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Development and Psychometric Validation of the Dementia Attitudes Scale

Development and Psychometric Validation of the Dementia Attitudes Scale SAGE-Hindawi Access to Research International Journal of Alzheimer’s Disease Volume 2010, Article ID 454218, 10 pages doi:10.4061/2010/454218 Research Article Development and Psychometric Validation of the Dementia Attitudes Scale 1 2 Melissa L. O’Connor and Susan H. McFadden School of Aging Studies, University of South Florida, 13301 Bruce B. Downs Blvd., MHC 1306, Tampa, FL 33612, USA Department of Psychology, University of Wisconsin at Oshkosh, 800 Algoma Blvd., Oshkosh, WI 54901, USA Correspondence should be addressed to Melissa L. O’Connor, mlunsman@cas.usf.edu Received 17 August 2009; Revised 2 December 2009; Accepted 11 February 2010 Academic Editor: Sara M. Debanne Copyright © 2010 M. L. O’Connor and S. H. McFadden. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This study employed qualitative construct mapping and factor analysis to construct a scale to measure attitudes toward dementia. Five family caregivers, five professionals, and five college students participated in structured interviews. Qualitative analysis of the interviews led to a 46-item scale, which was reduced to 20 items following principal axis factoring with two different samples: college students (N = 302) and certified nursing assistant students (N = 145). Confirmatory factor analysis was then conducted with another sample of college students (N = 157). The final scale, titled the Dementia Attitudes Scale (DAS), essentially had a two-factor structure; the factors were labeled “dementia knowledge” and “social comfort.” Total-scale Cronbach’s alphas ranged 0.83–0.85. Evidence for convergent validity was promising, as the DAS correlated significantly with scales that measured ageism and attitudes toward disabilities (range of correlations = 0.44–0.55; mean correlation = 0.50). These findings demonstrate the reliability and validity of the DAS, supporting its use as a research tool. 1. Intoduction a 10-week period than staff who had engaged in their usual activities at 5 control facilities. Because participation in cre- A“newculture”ofdementiacare[1, page 136] has been ative engagement programs enables persons with dementia embraced by long-term care residences, adult day programs, to reveal preserved abilities and insights about the world, support groups, and other programs and services devoted these programs may also help families and friends to view to promoting and sustaining life quality for persons living residents in a different light. Finally, with more newly retired with dementia. This new culture construes personhood as persons answering the call for civic engagement, community “a standing or status bestowed upon one human being, by volunteers may become involved in innovative creative others, in the context of relationship and social being” [1, engagement programs like Memories in the Making [3]and page 8]. An alternative to the biomedical view of dementia TimeSlips [4]. These creative activities promote relationality as a collection of neuropsychological symptoms reflecting and affirm personhood. These and other “new culture” brain pathology, this psychosocial perspective affirms the developments in adult day centers, long term care residences, unique personal histories of individuals living with dementia and community-based programs may also encourage posi- in particular social environments. tive attitude changes toward people with dementia among Employing an experimental design, Fritsch et al. [2] students, direct care workers, family members, and com- showed that staff working with residents using the TimeSlips munity volunteers. However, to measure attitude changes, creative story-telling method in 5 nursing home facilities had a validated scale for measuring attitudes toward dementia is more positive views of persons with dementia at the end of needed. 2 International Journal of Alzheimer’s Disease 2. Attitudes toward Dementia explored without a reliable, valid instrument to measure dementia attitudes. Since the late 1940s, social psychologists have employed a tripartite theoretical model of attitude. An attitude is a 3. Existing Measures response to a person, object, or event that combines three There are numerous self-report instruments for measuring components: emotional, cognitive, and behavioral. Each of these carries a valence: pleasurable to unpleasurable affect, ageism and attitudes toward disabilities. Although these favorable to unfavorable cognition, and supportive to hostile scales are not specific to dementia, they provide useful behavior [5]. starting points for conceptualizing a dementia attitudes Over the past five decades, a wide body of literature scale. Noteworthy disability scales include the Attitudes has examined attitudes toward older adults. The results of toward Disabled Persons Scale [28] and the Interaction with individual studies have been mixed, but a meta-analysis of Disabled Persons Scale [29]. Ageism scales include the Kogan 232 effect sizes found that individuals of all ages and back- Attitudes toward Old People Scale [30] and the Fraboni Scale grounds viewed older people as significantly less attractive of Ageism [31]. These scales are psychometrically sound, and competent than younger people [6]. Attitudes toward although social desirability, item transparency, obsolescence, older people are influenced by many factors, including their and limited generalizability have proven problematic [32– 34]. In addition, these attitude scales vary in how well they health [7], individuals’ exposure to older people [8], and education about aging and older people [9, 10]. Older adults tap each component of the tripartite model of attitude [5]. with disabilities may be seen in a particularly negative light Researchers who have examined attitudes toward AD [11, 12]. have constructed scale items specifically for particular stud- Although a common stereotype about older adults is ies. Such scales are useful, but lack validation in multiple that they are or will become cognitively impaired [13, 14], samples, do not encompass the entire attitude construct, comparatively few studies have examined attitudes toward and lack evidence for convergent and divergent validity. For individuals with dementia, and the picture is equivocal. example, Norbergh et al. [24] measured nurses’ attitudes using the semantic differential technique, which focused on On one hand, researchers have found that dementia carries anegativestigma[15, 16]. For example, Askham [17] affect. Lundquist and Ready [26] constructed a Likert-type found that caregivers described residents with dementia scale to measure sympathy and willingness to help individu- more negatively than positively, and Kahana and colleagues als with AD; this scale did not assess cognitive attitudes, and [11] found that nursing home workers evaluated healthy was used with one homogenous sample of undergraduates. older people more positively than those with Alzheimer’s Lintern, Woods et al. [35] developed the Approaches to disease (AD). In a study comparing perceived stigma in Dementia Questionnaire (ADQ), a Likert-type instrument persons with AD and persons with Parkinson’s disease, with 19 items. The ADQ measures hopefulness and person- Burgener and Berger [18] observed that the former group centered approaches, and has been used with care home staff experienced significantly more internalized shame. People in the UK [36]. However, a more general scale constructed living with AD are sensitive to others’ reactions to their via construct mapping is lacking. diagnosis [19] and engage in negative self-stereotyping [20]. These studies suggest that the experience of AD fits Link 4. Present Research and Phelan’s [21] conceptualization of stigma: people living with progressive memory loss are often labeled as different The purpose of the present study was to develop a psycho- from the norm, subjected to stereotyping, categorized as metrically sound instrument for measuring attitudes toward “other” and thus separated from persons without memory dementia, which we called the Dementia Attitudes Scale loss, and they experience loss of status. Finally, they are (DAS). The DAS was based upon the tripartite model of often “placed” in situations (e.g., long term care) where they attitude [5] and was developed using a modified version of the nine-step procedure described by Krause [37]. In Krause have no power over the decision-making that affects their lives. [37], focus groups and in-depth interviews provided material On the other hand, lay community members [22, 23] from which scale items were developed. Then, preliminary and health professionals [24, 25] have also reported positive items were written, reviewed by an expert panel, pilot-tested, attitudes about individuals with AD. Contact with people administered to a nationwide probability sample, and finally with dementia among college students [26]and caregivers subjected to rigorous psychometric testing. The present [25, 27] is correlated with these more positive responses, research involved four studies, beginning with structured particularly when these relationships are strengthened with interviews and qualitative construct mapping, proceeding the kind of communication that occurs in programs that to exploratory factor analysis (EFA), and ending with encourage creative expression [2, 4]. These findings suggest convergent validity testing. Our goal was to validate the DAS that attitudes toward dementia have positive elements, and for two intended user groups: college students and direct care that programs that encourage meaningful contact with per- workers. sons with dementia can foster attitude change. However, little One challenge we faced in constructing this scale con- is known about how attitudes toward dementia compare cerned terminology. Although AD is the leading form of across samples, or whether such attitudes form a construct the progressive cognitive deterioration that defines dementia, that is distinct from ageism. These areas cannot be fully there are many other types of dementia such as Lewy body International Journal of Alzheimer’s Disease 3 disease, vascular dementia, and frontotemporal dementia, thought they would experience in the presence of an agitated to name just a few. We have observed confusion about the person with ADRD. connection between AD and dementia. Some public media reports differentiate them rather than describing AD as a type 6.1.3. Procedure. We recruited family caregivers and profes- of dementia; few note other causes of progressive memory sionals via referrals from colleagues. Although this sample loss and confusion in older people. For this reason, we was not random or ethnically diverse, it included as many decided to refer to “Alzheimer’s disease and related disorders” occupations as possible. Student participants were recruited (ADRD) in the scale, with the expectation that some users from campus dormitories, and only individuals who did not will be knowledgeable about the “related disorders” and that know anyone with ADRD were eligible. It was necessary by completing the scale, others might become more aware to sample a variety of perspectives on ADRD in order to of the existence of “related disorders.” The name of the DAS highlight the most relevant content areas. The 15 interviews implies a broad application across forms of dementia and obtained in this study met the guidelines of McCracken [39], is in line with work like that of Askham [17], Kitwood [1], who suggested that eight in-depth interviews are adequate to MacDonald and Woods [36], and Sahin et al. [14]. However, cover a new domain. Interviews were conducted face-to-face because of public misunderstandings (also reflected in the with a trained interviewer, lasted between 60 and 90 minutes, responses of na¨ıve undergraduate participants in Study 1), and were tape-recorded. Neutral probes were used to guide we were concerned that if we referred only to “dementia” in discussion of each question. Audiotapes were transcribed the scale items, people would ask “Do you mean Alzheimer’s verbatim, and using a standard qualitative data analysis disease?” technique [40], we noted recurring themes and patterns, critiqued the plausibility of our observations, clustered and counted similar responses, and compared responses from the 5. Ethical Considerations different groups. The Institutional Review Board (IRB) of the University of Wisconsin at Oshkosh approved the four studies reported 6.2. Results and Discussion. Professionals and family care- here (protocol number 97662). The research complied with givers stressed that (a) people with ADRD are individuals; the ethical principles of psychologists and code of conduct (b) social interaction is important at all stages of ADRD; (c) of the American Psychological Association [38]. Informed people with ADRD communicate through behavior; and (e) consent was obtained from all participants. Because their familiar routines provide security for people with ADRD. identities were known to the researchers, interviewees signed A frequent comment was “Emphasize the person, not the consent statements. Participants in Studies 2, 3, and 4 were disease.” All students reported having sympathy for people declared by the IRB to be exempt from signing consent with ADRD, but not knowing how to help. Three students forms because they completed anonymous surveys. They were uncomfortable with the difficult behaviors sometimes received information sheets that described the study and exhibited by people with ADRD. stated that their completion of the survey signified their Overall responses were grouped into six categories. voluntary consent to participate. The first two categories, labeled “knowledge” and “beliefs”, addressed the cognitive aspect of attitude. Another two categories, “acceptance” and “empathy”, were affective in 6. Study 1: Structured Interviews nature, and the last two categories, “avoidance behaviors” 6.1. Method and “person-centered behaviors”, were behavioral. Forty scale items were derived from the above categories; six 6.1.1. Participants. Five family caregivers, five professionals additional items were adapted from old culture/new culture in the dementia care field, and five undergraduate students characteristics as depicted by Kitwood [1]. This initial with limited knowledge about dementia participated in version of the Dementia Attitudes Scale (DAS) is described structured interviews. The family caregivers included two andfactoranalyzedinStudy 2. men and two women who had spouses with dementia and one woman whose father had dementia. All the professionals 7. Study 2: Forty-Six Item Scale were female and consisted of two recreation therapy pro- fessionals, a long-term care nurse, a social worker, and a 7.1. Method representative of the Wisconsin Alzheimer’s Association. The students included two males and three females from the 7.1.1. Participants. A total of 307 undergraduate students in University of Wisconsin at Oshkosh. All participants were psychology, biology, and special education classes completed Caucasian. the initial DAS. Five participants were excluded due to missing data, so the valid N = 302. Participant ages ranged 6.1.2. Materials. A series of open-ended questions specifi- from 18 to 41 (M = 23.5, SD = 5.7). The sample was 63% cally addressed affect, behavior, and cognition. Participants female and over 95% Caucasian. were asked to describe their general knowledge about Alzheimer’s disease and related disorders (ADRD); their 7.1.2. Materials. Of the 46 items on the initial DAS, ap- perceptions of the competence and emotional well-being proximately a third reflected the cognitive component of of people with ADRD, and the reactions and feelings they attitude (e.g., “I am not very familiar with ADRD”), a third 4 International Journal of Alzheimer’s Disease reflected the affective component (e.g., “I feel relaxed around content of these items seemed relevant. The following items people with ADRD”), and a third reflected the behavioral loaded on Factor 3: “It is easy to get impatient with people component(e.g.,“Iwould avoidanagitatedpersonwith with ADRD”; “It is okay to redirect people with ADRD by ADRD.”) Each item was rated on a 7-point Likert scale telling small fibs”; “I would talk to someone with ADRD ranging from 1 (strongly disagree)to7(strongly agree). Half the way I would talk to a child”; and “People with ADRD of the items were reverse scored. Possible scores could range are child-like.” Factor 4 included these items: “I dread the from 46 to 322, with higher scores indicating more positive thought of becoming like someone with ADRD”; “Everyone attitudes. will get ADRD if they live long enough”; “When someone with ADRD gets agitated, they should be given tranquilizing medication; and “Social interaction is only important in the 7.1.3. Procedure and Analyses. Participants were recruited early stages of ADRD.” We decided to retain all 30 items from from undergraduate classes, and interested students had the opportunity to complete the DAS during class breaks. the four factors described above and conduct another EFA with a different sample, to ensure that the results were not Less than 0.5% of the data were missing, so missing items merely sample-specific. were estimated using person mean substitution [41]. To Range restriction and a ceiling effect were potential guide scale revision and determine the number of factors problems, as evidenced by the 13 negatively skewed items underlying the DAS, participants’ total scores underwent and the high mean total score. However, some skewed items principal axis factoring, which may yield less biased estimates were eliminated from the scale, and the mean item score was than principal components analysis [42]. The number of close to four, the midpoint. Only six of the items in Factor 1 factors was determined using a scree plot and the Kaiser- and Factor 2 were reverse scored, but the impact of reverse Guttman criterion (i.e., eigenvalues greater than one). scoring on response sets is debatable (Comrey, [43]) . These issues were further examined in Study 3. 7.2. Results 7.2.1. Descriptive Statistics and Reliability. Total scores 8. Study 3: Thirty-Item Scale ranged from 122 to 288 (M = 219.63, SD = 22.11), so attitudes were generally positive. The mean item score was 8.1. Method 4.78 (SD = 0.48). Coefficient alpha for the scale was 0.86. 8.1.1. Participants. One hundred forty-five students enrolled in a Certified Nursing Assistant (CNA) program at a 7.2.2. Exploratory Factor Analysis. Following principal axis technical college completed the 30-item DAS. Ages ranged factoring, eigenvalues and a scree plot suggested a four- from 17 to 63 (M = 29.70, SD = 10.62). Participants were factor solution. However, the reproduced correlation matrix predominantly female (88%) and either Caucasian (80.6%) showed that 266 nonredundant residuals (26%) exceeded or Hispanic (10.3%). 0.05. The analysis was duplicated with three, five, and six factors extracted, but a four-factor solution was most 8.1.2. Materials. In addition to the completing the 30-item interpretable. Both varimax rotation and oblimin rotation DAS, participants responded to the question, “Have you ever were conducted. The orthogonal model was less interpretable known or cared for someone with ADRD?” This question and had more cross-loading items, so the oblique model was was included to examine whether familiarity with ADRD selected for presentation and interpretation. Distributions correlated with positive attitudes. for 13 of the items were significantly negatively skewed, and one item was positively skewed. Transforming these items did not change any of the results. Pattern and structure coeffi- 8.1.3. Procedure and Analyses. The CNA course instructor cients were examined, and items were included in a factor offered students the chance to complete the scale during if their pattern loading was at least 0.32. Sixteen items were class breaks. Missing items (less than 0.1% of the data) excluded due to having low loadings, communalities less were again estimated via person mean substitution. Principal than 0.2, or multiple cross-loadings. Factor 1 (Cronbach’s α axis factoring with Oblimin rotation was conducted on = 0.82) contained 11 items that corresponded to behaviors participants’ total scores, and the results guided further scale and feelings of comfort around people with ADRD; thus, this revision.AsinStudy 2, only itemswithpattern coefficients ≥ factor was labeled “social comfort.” Factor 2 (α = 0.78) also 0.32 were included in a factor. Finally, the factor structures contained 11 items, all of which referred to knowledge and generatedinStudy 2and Study3were compared viathe beliefs about persons with dementia. This factor was labeled coefficient of congruence (r ), an index of factorial similarity cc “dementia knowledge.” Factor 3 (α = 0.10) and Factor 4 (α [44]. The minimum criterion for similarity was an r greater cc = 0.10) each contained four items and could not be readily than 0.90 [45]. interpreted. 8.2. Results 7.3. Discussion. Factor analysis of the 46-item DAS revealed two reliable factors with 11 items each. Sixteen items were 8.2.1. Descriptive Statistics and Reliability. Total scores on the eliminated from the scale. The eight unreliable items in scale ranged from 114 to 189 (M = 154.37, SD = 15.81) Factors 3 and 4 were also candidates for exclusion, but the out of a possible range of 30 to 210. The mean item score International Journal of Alzheimer’s Disease 5 was 5.15 (SD = 0.53). One hundred twelve participants, or validity of the DAS by comparing it to two measures of 77.2% of the sample, indicated that they knew someone with ageism and two measures of attitudes toward people with ADRD. A one-way ANOVA showed that individuals who disabilities. Divergent validity with a social desirability scale knew someone with ADRD had significantly more positive was also examined, and confirmatory factor analysis (CFA) attitudes than individuals who did not, F(1, 141) = 19.38, was conducted. The purpose of the CFA was to examine P< .001. Cronbach’s alpha for the 30-item scale was 0.79. whether, in a different sample, a two-factor structure would fit the DAS better than a single-factor structure. If this were 8.2.2. Exploratory Factor Analysis. Following principal axis the case, it would support the previous EFA findings. Similar procedures were used in Chumbler [46] and Thomas et al. factoring, a scree plot indicated a four-factor solution. The rotated solution yielded one factor with 11 items, one [34]. factor with 10 items, and two factors with four items each. Seventeen items were significantly negatively skewed. As in 9. Study 4: Validity Testing Study 2, transforming these items did not alter the results. The two four-item factors were identical to Factors 3 and 9.1. Method 4inStudy 2, andwereagain characterizedbylackof 9.1.1. Participants. Participants were 160 undergraduate interpretability and low reliability. Because these items were psychology students. There were 51 males and 109 females problematic in two different samples, they were eliminated. ranging in age from 18 to 47 (M = 19.95; SD = 4.20). The Two additional items (“I would find it difficult not to take sample was 92.5% Caucasian. it personally if someone with ADRD called me a name”; “Meeting the physical needs of people with ADRD is just one goal of caregiving”) were eliminated because they displayed 9.1.2. Materials relatively low loadings (<0.35) in both Study 2 and Study 3. DAS. The final 20-item DAS from Study 3 was administered. Cronbach’s alpha for the remaining 20 items was 0.85. Factor 1 (α = 0.82) was again labeled “social comfort”, and Factor 2 (α = 0.75) was again labeled “dementia knowledge.” Kogan Attitudes toward Old People Scale [30]. The OP is Thesetwo factorsweremoderatelycorrelated, r = 0.29, P< a reliable, widely used measure of ageism, although it is .01, and together explained 38.72% of the variance. Table 1 dated and has been criticized for its 34-item length and item displays the pattern coefficients for the final 20 items as transparency [33]. Items focus on stereotypes, are presented generated in Study 2 and Study 3. The r was 0.96 for Factor cc in positive-negative pairs, and are rated on a 7-point Likert 1 and 0.92 for Factor 2, which demonstrated that the final scale [30]. Higher scores indicate more positive attitudes. DAS items showed similar factor loadings across Study 2 and Study 3. Fraboni Scale of Ageism [31]. The 29-item FSA measures discrimination and avoidance aspects of ageism [31, 47]. 8.3. Discussion. The original 46-item DAS was reduced Scale items are rated on a 4-point Likert scale, where higher to 20 items with a two-factor structure. Scale reliability scores indicate more positive attitudes. was acceptable. Items reflected the components of attitude, although more items addressed the cognitive domain (Factor Attitudes toward Disabled Persons Scale [28]. The 20-item 1) than the affective and behavioral domains which merged ADP assesses attitude at the societal level. Items are rated into one factor (Factor 2), and only six items were reverse on a 6-point Likert scale that ranges from −3to+3, scored. Several items were negatively skewed, and a ceiling and respondents rate how society should treat individuals effect could not be ruled out. Social desirability may have with disabilities [28]. Higher scores indicate more positive influenced the results. However, most participants knew attitudes. In the current study, ADP items were converted to someone with ADRD, which was associated with more a scale ranging from 1 to 6 for ease of comparisons. positive attitudes. DAS scores may also have been higher for the CNA students because they had chosen caregiving as an Interaction with Disabled Persons Scale [29]. The IDP mea- occupation. To see whether the Study 3 sample had more sures the amount of discomfort respondents feel interacting positive attitudes than the Study 2 sample, a t-test was used on a personal level with disabled people. It assesses attitude to compare mean total scores for the final 20 scale items in at the individual level [34]. The 20 items are rated on a 5- both samples. The Study 3 sample had significantly higher point scale [29]; higher scores again indicate more positive scores, t(445) = 11.41, P< .001. attitudes. Although the sample in Study 3 was smaller and less homogeneous than the sample in Study 2, the factor structure of the DAS was consistent across the two samples. Marlowe-Crowne Social Desirability Scale, 13 items [48, 49]. Items 18 and 19 were potentially problematic, as they had The original SDS has 33 true-false items describing various cross-loadings above 0.2 and relatively low loadings (0.34 behaviors (e.g., “I’m always willing to admit it when I make and 0.32, resp.) in Study 3. These items could be eliminated a mistake”). Agreement with items containing absolutes like if they exhibit low loadings in future studies. Overall, the “always”, and disagreement with items containing qualifiers DAS factor structure appeared to be stable, as it replicated like “sometimes”, indicate socially desirable responding and in two different samples. Study 4 explored the convergent result in higher scores [48]. Shorter forms of the SDS have 6 International Journal of Alzheimer’s Disease Table 1: Exploratory factor analyses of the final 20 items in the dementia attitudes scale with oblimin rotation. Study 2 Study 3 Item Factor 1: Factor 2: Factor 1: Factor 2: Comfort Knowledge Comfort Knowledge 4. I feel confident around peoplewith ADRD. .70 .03 .73 .16 5. I am comfortable touching people with ADRD. .47 .08 .72 .11 6. I feel uncomfortable being around people with ADRD. .54 −.03 .56 −.06 8. I am not very familiar with ADRD. .48 .01 .55 −.07 9. I would avoid an agitated person with ADRD. .57 .03 .45 −.09 13. I feel relaxed around people with ADRD. .74 .04 .73 −.07 16. I feel frustrated because I do not know how to help people with ADRD. .58 −.21 .54 −.09 1. It is rewarding to work with people who have ADRD. .51 .06 .41 .16 17. I cannot imagine caring for someone with ADRD. .57 −.21 .46 .22 2. I am afraid of people with ADRD. .52 .11 .48 −.07 3. People with ADRD can be creative. .03 .59 .08 .52 7. Every person with ADRD has different needs. −.08 .56 −.02 .44 Study 1 Study 2 Item Factor 1 Factor 2 Factor 1 Factor 2 10. People with ADRD like having familiar things nearby. .04 .42 −.05 .55 11. It is important to know the past history of people with ADRD. −.13 .57 −.17 .40 12. It is possible to enjoy interacting with people with ADRD. .15 .51 −.02 .41 14. People with ADRD can enjoy life. .21 .43 .28 .53 15. People with ADRD can feel when others are kind to them. .21 .53 .23 .60 19. We can do a lot now to improve the lives of people with ADRD. .12 .44 .25 .32 18. I admire the coping skills of people with ADRD. .02 .44 .29 .34 20. Difficult behaviors may be a form of communication for people with ADRD. −.09 .58 −.06 .53 Note. Factor pattern coefficients are displayed. ADRD = Alzheimer’s disease and related disorders. Reverse scored item. been developed [49, 50], and a 13-item form was used desirable), and the root mean square error of approximation in the current study [49]. Participants’ total scores on the (RMSEA; values < 0.08 are desirable). SDS-13 could range from 0 to 13. A significant positive correlation between SDS-13 scores and DAS scores could 9.2. Results indicate that scores on the DAS were affected by socially desirable responding. 9.2.1. Descriptives and Correlations. Descriptive statistics for each scale, including mean total scores and Cronbach’s 9.1.3. Procedure and Analyses. Participants were recruited alphas, are displayed in Table 2. The DAS correlated sig- via a participant pool web site. Each participant filled nificantly with the OP, FSA, ADP, and IDP; all of the out a packet of four questionnaires: the 20-item DAS, the scales correlated significantly with the SDS-13 (Table 3). SDS-13, either the FSA or OP, and either the ADP or Fisher’s r-to-z comparisons showed that the magnitude of IDP. That is, each participant completed one of the two the correlation between the DAS and the SDS-13 was not ageism scales and one of the two disability attitude scales. significantly different than the magnitudes of the correlations The study was constructed this way in order to minimize between the other scales and the SDS-13. participant fatigue, boredom, and missing data. The order of the questionnaires varied randomly from packet to packet. Pearson correlations were calculated between total DAS 9.2.2. Confirmatory Factor Analysis. For the single-factor scores and total scores on each other scale, and CFA was model, the sample size-dependent chi-square was significant, conducted on the DAS using LISREL 8.80 [51]. Models were χ (170) = 472.65, P< .001. Chi-square was also significant run with a single factor and with two factors. Because a for the two-factor model, χ (167) = 260.83, P< .001; nonorthogonal rotation method was used in the previous however, this model fit significantly better than the single- EFAs, the two factors were allowed to correlate. Chi-square factor model, χ (3) = 211.82, P< .001. Goodness-of-fit difference tests were used to examine the relative fit of the indices for the single-factor model were not adequate (CFI = single-factor and two-factor models. Goodness of fit was 0.86, RMSEA = 0.11, GFI = 0.77). For the two-factor model, assessed via the goodness-of-fit index (GFI; values > 0.95 are the CFI was 0.95, the RMSEA was 0.06, and the GFI was desirable), the comparative fit index (CFI; values > 0.90 are 0.87, reflecting a reasonable, though not ideal, model fit. International Journal of Alzheimer’s Disease 7 Table 2: Descriptive statistics and reliability for the DAS, OP, FSA, 9.3. Discussion. Correlations between the DAS and the other ATDP, IDP, and SDS-13. scales were significant, providing evidence for construct validity. The correlation between the DAS and SDS-13 was Scale NM SD Cronbach’s α significant, but similar in magnitude to the correlations DAS 157 98.64 12.82 0.83 between the SDS-13 and other scales. As measured by the OP 77 163.69 18.73 0.85 SDS-13, social desirability does not appear to be more FSA 80 89.17 9.30 0.87 problematic on the DAS than on comparable scales. The ATDP 79 83.41 9.54 0.72 mean total score distribution was negatively skewed not IDP 78 63.13 8.82 0.81 just for the DAS, but for all the scales (excluding the SDS- SDS-13 157 4.21 2.91 0.74 13); inflated positivity appears to be common with self- report measures of this type. The CFA provided support Note. DAS = Dementia Attitudes Scale. OP = Kogan Attitudes toward Old People Scale. FSA = Fraboni Scale of Ageism. ATDP = Attitudes Towards for the previous EFAs, despite the relatively small sample Disabled Persons Scale. IDP = Interaction with Disabled Persons Scale. size. Overall, the DAS appears to have solid psychometric properties and evidence for convergent validity. Table 3: Intercorrelations between the DAS, OP, FSA, ADP, IDP, and SDS-13. 10. General Discussion Scale 1 2345 6 Structured interviews, exploratory factor analysis, conver- ∗∗ ∗∗ ∗∗ ∗∗ ∗∗ 1. DAS — .51 .55 .44 .49 0.34 gent validity testing, and confirmatory factor analysis were ∗ ∗∗ ∗ 2. OP — — .41 .61 0.26 employed to develop the 20-item Dementia Attitudes Scale. ∗∗ ∗ 3. FSA — .51 .57 0.23 DAS items reflect the affective, behavioral, and cognitive ∗∗ 4. ADP — — 0.32 components of an attitude (Table 1), although the two-factor ∗∗ 5. IDP — 0.30 model noted in three administrations of DAS items suggests a strong connection between people’s feelings and behaviors 6. SDS-13 — ∗ ∗∗ toward those living with ADRD. The psychometric proper- P <.05, two-tailed. P <.01, two-tailed. ties of the DAS compare favorably with the psychometric properties of similar scales (e.g., Thomas et al., [34]), and Table 4: Confirmatory factor analysis of the dementia attitudes it appears to be a useful tool for assessing attitudes toward scale (DAS). dementia [1, 14, 36]. Item Factor 1: Comfort Factor 2: Knowledge The greatest strength of the DAS lies in its multistep construction, which combined qualitative and quantitative 40.76 0 methods, and its development based on the widely-accepted 50.68 0 tripartite model of attitude. This approach helped ensure 60.55 0 that relevant construct areas were represented [37]. Nunnally 80.52 0 [52] recommended a subject-to-item ratio of at least 5 : 1 90.55 0 for conducting factor analyses, and the sample sizes within 13 0.71 0 each study met this criterion. Other strengths of the DAS 16 0.44 0 include reliability, which was consistently above 0.8, the 10.57 0 replicability of the factor structure across independent 17 0.74 0 samples, convergent validity evidence, practical length; and 20.64 0 ease of administration. Previous studies (Jackson et al. [53]) found that participants who had higher levels of contact 3 0 0.64 and experience with people with dementia reported more 7 0 0.46 positive attitudes than participants with less contact. The 10 0 0.32 current study also found a positive association between 11 0 0.31 contact and attitudes, which further validated the DAS. 12 0 0.51 To test for item redundancy, we ran bivariate correlations 14 0 0.50 between all of the scale items using the sample from Study 4. 15 0 0.70 The largest correlation was 0.57, which does not exceed the 19 0 0.33 cutoff of 0.80 often used to indicate strong multicollinearity 18 0 0.37 [54]. 20 0 0.33 The limitations of the DAS tend to be shared by self- Variance (%) 26.03 11.60 report measures in general. Our samples were primarily young, female, and Caucasian, so generalizability is limited, Note. Standardized loadings are displayed. All coefficients were significant at P< .05. although we did sample both college students and future CNAs (i.e., caregivers or care professionals). Additional research should include middle aged and older persons, The results of the CFA are displayed in Table 4. The two and a more racially diverse sample. Numerous negatively factors were correlated at r = 0.21, P< .01. skewed items were obtained across the three samples, which 8 International Journal of Alzheimer’s Disease may limit the precision of the scale. Inflated positivity in affirmations of personhood and relationality, there is was especially pronounced in the sample of CNA stu- a growing need to assess attitudes about dementia held dents. However, students who knew someone with ADRD by students and direct care workers and to observe the had significantly higher scores than students who did conditions under which attitudes become more positive. not, suggesting that the DAS can differentiate between The DAS was developed for this purpose. Evidence for the groups despite inflated positivity. Social desirability and psychometric properties of the DAS supports its use as a item transparency are common in measures like the DAS research tool. (e.g., Thomas et al., [34]). The DAS showed evidence of these problems, but not to an extent that differentiated it References from older, more established measures. In addition, it is [1] T. Kitwood, Dementia Reconsidered: The Person Comes First, possible that SDS-13 scores measure the personality traits of Open University Press, Philadelphia, Pa, USA, 1997. agreeableness and conscientiousness [55], rather than a true [2] T.Fritsch,J.Kwak, S. Grant, J. 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Development and Psychometric Validation of the Dementia Attitudes Scale

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Copyright © 2010 Melissa L. O'Connor and Susan H. McFadden. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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SAGE-Hindawi Access to Research International Journal of Alzheimer’s Disease Volume 2010, Article ID 454218, 10 pages doi:10.4061/2010/454218 Research Article Development and Psychometric Validation of the Dementia Attitudes Scale 1 2 Melissa L. O’Connor and Susan H. McFadden School of Aging Studies, University of South Florida, 13301 Bruce B. Downs Blvd., MHC 1306, Tampa, FL 33612, USA Department of Psychology, University of Wisconsin at Oshkosh, 800 Algoma Blvd., Oshkosh, WI 54901, USA Correspondence should be addressed to Melissa L. O’Connor, mlunsman@cas.usf.edu Received 17 August 2009; Revised 2 December 2009; Accepted 11 February 2010 Academic Editor: Sara M. Debanne Copyright © 2010 M. L. O’Connor and S. H. McFadden. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This study employed qualitative construct mapping and factor analysis to construct a scale to measure attitudes toward dementia. Five family caregivers, five professionals, and five college students participated in structured interviews. Qualitative analysis of the interviews led to a 46-item scale, which was reduced to 20 items following principal axis factoring with two different samples: college students (N = 302) and certified nursing assistant students (N = 145). Confirmatory factor analysis was then conducted with another sample of college students (N = 157). The final scale, titled the Dementia Attitudes Scale (DAS), essentially had a two-factor structure; the factors were labeled “dementia knowledge” and “social comfort.” Total-scale Cronbach’s alphas ranged 0.83–0.85. Evidence for convergent validity was promising, as the DAS correlated significantly with scales that measured ageism and attitudes toward disabilities (range of correlations = 0.44–0.55; mean correlation = 0.50). These findings demonstrate the reliability and validity of the DAS, supporting its use as a research tool. 1. Intoduction a 10-week period than staff who had engaged in their usual activities at 5 control facilities. Because participation in cre- A“newculture”ofdementiacare[1, page 136] has been ative engagement programs enables persons with dementia embraced by long-term care residences, adult day programs, to reveal preserved abilities and insights about the world, support groups, and other programs and services devoted these programs may also help families and friends to view to promoting and sustaining life quality for persons living residents in a different light. Finally, with more newly retired with dementia. This new culture construes personhood as persons answering the call for civic engagement, community “a standing or status bestowed upon one human being, by volunteers may become involved in innovative creative others, in the context of relationship and social being” [1, engagement programs like Memories in the Making [3]and page 8]. An alternative to the biomedical view of dementia TimeSlips [4]. These creative activities promote relationality as a collection of neuropsychological symptoms reflecting and affirm personhood. These and other “new culture” brain pathology, this psychosocial perspective affirms the developments in adult day centers, long term care residences, unique personal histories of individuals living with dementia and community-based programs may also encourage posi- in particular social environments. tive attitude changes toward people with dementia among Employing an experimental design, Fritsch et al. [2] students, direct care workers, family members, and com- showed that staff working with residents using the TimeSlips munity volunteers. However, to measure attitude changes, creative story-telling method in 5 nursing home facilities had a validated scale for measuring attitudes toward dementia is more positive views of persons with dementia at the end of needed. 2 International Journal of Alzheimer’s Disease 2. Attitudes toward Dementia explored without a reliable, valid instrument to measure dementia attitudes. Since the late 1940s, social psychologists have employed a tripartite theoretical model of attitude. An attitude is a 3. Existing Measures response to a person, object, or event that combines three There are numerous self-report instruments for measuring components: emotional, cognitive, and behavioral. Each of these carries a valence: pleasurable to unpleasurable affect, ageism and attitudes toward disabilities. Although these favorable to unfavorable cognition, and supportive to hostile scales are not specific to dementia, they provide useful behavior [5]. starting points for conceptualizing a dementia attitudes Over the past five decades, a wide body of literature scale. Noteworthy disability scales include the Attitudes has examined attitudes toward older adults. The results of toward Disabled Persons Scale [28] and the Interaction with individual studies have been mixed, but a meta-analysis of Disabled Persons Scale [29]. Ageism scales include the Kogan 232 effect sizes found that individuals of all ages and back- Attitudes toward Old People Scale [30] and the Fraboni Scale grounds viewed older people as significantly less attractive of Ageism [31]. These scales are psychometrically sound, and competent than younger people [6]. Attitudes toward although social desirability, item transparency, obsolescence, older people are influenced by many factors, including their and limited generalizability have proven problematic [32– 34]. In addition, these attitude scales vary in how well they health [7], individuals’ exposure to older people [8], and education about aging and older people [9, 10]. Older adults tap each component of the tripartite model of attitude [5]. with disabilities may be seen in a particularly negative light Researchers who have examined attitudes toward AD [11, 12]. have constructed scale items specifically for particular stud- Although a common stereotype about older adults is ies. Such scales are useful, but lack validation in multiple that they are or will become cognitively impaired [13, 14], samples, do not encompass the entire attitude construct, comparatively few studies have examined attitudes toward and lack evidence for convergent and divergent validity. For individuals with dementia, and the picture is equivocal. example, Norbergh et al. [24] measured nurses’ attitudes using the semantic differential technique, which focused on On one hand, researchers have found that dementia carries anegativestigma[15, 16]. For example, Askham [17] affect. Lundquist and Ready [26] constructed a Likert-type found that caregivers described residents with dementia scale to measure sympathy and willingness to help individu- more negatively than positively, and Kahana and colleagues als with AD; this scale did not assess cognitive attitudes, and [11] found that nursing home workers evaluated healthy was used with one homogenous sample of undergraduates. older people more positively than those with Alzheimer’s Lintern, Woods et al. [35] developed the Approaches to disease (AD). In a study comparing perceived stigma in Dementia Questionnaire (ADQ), a Likert-type instrument persons with AD and persons with Parkinson’s disease, with 19 items. The ADQ measures hopefulness and person- Burgener and Berger [18] observed that the former group centered approaches, and has been used with care home staff experienced significantly more internalized shame. People in the UK [36]. However, a more general scale constructed living with AD are sensitive to others’ reactions to their via construct mapping is lacking. diagnosis [19] and engage in negative self-stereotyping [20]. These studies suggest that the experience of AD fits Link 4. Present Research and Phelan’s [21] conceptualization of stigma: people living with progressive memory loss are often labeled as different The purpose of the present study was to develop a psycho- from the norm, subjected to stereotyping, categorized as metrically sound instrument for measuring attitudes toward “other” and thus separated from persons without memory dementia, which we called the Dementia Attitudes Scale loss, and they experience loss of status. Finally, they are (DAS). The DAS was based upon the tripartite model of often “placed” in situations (e.g., long term care) where they attitude [5] and was developed using a modified version of the nine-step procedure described by Krause [37]. In Krause have no power over the decision-making that affects their lives. [37], focus groups and in-depth interviews provided material On the other hand, lay community members [22, 23] from which scale items were developed. Then, preliminary and health professionals [24, 25] have also reported positive items were written, reviewed by an expert panel, pilot-tested, attitudes about individuals with AD. Contact with people administered to a nationwide probability sample, and finally with dementia among college students [26]and caregivers subjected to rigorous psychometric testing. The present [25, 27] is correlated with these more positive responses, research involved four studies, beginning with structured particularly when these relationships are strengthened with interviews and qualitative construct mapping, proceeding the kind of communication that occurs in programs that to exploratory factor analysis (EFA), and ending with encourage creative expression [2, 4]. These findings suggest convergent validity testing. Our goal was to validate the DAS that attitudes toward dementia have positive elements, and for two intended user groups: college students and direct care that programs that encourage meaningful contact with per- workers. sons with dementia can foster attitude change. However, little One challenge we faced in constructing this scale con- is known about how attitudes toward dementia compare cerned terminology. Although AD is the leading form of across samples, or whether such attitudes form a construct the progressive cognitive deterioration that defines dementia, that is distinct from ageism. These areas cannot be fully there are many other types of dementia such as Lewy body International Journal of Alzheimer’s Disease 3 disease, vascular dementia, and frontotemporal dementia, thought they would experience in the presence of an agitated to name just a few. We have observed confusion about the person with ADRD. connection between AD and dementia. Some public media reports differentiate them rather than describing AD as a type 6.1.3. Procedure. We recruited family caregivers and profes- of dementia; few note other causes of progressive memory sionals via referrals from colleagues. Although this sample loss and confusion in older people. For this reason, we was not random or ethnically diverse, it included as many decided to refer to “Alzheimer’s disease and related disorders” occupations as possible. Student participants were recruited (ADRD) in the scale, with the expectation that some users from campus dormitories, and only individuals who did not will be knowledgeable about the “related disorders” and that know anyone with ADRD were eligible. It was necessary by completing the scale, others might become more aware to sample a variety of perspectives on ADRD in order to of the existence of “related disorders.” The name of the DAS highlight the most relevant content areas. The 15 interviews implies a broad application across forms of dementia and obtained in this study met the guidelines of McCracken [39], is in line with work like that of Askham [17], Kitwood [1], who suggested that eight in-depth interviews are adequate to MacDonald and Woods [36], and Sahin et al. [14]. However, cover a new domain. Interviews were conducted face-to-face because of public misunderstandings (also reflected in the with a trained interviewer, lasted between 60 and 90 minutes, responses of na¨ıve undergraduate participants in Study 1), and were tape-recorded. Neutral probes were used to guide we were concerned that if we referred only to “dementia” in discussion of each question. Audiotapes were transcribed the scale items, people would ask “Do you mean Alzheimer’s verbatim, and using a standard qualitative data analysis disease?” technique [40], we noted recurring themes and patterns, critiqued the plausibility of our observations, clustered and counted similar responses, and compared responses from the 5. Ethical Considerations different groups. The Institutional Review Board (IRB) of the University of Wisconsin at Oshkosh approved the four studies reported 6.2. Results and Discussion. Professionals and family care- here (protocol number 97662). The research complied with givers stressed that (a) people with ADRD are individuals; the ethical principles of psychologists and code of conduct (b) social interaction is important at all stages of ADRD; (c) of the American Psychological Association [38]. Informed people with ADRD communicate through behavior; and (e) consent was obtained from all participants. Because their familiar routines provide security for people with ADRD. identities were known to the researchers, interviewees signed A frequent comment was “Emphasize the person, not the consent statements. Participants in Studies 2, 3, and 4 were disease.” All students reported having sympathy for people declared by the IRB to be exempt from signing consent with ADRD, but not knowing how to help. Three students forms because they completed anonymous surveys. They were uncomfortable with the difficult behaviors sometimes received information sheets that described the study and exhibited by people with ADRD. stated that their completion of the survey signified their Overall responses were grouped into six categories. voluntary consent to participate. The first two categories, labeled “knowledge” and “beliefs”, addressed the cognitive aspect of attitude. Another two categories, “acceptance” and “empathy”, were affective in 6. Study 1: Structured Interviews nature, and the last two categories, “avoidance behaviors” 6.1. Method and “person-centered behaviors”, were behavioral. Forty scale items were derived from the above categories; six 6.1.1. Participants. Five family caregivers, five professionals additional items were adapted from old culture/new culture in the dementia care field, and five undergraduate students characteristics as depicted by Kitwood [1]. This initial with limited knowledge about dementia participated in version of the Dementia Attitudes Scale (DAS) is described structured interviews. The family caregivers included two andfactoranalyzedinStudy 2. men and two women who had spouses with dementia and one woman whose father had dementia. All the professionals 7. Study 2: Forty-Six Item Scale were female and consisted of two recreation therapy pro- fessionals, a long-term care nurse, a social worker, and a 7.1. Method representative of the Wisconsin Alzheimer’s Association. The students included two males and three females from the 7.1.1. Participants. A total of 307 undergraduate students in University of Wisconsin at Oshkosh. All participants were psychology, biology, and special education classes completed Caucasian. the initial DAS. Five participants were excluded due to missing data, so the valid N = 302. Participant ages ranged 6.1.2. Materials. A series of open-ended questions specifi- from 18 to 41 (M = 23.5, SD = 5.7). The sample was 63% cally addressed affect, behavior, and cognition. Participants female and over 95% Caucasian. were asked to describe their general knowledge about Alzheimer’s disease and related disorders (ADRD); their 7.1.2. Materials. Of the 46 items on the initial DAS, ap- perceptions of the competence and emotional well-being proximately a third reflected the cognitive component of of people with ADRD, and the reactions and feelings they attitude (e.g., “I am not very familiar with ADRD”), a third 4 International Journal of Alzheimer’s Disease reflected the affective component (e.g., “I feel relaxed around content of these items seemed relevant. The following items people with ADRD”), and a third reflected the behavioral loaded on Factor 3: “It is easy to get impatient with people component(e.g.,“Iwould avoidanagitatedpersonwith with ADRD”; “It is okay to redirect people with ADRD by ADRD.”) Each item was rated on a 7-point Likert scale telling small fibs”; “I would talk to someone with ADRD ranging from 1 (strongly disagree)to7(strongly agree). Half the way I would talk to a child”; and “People with ADRD of the items were reverse scored. Possible scores could range are child-like.” Factor 4 included these items: “I dread the from 46 to 322, with higher scores indicating more positive thought of becoming like someone with ADRD”; “Everyone attitudes. will get ADRD if they live long enough”; “When someone with ADRD gets agitated, they should be given tranquilizing medication; and “Social interaction is only important in the 7.1.3. Procedure and Analyses. Participants were recruited early stages of ADRD.” We decided to retain all 30 items from from undergraduate classes, and interested students had the opportunity to complete the DAS during class breaks. the four factors described above and conduct another EFA with a different sample, to ensure that the results were not Less than 0.5% of the data were missing, so missing items merely sample-specific. were estimated using person mean substitution [41]. To Range restriction and a ceiling effect were potential guide scale revision and determine the number of factors problems, as evidenced by the 13 negatively skewed items underlying the DAS, participants’ total scores underwent and the high mean total score. However, some skewed items principal axis factoring, which may yield less biased estimates were eliminated from the scale, and the mean item score was than principal components analysis [42]. The number of close to four, the midpoint. Only six of the items in Factor 1 factors was determined using a scree plot and the Kaiser- and Factor 2 were reverse scored, but the impact of reverse Guttman criterion (i.e., eigenvalues greater than one). scoring on response sets is debatable (Comrey, [43]) . These issues were further examined in Study 3. 7.2. Results 7.2.1. Descriptive Statistics and Reliability. Total scores 8. Study 3: Thirty-Item Scale ranged from 122 to 288 (M = 219.63, SD = 22.11), so attitudes were generally positive. The mean item score was 8.1. Method 4.78 (SD = 0.48). Coefficient alpha for the scale was 0.86. 8.1.1. Participants. One hundred forty-five students enrolled in a Certified Nursing Assistant (CNA) program at a 7.2.2. Exploratory Factor Analysis. Following principal axis technical college completed the 30-item DAS. Ages ranged factoring, eigenvalues and a scree plot suggested a four- from 17 to 63 (M = 29.70, SD = 10.62). Participants were factor solution. However, the reproduced correlation matrix predominantly female (88%) and either Caucasian (80.6%) showed that 266 nonredundant residuals (26%) exceeded or Hispanic (10.3%). 0.05. The analysis was duplicated with three, five, and six factors extracted, but a four-factor solution was most 8.1.2. Materials. In addition to the completing the 30-item interpretable. Both varimax rotation and oblimin rotation DAS, participants responded to the question, “Have you ever were conducted. The orthogonal model was less interpretable known or cared for someone with ADRD?” This question and had more cross-loading items, so the oblique model was was included to examine whether familiarity with ADRD selected for presentation and interpretation. Distributions correlated with positive attitudes. for 13 of the items were significantly negatively skewed, and one item was positively skewed. Transforming these items did not change any of the results. Pattern and structure coeffi- 8.1.3. Procedure and Analyses. The CNA course instructor cients were examined, and items were included in a factor offered students the chance to complete the scale during if their pattern loading was at least 0.32. Sixteen items were class breaks. Missing items (less than 0.1% of the data) excluded due to having low loadings, communalities less were again estimated via person mean substitution. Principal than 0.2, or multiple cross-loadings. Factor 1 (Cronbach’s α axis factoring with Oblimin rotation was conducted on = 0.82) contained 11 items that corresponded to behaviors participants’ total scores, and the results guided further scale and feelings of comfort around people with ADRD; thus, this revision.AsinStudy 2, only itemswithpattern coefficients ≥ factor was labeled “social comfort.” Factor 2 (α = 0.78) also 0.32 were included in a factor. Finally, the factor structures contained 11 items, all of which referred to knowledge and generatedinStudy 2and Study3were compared viathe beliefs about persons with dementia. This factor was labeled coefficient of congruence (r ), an index of factorial similarity cc “dementia knowledge.” Factor 3 (α = 0.10) and Factor 4 (α [44]. The minimum criterion for similarity was an r greater cc = 0.10) each contained four items and could not be readily than 0.90 [45]. interpreted. 8.2. Results 7.3. Discussion. Factor analysis of the 46-item DAS revealed two reliable factors with 11 items each. Sixteen items were 8.2.1. Descriptive Statistics and Reliability. Total scores on the eliminated from the scale. The eight unreliable items in scale ranged from 114 to 189 (M = 154.37, SD = 15.81) Factors 3 and 4 were also candidates for exclusion, but the out of a possible range of 30 to 210. The mean item score International Journal of Alzheimer’s Disease 5 was 5.15 (SD = 0.53). One hundred twelve participants, or validity of the DAS by comparing it to two measures of 77.2% of the sample, indicated that they knew someone with ageism and two measures of attitudes toward people with ADRD. A one-way ANOVA showed that individuals who disabilities. Divergent validity with a social desirability scale knew someone with ADRD had significantly more positive was also examined, and confirmatory factor analysis (CFA) attitudes than individuals who did not, F(1, 141) = 19.38, was conducted. The purpose of the CFA was to examine P< .001. Cronbach’s alpha for the 30-item scale was 0.79. whether, in a different sample, a two-factor structure would fit the DAS better than a single-factor structure. If this were 8.2.2. Exploratory Factor Analysis. Following principal axis the case, it would support the previous EFA findings. Similar procedures were used in Chumbler [46] and Thomas et al. factoring, a scree plot indicated a four-factor solution. The rotated solution yielded one factor with 11 items, one [34]. factor with 10 items, and two factors with four items each. Seventeen items were significantly negatively skewed. As in 9. Study 4: Validity Testing Study 2, transforming these items did not alter the results. The two four-item factors were identical to Factors 3 and 9.1. Method 4inStudy 2, andwereagain characterizedbylackof 9.1.1. Participants. Participants were 160 undergraduate interpretability and low reliability. Because these items were psychology students. There were 51 males and 109 females problematic in two different samples, they were eliminated. ranging in age from 18 to 47 (M = 19.95; SD = 4.20). The Two additional items (“I would find it difficult not to take sample was 92.5% Caucasian. it personally if someone with ADRD called me a name”; “Meeting the physical needs of people with ADRD is just one goal of caregiving”) were eliminated because they displayed 9.1.2. Materials relatively low loadings (<0.35) in both Study 2 and Study 3. DAS. The final 20-item DAS from Study 3 was administered. Cronbach’s alpha for the remaining 20 items was 0.85. Factor 1 (α = 0.82) was again labeled “social comfort”, and Factor 2 (α = 0.75) was again labeled “dementia knowledge.” Kogan Attitudes toward Old People Scale [30]. The OP is Thesetwo factorsweremoderatelycorrelated, r = 0.29, P< a reliable, widely used measure of ageism, although it is .01, and together explained 38.72% of the variance. Table 1 dated and has been criticized for its 34-item length and item displays the pattern coefficients for the final 20 items as transparency [33]. Items focus on stereotypes, are presented generated in Study 2 and Study 3. The r was 0.96 for Factor cc in positive-negative pairs, and are rated on a 7-point Likert 1 and 0.92 for Factor 2, which demonstrated that the final scale [30]. Higher scores indicate more positive attitudes. DAS items showed similar factor loadings across Study 2 and Study 3. Fraboni Scale of Ageism [31]. The 29-item FSA measures discrimination and avoidance aspects of ageism [31, 47]. 8.3. Discussion. The original 46-item DAS was reduced Scale items are rated on a 4-point Likert scale, where higher to 20 items with a two-factor structure. Scale reliability scores indicate more positive attitudes. was acceptable. Items reflected the components of attitude, although more items addressed the cognitive domain (Factor Attitudes toward Disabled Persons Scale [28]. The 20-item 1) than the affective and behavioral domains which merged ADP assesses attitude at the societal level. Items are rated into one factor (Factor 2), and only six items were reverse on a 6-point Likert scale that ranges from −3to+3, scored. Several items were negatively skewed, and a ceiling and respondents rate how society should treat individuals effect could not be ruled out. Social desirability may have with disabilities [28]. Higher scores indicate more positive influenced the results. However, most participants knew attitudes. In the current study, ADP items were converted to someone with ADRD, which was associated with more a scale ranging from 1 to 6 for ease of comparisons. positive attitudes. DAS scores may also have been higher for the CNA students because they had chosen caregiving as an Interaction with Disabled Persons Scale [29]. The IDP mea- occupation. To see whether the Study 3 sample had more sures the amount of discomfort respondents feel interacting positive attitudes than the Study 2 sample, a t-test was used on a personal level with disabled people. It assesses attitude to compare mean total scores for the final 20 scale items in at the individual level [34]. The 20 items are rated on a 5- both samples. The Study 3 sample had significantly higher point scale [29]; higher scores again indicate more positive scores, t(445) = 11.41, P< .001. attitudes. Although the sample in Study 3 was smaller and less homogeneous than the sample in Study 2, the factor structure of the DAS was consistent across the two samples. Marlowe-Crowne Social Desirability Scale, 13 items [48, 49]. Items 18 and 19 were potentially problematic, as they had The original SDS has 33 true-false items describing various cross-loadings above 0.2 and relatively low loadings (0.34 behaviors (e.g., “I’m always willing to admit it when I make and 0.32, resp.) in Study 3. These items could be eliminated a mistake”). Agreement with items containing absolutes like if they exhibit low loadings in future studies. Overall, the “always”, and disagreement with items containing qualifiers DAS factor structure appeared to be stable, as it replicated like “sometimes”, indicate socially desirable responding and in two different samples. Study 4 explored the convergent result in higher scores [48]. Shorter forms of the SDS have 6 International Journal of Alzheimer’s Disease Table 1: Exploratory factor analyses of the final 20 items in the dementia attitudes scale with oblimin rotation. Study 2 Study 3 Item Factor 1: Factor 2: Factor 1: Factor 2: Comfort Knowledge Comfort Knowledge 4. I feel confident around peoplewith ADRD. .70 .03 .73 .16 5. I am comfortable touching people with ADRD. .47 .08 .72 .11 6. I feel uncomfortable being around people with ADRD. .54 −.03 .56 −.06 8. I am not very familiar with ADRD. .48 .01 .55 −.07 9. I would avoid an agitated person with ADRD. .57 .03 .45 −.09 13. I feel relaxed around people with ADRD. .74 .04 .73 −.07 16. I feel frustrated because I do not know how to help people with ADRD. .58 −.21 .54 −.09 1. It is rewarding to work with people who have ADRD. .51 .06 .41 .16 17. I cannot imagine caring for someone with ADRD. .57 −.21 .46 .22 2. I am afraid of people with ADRD. .52 .11 .48 −.07 3. People with ADRD can be creative. .03 .59 .08 .52 7. Every person with ADRD has different needs. −.08 .56 −.02 .44 Study 1 Study 2 Item Factor 1 Factor 2 Factor 1 Factor 2 10. People with ADRD like having familiar things nearby. .04 .42 −.05 .55 11. It is important to know the past history of people with ADRD. −.13 .57 −.17 .40 12. It is possible to enjoy interacting with people with ADRD. .15 .51 −.02 .41 14. People with ADRD can enjoy life. .21 .43 .28 .53 15. People with ADRD can feel when others are kind to them. .21 .53 .23 .60 19. We can do a lot now to improve the lives of people with ADRD. .12 .44 .25 .32 18. I admire the coping skills of people with ADRD. .02 .44 .29 .34 20. Difficult behaviors may be a form of communication for people with ADRD. −.09 .58 −.06 .53 Note. Factor pattern coefficients are displayed. ADRD = Alzheimer’s disease and related disorders. Reverse scored item. been developed [49, 50], and a 13-item form was used desirable), and the root mean square error of approximation in the current study [49]. Participants’ total scores on the (RMSEA; values < 0.08 are desirable). SDS-13 could range from 0 to 13. A significant positive correlation between SDS-13 scores and DAS scores could 9.2. Results indicate that scores on the DAS were affected by socially desirable responding. 9.2.1. Descriptives and Correlations. Descriptive statistics for each scale, including mean total scores and Cronbach’s 9.1.3. Procedure and Analyses. Participants were recruited alphas, are displayed in Table 2. The DAS correlated sig- via a participant pool web site. Each participant filled nificantly with the OP, FSA, ADP, and IDP; all of the out a packet of four questionnaires: the 20-item DAS, the scales correlated significantly with the SDS-13 (Table 3). SDS-13, either the FSA or OP, and either the ADP or Fisher’s r-to-z comparisons showed that the magnitude of IDP. That is, each participant completed one of the two the correlation between the DAS and the SDS-13 was not ageism scales and one of the two disability attitude scales. significantly different than the magnitudes of the correlations The study was constructed this way in order to minimize between the other scales and the SDS-13. participant fatigue, boredom, and missing data. The order of the questionnaires varied randomly from packet to packet. Pearson correlations were calculated between total DAS 9.2.2. Confirmatory Factor Analysis. For the single-factor scores and total scores on each other scale, and CFA was model, the sample size-dependent chi-square was significant, conducted on the DAS using LISREL 8.80 [51]. Models were χ (170) = 472.65, P< .001. Chi-square was also significant run with a single factor and with two factors. Because a for the two-factor model, χ (167) = 260.83, P< .001; nonorthogonal rotation method was used in the previous however, this model fit significantly better than the single- EFAs, the two factors were allowed to correlate. Chi-square factor model, χ (3) = 211.82, P< .001. Goodness-of-fit difference tests were used to examine the relative fit of the indices for the single-factor model were not adequate (CFI = single-factor and two-factor models. Goodness of fit was 0.86, RMSEA = 0.11, GFI = 0.77). For the two-factor model, assessed via the goodness-of-fit index (GFI; values > 0.95 are the CFI was 0.95, the RMSEA was 0.06, and the GFI was desirable), the comparative fit index (CFI; values > 0.90 are 0.87, reflecting a reasonable, though not ideal, model fit. International Journal of Alzheimer’s Disease 7 Table 2: Descriptive statistics and reliability for the DAS, OP, FSA, 9.3. Discussion. Correlations between the DAS and the other ATDP, IDP, and SDS-13. scales were significant, providing evidence for construct validity. The correlation between the DAS and SDS-13 was Scale NM SD Cronbach’s α significant, but similar in magnitude to the correlations DAS 157 98.64 12.82 0.83 between the SDS-13 and other scales. As measured by the OP 77 163.69 18.73 0.85 SDS-13, social desirability does not appear to be more FSA 80 89.17 9.30 0.87 problematic on the DAS than on comparable scales. The ATDP 79 83.41 9.54 0.72 mean total score distribution was negatively skewed not IDP 78 63.13 8.82 0.81 just for the DAS, but for all the scales (excluding the SDS- SDS-13 157 4.21 2.91 0.74 13); inflated positivity appears to be common with self- report measures of this type. The CFA provided support Note. DAS = Dementia Attitudes Scale. OP = Kogan Attitudes toward Old People Scale. FSA = Fraboni Scale of Ageism. ATDP = Attitudes Towards for the previous EFAs, despite the relatively small sample Disabled Persons Scale. IDP = Interaction with Disabled Persons Scale. size. Overall, the DAS appears to have solid psychometric properties and evidence for convergent validity. Table 3: Intercorrelations between the DAS, OP, FSA, ADP, IDP, and SDS-13. 10. General Discussion Scale 1 2345 6 Structured interviews, exploratory factor analysis, conver- ∗∗ ∗∗ ∗∗ ∗∗ ∗∗ 1. DAS — .51 .55 .44 .49 0.34 gent validity testing, and confirmatory factor analysis were ∗ ∗∗ ∗ 2. OP — — .41 .61 0.26 employed to develop the 20-item Dementia Attitudes Scale. ∗∗ ∗ 3. FSA — .51 .57 0.23 DAS items reflect the affective, behavioral, and cognitive ∗∗ 4. ADP — — 0.32 components of an attitude (Table 1), although the two-factor ∗∗ 5. IDP — 0.30 model noted in three administrations of DAS items suggests a strong connection between people’s feelings and behaviors 6. SDS-13 — ∗ ∗∗ toward those living with ADRD. The psychometric proper- P <.05, two-tailed. P <.01, two-tailed. ties of the DAS compare favorably with the psychometric properties of similar scales (e.g., Thomas et al., [34]), and Table 4: Confirmatory factor analysis of the dementia attitudes it appears to be a useful tool for assessing attitudes toward scale (DAS). dementia [1, 14, 36]. Item Factor 1: Comfort Factor 2: Knowledge The greatest strength of the DAS lies in its multistep construction, which combined qualitative and quantitative 40.76 0 methods, and its development based on the widely-accepted 50.68 0 tripartite model of attitude. This approach helped ensure 60.55 0 that relevant construct areas were represented [37]. Nunnally 80.52 0 [52] recommended a subject-to-item ratio of at least 5 : 1 90.55 0 for conducting factor analyses, and the sample sizes within 13 0.71 0 each study met this criterion. Other strengths of the DAS 16 0.44 0 include reliability, which was consistently above 0.8, the 10.57 0 replicability of the factor structure across independent 17 0.74 0 samples, convergent validity evidence, practical length; and 20.64 0 ease of administration. Previous studies (Jackson et al. [53]) found that participants who had higher levels of contact 3 0 0.64 and experience with people with dementia reported more 7 0 0.46 positive attitudes than participants with less contact. The 10 0 0.32 current study also found a positive association between 11 0 0.31 contact and attitudes, which further validated the DAS. 12 0 0.51 To test for item redundancy, we ran bivariate correlations 14 0 0.50 between all of the scale items using the sample from Study 4. 15 0 0.70 The largest correlation was 0.57, which does not exceed the 19 0 0.33 cutoff of 0.80 often used to indicate strong multicollinearity 18 0 0.37 [54]. 20 0 0.33 The limitations of the DAS tend to be shared by self- Variance (%) 26.03 11.60 report measures in general. Our samples were primarily young, female, and Caucasian, so generalizability is limited, Note. Standardized loadings are displayed. All coefficients were significant at P< .05. although we did sample both college students and future CNAs (i.e., caregivers or care professionals). Additional research should include middle aged and older persons, The results of the CFA are displayed in Table 4. The two and a more racially diverse sample. Numerous negatively factors were correlated at r = 0.21, P< .01. skewed items were obtained across the three samples, which 8 International Journal of Alzheimer’s Disease may limit the precision of the scale. Inflated positivity in affirmations of personhood and relationality, there is was especially pronounced in the sample of CNA stu- a growing need to assess attitudes about dementia held dents. 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International Journal of Alzheimer's DiseaseHindawi Publishing Corporation

Published: Mar 22, 2010

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