respectively. The question 19 was the most incompatible item in questionnaire which was regarded in second subscale (professional autonomy). The 19th item had a reverse content compatibility.
Although it was less than 0.5 and could be ignored, its consistency with the other items of second subscale, caused to keep it like the original study.

Discussion
The aim of this research was to review the standardization process of AHPQ in Iran in order to study the attitude towards health care professions.
Validity and reliability of AHPQ were con rmed in two elds of medicine and nursing. Also, the participants were selected from main and referral hospitals; therefore, the results may be different in other parts of Iran.
In the rst phase, the questionnaire included 20 semantic differential questions ranged between 1-10 point scales. As to the results, extent of scale has caused unnecessary dispersion in responses, also larger sample size is necessary. Decreasing the extent of scale from 10 to 5 points and increasing sample size in the second phase, led to revealing three underlying constructs of professional ethics, professional autonomy and patient-centered care in the questionnaire.
The validity of AHPQ is also evaluated in Danish. The questionnaire in Danish has been valid in its original form; contains 20 items, each consisting of two opposite attributes, serves as verbal anchors for each end of a 10 cm visual scale. The word "Assertive" is unclear in Danish, so for a better understanding the short explanation has been presented in Danish in brackets in front of the word. (25) In our study, according to Delphi it was suggested that the words caring and empathetic should be explained too.
The triple constructs are not necessarily in disagreement with each other. In other words, the individuals with attitudes towards professional ethics or professional autonomy are not necessarily opposed to patient-centered care and vice-versa; but it reveals that they preferred the relevant items. This nding is consistent with the original questionnaire. According to the original questionnaire, the relationship between the two components has remained constant during the AHPQ tool development process. The components are in direct relationship with each other so that the lower score in the caring Component has a lower score in the subservient component and vice versa. Therefore, professions that are less caring, seems to have less activity than other colleagues in equal positions in the health team and, instead, are more dominant. (26) For example, most participants believed in respecting ethical principles in communication skills ( rst factor) such as Caring, Empathy, Approachability, Values team work, Sympathy, Thoughtfulness, Flexibility, Gently, Not arrogantly, Practicality, Conciliatory, Not confrontationally, are the key fundamentals for inter professional collaboration.
The others preferred expertise and professional autonomy of members (second factor) manifested by indicators such as con dence, assertiveness, values autonomy, technically focus, independency and observe economic value of professional services in inter professional collaboration.
At the same time, for the other participants, the patient-centered care and respect for patient rights and conditions (third factor) is the most important basis for inter professional collaboration. Patient-centered care directs the basis of inter professional collaboration, health care team and their relationships in the rst two factors, towards patient, and in fact, it encourages the health care member to sacri ce and selfdevotion in favor of the patient. The third factor in factor analysis is con rmed weekly but based on maximum difference it is con rmed in a clearly.
Thus, the present study improves the concept of attitude towards inter professional collaboration in health care team compared with the idea suggested by Lindquist et al. (11). In Lindquist study, three underlying constructs has been identi ed by factor analysis through underlying construct method with factor value higher than 1; but, just two constructs of care and service have been analyzed. Ignoring the third valuable factor has leaded that this study covers only 43% population variance and identi es construct by 18 out of 20 items of the questionnaire.
In this study, two methods of underlying constructs and maximum difference in factor analysis, have been applied, therefore, the constructs of all questionnaire's items have been determined and the variance coverage of the population exceeds up to 58%, but also the third factor has been analyzed and nally, all constructs of the questionnaire have been analyzed more appropriately; patient care and providing health care services are of the health care team responsibilities, however, the questionnaire seeks to identify the attitude of health team during such inter professional duties.
