CONTENT VALIDITY

According to WHO (2007), content validity encompasses the demonstration of the existence of a strong relationship between the content that was used in the study and the variables under investigation. As such, it provides information related to the representation of the population by a specific study sample. Content validity analysis was performed to determine the appropriateness of the language, content, and structure of the Arabic versions for measuring the research variables. The variables included attitudes and knowledge about asthma in children. The snowballing technique was used to recruit a panel including six experts to perform a content validity analysis of the questionnaires. The process entailed contacting a small group of people with experience in asthma management who were known to the researcher, those people identified other colleagues who were then invited to participate in the content validity assessment. The process was done in accordance with the procedure described by Polit and Beck (2006). The six individuals included two general practitioners experienced in the management of childhood asthma, two nurses that have regular contact with asthmatic children, one primary school teacher, and one social worker. This was a sufficient number of experts to perform the process of content validity as acknowledged by Polit and Beck (2006). Each panel member was sent a questionnaire that included the revised list of asthma knowledge items and asthma attitude items, and asked to rate each item using a 5-point Likert scale for appropriateness (1=not appropriate to 5=most appropriate). Panel members were also invited to comment on the wording of items and response format, and to suggest other items to be added to the instrument.

The approach to establishing the Content Validity Index (CVI) was identified in Polit and Beck (2006). The CVI consists of two domains. The representativeness domain (R-CVI) which identifies to which extent the item is representative of a scale within an instrument, and the clarity domain (C-CVI) which identifies the clarity of the item to the reader.

Both the R-CVI which relates to the representativeness and the C-CVI which relates to the clarity are applied to each item and then to the scale as a whole in the form of the Item CVI (I- CVI) and the Scale CVI (S-CVI). The ICV is the proportion of experts who rate an item as relevant, while the S-CVI is the proportion of items rated as relevant by all raters (Polit & Beck, 2006). TheI-CVI agreement proportion of .78 or above indicates acceptable content validity (Polit et al., 2007). The overall S-CVI score is calculated by taking the average of the items scores (Lynn, 1986).

Content validity index report

In the AAQ, the representativeness analysis identified two items with 89% representativeness and three items with 92% representativeness in NAKQ. The remaining items demonstrated 100% representativeness in both questionnaires. Subsequently, all items were retained in the translated questionnaire.

Content validity analysis was done by summing I-CVI results as percentages and dividing the results by the number of items in each of the questionnaires. Content validity analysis revealed high representativeness and clarity outcomes reporting representativeness score (R- CVI) of 99% and clarity score (C-CVI) of (98%). These scores indicate good agreement between panel members. The panel members’ comments were very helpful in providing a wider perspective about the translation process. The result of the validation process was the third version of the Arabic AAQ and NAKQ (Appendix 16 and 17 respectively).

Reliability of the instruments

To determine the feasibility and if any modifications were needed before using the instruments in the main study, a pre-test pilot study using the AAQ and NAKQ was conducted with 20 children diagnosed with asthma. The recruitment of 20 children rested on the recommendations of Lackey and Wingate (1998) that a pilot test should be carried out the equivalent of one tenth of the main sample. Pilot testing is conducted to refine a tool or instrument to ensure clarity, understanding, and acceptability (Polit and Hungler 1999). In this case both the AAQ and NAKQ were tested. The group consisted of 12 male and 8 female children diagnosed with asthma and living in the Ha’il region, KSA. Their ages ranged between 7 to 12 years. The answers of the pilot study population suggested that all items in both AAQ and NAKQ and their options for response were clear and understandable.

Reliability means the extent of measurement for certain participants is similar on applying this tool at different time (Polit and Beck 2008). So, it can be achieved when keeping results at a consistent level despite changing of time and place. Internal consistency comprises testing the homogeneity that assesses the extent to which personal items are inter-correlated, and the extent to which they correlate with overall scale findings (Polit and Beck 2008). This can be performed by using Cronbach‘s alpha test. Many references state that an alpha 0.85 or above indicates adequate internal consistency, meaning, findings are consistent, so the items are representative (Polit and Beck 2008). Cronbach's Alpha for both scales from the pilot testing

were measured and revealed high internal consistency values in NAKQ (0.882) and AAQ (0.935). These results established that there was no further need to modify any of the questionnaires before field-testing with the target population. However, it is important to note that the children that took part in the pilot test were not considered eligible for the main study. This was simply carried out when establishing the final list of eligible students (mentioned earlier in sampling section). However, those included in the pilot study were given the chance to attend the asthma education programmes but they were not allowed to contribute to the study findings through completing the study instruments.

Negotiating Access to Schools

The researcher met the school principal and the social worker (normally employed in each school in KSA to provide psychosocial counselling for the students who were to take part from the targeted schools) and showed them the ethics approval gained from the Head of MoE in Ha’il Region. The researcher explained to them the aim of the study, explained the process of conducting the study and its stages in their schools, and gave them a detailed description of each step. Sufficient information about the whole study was provided to the intervention and control schools to create awareness and enable them to assist children in making a decision regarding whether or not to take part.

Strengthening support from the key stakeholders was an important part of ensuring the success of the research. The success of any study often depends on the contribution of the gatekeepers. The gatekeepers play the role of representing the interests of the host organisations, and there members (Burns and Grove, 2010).

The education programme was started after the children and parents had been informed about the study requirements and had given their consent.