Job stress is normally reported by health care professionals, such as nurses. Studies suggest that problems due to work load, inadequate time off from work scheduled and job independency limitations could lead to emotional exhaustion and even hatred toward patients. (27) In contrast, nurses' satisfaction increases, when they feel independency and make good working relationship with their managers and peers. (28) Wageman (2005) and Campion (1993) are the most comprehensive instruments, measure enabling conditions and cover aspects of task design (e.g., interdependence, autonomy), team composition (e.g., competencies, diversity), as well as organizational climate (e.g., recognition, training). Neither instrument was developed in healthcare, nor have they had much prior use in healthcare contexts. (29) The dominance of the attitude of inter professional autonomy (second factor) in a health care team means that the members of the team do not interfere in the specialized tasks of one another. Therefore, each member, after independently carrying out the relevant duties to his/her own profession, will refer the patient to other team member with the results of his/her work. In this type of attitude, o cial interaction governs the activity of health care team, and any action by any member has been regarded as interference in his/her own expertise and could result in con ict and in severe cases can conducive to team disjoint.
Whereas, a health care team, in which the attitude of inter professional ethics prevails, the team members' interaction goes beyond o cial relationships of technical professions, but rather respect and friendly cooperation among team members makes the basis of their interaction. This way, team members may perform organizational tasks of each other with resilience, empathy and compassion, and defend their colleagues' performance before the non-team elements. Patient care is always high on healthcare delivery agenda. Team work is essential.
As a doctor, key player in a team, is trying to improve patient's health. The rst priority must be optimal collaboration in order to help patients. Multi-disciplinary care as a team approach is not restricted to some hospitals rich in resources, but when there is challenging environments with limited resources, multi-disciplinary care approach could be included as a clinical performance in a developing country. A team consists of trainees, colleagues and advisors, nurses, medical assistants, managers, social workers, technicians and secretaries. Thus, it is necessary to learn how to work with others members properly. If a member had a hard day, he should be helped, ethics is a topic in WHO. (30) Facilitating team performance behaviors, need to distinguished personal values based on merits or ethics for team members. (31) Although this attitude increases group cohesion, it should be taken into account that the concepts of exibility, courtesy, tranquility, sobriety and paci sm in group interactions should not cause to rot patients' rights which could be eliminated by overcoming the attitude towards patient-centered care in inter professional collaborations. In this attitude patients' rights and their health overweight pseudo respect to colleagues and their professional independency. The way of interaction and inter professional collaboration of team could be linked with the missions and visions of forming team. In such a team, the concept of specialized tasks of team members and common ceremonies cause no mental and social barrier for patient care and health services provision. The representative characteristic of high quality health care system is providing health care based on patients' needs and expectations. Most systems where physicians have been supported, bene t of the modi ed redesign models in which health care is fully adjusted with patients' needs. Planning a medical examination in a clinic, speci c for patient's anxiety, encourages them to participate in care control process. (32) The results of this study suggest that major part of the statistical population, both physicians and nurses, have crossed the mental barrier caused by administrative structure based on specialization and independence of activities and duties of each profession to a great extent, and have undertaken responsibilities based on inter professional human relationship in health team. In such a society, team work needs to be promoted based on professional ethics and mutual respect among co-workers; besides, prioritizing patient-centered care and sense of responsibility for patient to interpersonal ceremonies and interests of health team members should also be taught.

Conclusion
The present study, in addition to con rmation of AHPQ construct validity, reveals that such a tool is able to specify the attitude of health team members based on their perceived importance towards the basis of inter professional collaboration. Thus, recognizing and directing priorities of health care team in inter professional collaboration enables us to manage establishment, integrity, sustainability and coordination of group activities.
Further research is necessary to study the other professions of health system beyond physicians and nurses. Regarding the results, the weight of the three main constructs needs to be balanced by changing similar items or adding new ones. In the future, it will be tried to apply this tool in order to review attitude change over the time. Participants were assured that their data will be kept con dential and the results will be reported as analysis of data anonymously Consent for publications Not applicable Availability of data and materials:

List Of Abbreviations
The data that support the ndings of this study are available from Students' Scienti c Research Center but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission