Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Development and validation of a questionnaire to evaluate the knowledge, attitude and practices regarding travel medicine amongst physicians in an apex tertiary hospital in Northern India

Development and validation of a questionnaire to evaluate the knowledge, attitude and practices... Objectives: Travel medicine focuses primarily on pre-travel preventive care and the conditions and diseases acquired during or after travel. There is a paucity of validated tools to assess the knowledge, attitude and practises of physicians with regard to travel medicine. We attempted to develop a tool to assess existing expertise among Medicine and Infectious Diseases resident doctors with respect to travel medicine. Methods: Item level content validity index (I-CVI) and scale level content validity index (S-CVI/Ave) were estimated for each of the items to establish the content validity. Refined measures of inter-rater agreement (Brennan and Predi- ger Agreement Coefficient and Gwet’s Agreement Coefficient) were estimated for the tool. Results: The final version of the questionnaire had satisfactory content validity (I-CVI > 0∙6 and S-CVI/Ave > 0∙9) and possessed high agreement among the raters (Brennan and Prediger AC > 0∙7, p < 0∙01 and Gwet’s AC > 0∙8, p < 0∙01) with regard to necessity, clarity and relevance of the scale. Conclusions: This tool covers a wide range of questions and is scientifically validated. The final version of the tool can be used largely for the assessment of knowledge, attitude and practices among medical practitioners. This is instru- mental to build targeted intervention programs to enhance the knowledge regarding travel medicine among health care providers. Keywords: Travel Medicine, Knowledge, Practice, Questionnaire, Development, Validation care system should be geographically inclusive and not be Introduction confined to a region or a country because a pandemic like After a long gap of the Spanish flu pandemic, the emer - this has no boundaries. Travel medicine globalizes health gence of COVID-19 has taught many lessons to human- care in terms of providing preventive and curative health ity. One of the key message is to realize the importance across boundaries. of public health from a global perspective. The health Travel medicine or emporiatrics is the field of medi- cine which is concerned with the promotion and *Correspondence: linktoarvind@gmail.com protection of health of travellers. It aims to prevent Department of Medicine, AIIMS, New Delhi, India diseases and other adverse health outcomes among Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 2 of 9 international travellers. It requires up-to-date informa- Material and methods tion on the global epidemiology of the non-infectious Development and validation of the travel medicine and infectious health risks, health regulations and vac- questionnaire cination necessities in various countries along with the Step I: Conceptualization and identification of domains emerging patterns of medication-resistant infections and sub‑domains for the travel medicine knowledge, attitude [1]. As international travel becomes more accessible, and practices assessment tool knowledge of this field is likely to become essential For conceptualizing and identification of domains and for a physician [2, 3]. Although derived from the tradi- sub-domains to develop the initial pool of items, multi- tional medicine disciplines, this branch of medicine is ple round table discussions and focus group discussions a newly emerging field given the increasing number of (FGDs) were held among experts from different fields of international travellers and reporting of various infec- medicine, infectious diseases and travel medicine from tious and non-infectious diseases [4], injuries [5] and five tertiary care centers in different parts of India. This other health risks among international travellers [6–8]. included subject experts with certifications in travel Since travel medicine is a new discipline, expert opin- medicine from the International Society of Travel Medi- ion and experience still dominate many areas in this cine (ISTM) and physicians currently practicing in travel branch, highlighting the need for continuous investi- clinics across the country (Fig. 1). gation in the field [9]. International travellers are at higher risk of devel- Step II: Literature review to identify domains oping various health threats, which depend on both and sub‑domains and generating preliminary item pool the health needs of the traveller and on the type of for the tool travel to be undertaken. The traveller’s triad includes An extensive literature review was carried out to ana- the three major components that influence the risk lyse the existing evidence on travel medicine. The litera - associated with a specific travel plan i.e. place, time ture search aimed to identify domains and sub-domains and person. The region of the world being visited required to develop the travel medicine KAP assessment determines the altitude, humidity, temperature and tool. We used the standard textbooks, journals, and inter- infection profile etc. The travellers’ vulnerability to net databases for the identification of relevant concepts. these exposures may be determined by their age, gen- The internet search engines used were Google Scholar, eral well-being, the trip’s length, and the diversity of PubMed, Scopus and JSTOR using the keywords string: planned activities [10]. Pre-travel health education, (Travel Medicine) AND (Knowledge) AND (Attitude) vaccination and prophylactic drugs may serve to miti- AND (Practices) published in or after year 2000. Table  1 gate these risks [10–12]. shows the details of some of the sources used to identify With rapidly evolving travel regulations, there is a the domains and sub-domains and to generate a prelimi- need to provide training to practicing physicians to nary item pool for our travel medicine tool. predict travel-associated health risks and recognise untoward exposures. As travel medicine gains promi- Step‑III: Developing the structure of the questionnaire nence worldwide, we recognise the dearth of ade- through expert review quately trained field experts. In the absence of subject The initial pool of 157 questions was again reviewed by specialists, general physicians must be provided formal the experts, and the number of items was reduced to 143. training to ensure adequate care [13]. In this regard, This set of identified items was organized into the form of an assessment of the existing knowledge among health a questionnaire. The questionnaire was constructed in a care practitioners is necessary to develop interventions simple and lucid language, and the flow of the questions for targeting gaps in knowledge. was maintained, keeping in mind the purpose of assess- With this objective in mind, an attempt was made at ment of KAP. our tertiary care facility to develop a comprehensive tool covering major aspects of travel medicine. Cur- Step‑IV: Establishing face and content validity and estimation rently, no widely disseminated, valid instrument for of agreement coefficients assessing travel medicine’s knowledge, attitude, and Face validity is the lowest level of validity and repre- practices is available in India. This tool assesses the sents the assumption of an expert and acceptance that a knowledge, attitude and practices (KAP) regarding test represents the domain being assessed. After prepar- travel medicine in the form of a questionnaire. We also ing the first draft, the questionnaire was reviewed by the attempted to validate this tool in primary care physi- experts in the field for face validity (by assessing for read - cians, internist, infectious disease specialists, and other ability, comprehensibility, feasibility, completeness and health care providers. layout and style). K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 3 of 9 Fig. 1 Flow chart of the development and validity of the travel medicine tool The purpose of content validation is to reduce the bias question relevant as far as branch of travel medicine is associated with the operationalization of the instrument concerned with respect to knowledge/attitude/prac- in the initial stages [14]. To establish the content validity tice?). Each question was evaluated by the experts for of the travel medicine tool, we chose three components these components separately. The rating protocol was to judge the overall content validity. Studies estimate the designed into the form of a Likert scale as- content validity indices with a single validity parameter. However, a few studies adopted a different approach and 1) Necessity (N): Each item was rated as: 1 (neither decomposed the overall validity into its components [15, useful nor necessary), 2 (useful but not necessary) and 16]. We adopted this technique and judged the over- 3 (essential). all content validity in terms of—Necessity (Is the ques- 2) Clarity (C): Rate each item as 1(not clear), tion necessary to be asked to the resident to assess their 2(slightly clear/needs major revision), 3 (clear/ knowledge/attitude/practices of travel medicine?), Clar- needs minor revision), 4 (very clear). ity (Is the question wording/structure/options given convey the meaning effectively?) and Relevance (Is the Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 4 of 9 Table 1 List of various books/journals used to identify the domains and sub-domains and to develop the preliminary pool of items for travel medicine tool Name of the Journal/Book Name of the author(s)/editor(s) Name of the Publisher Publication year/reference period 1.Principles and Practice of Travel Medicine Jane N. Zuckerman John Wiley & Sons 2013 2.Travel Medicine Jay S. Keystone Elsevier 2019 Phyllis E. Kozarsky Bradley A. Connor Hans D. Nothdurft Marc Mendelson Karin Leder 3.Manual of Travel Medicine Joseph Torresi Springer 2019 Sarah McGuinness Karin Leder Daniel O’Brien Tilman Ruff Mike Starr Katherine Gibney 4.CDC Health Information for International Gary W. Brunette Oxford University Press 2018 Travel 2018. The Yellow Book 5.Manual of Travel Medicine and Health Robert Steffen BC Decker Inc 2003 Herbert L. DuPont Annelies Wilder-Smith 6.Journal of Travel Medicine Annelies Wilder-Smith Oxford University Press 2000 or later 7.Travel Medicine and Infectious Disease Patricia Schlagenhauf-Lawlor Elsevier 2000 or later 8.International Travel and Health Gilles Poumerol World Health Organization ( WHO) 2012 Annelies Wilder-Smith 3) Relevance (R): Each item was rated as: 1 (not rel- Likewise, for clarity and relevance the dichotomous vari- evant), 2 (slightly relevant/needs major revision), 3 ables were generated as ‘1’ for experts giving a rating of (relevant/needs minor revision), 4 (very relevant). 3 or 4 and ‘0’ otherwise. These dichotomous variables were then used to estimate the content validity indices The idea behind decomposing the overall quality judge - (I-CVI and S-CVI/Ave) for each of these characteristics. ment into its components (N, C and R) was to give more The item-level CVI (I-CVI) is computed by dividing the freedom to the experts to judge and to provide more total number of ‘1’s by the total number of experts [17, strength to the validation process. Furthermore, we also 18]. The S-CVI/Ave is then calculated by averaging the looked for any lack of consistency between experts for I-CVIs estimated for each item of the instrument. This travel medicine questionnaire in terms of three above exercise was repeated for each of the parameters of con- mentioned parameters. tent validity (necessity, clarity and relevance). Polit and Beck [17] recommended an S-CVI/Ave of 0∙90 or above Measures as excellent. We chose several measures of inter-rater agreement as well as indices of validity to validate the travel medicine Agreement Coefficients (AC) tool. The most popular method of quantification of inter- rater agreement among researchers has been the Cohen’s Content validity indices (CVI) Kappa [19–22]. Recent published literature discussed the Two indices have been proposed by researchers for judge- limitations of kappa statistic and proposed other meas- ment of content validity of a tool. This includes-item level ures of inter-rater agreement [19, 22]. Klein [19] has content validity index (I-CVI) and scale level content pointed out the limitations of Cohen’s Kappa and sug- validity index (S-CVI)[17]. The eight experts rated each gested that the Brennan and Prediger [23] coefficient and of the item in terms of N, C and R as mentioned above. Gwet’s [24, 25] agreement coefficient arguably represent In the next step, these scores were dichotomized. For the data more accurately. Further, he suggested that these necessity, the dichotomous variable was categorized as two agreement measures are found to be more robust ‘1’ if the item was rated as ‘3’ (essential) or ‘0’ otherwise. than any other measure of inter rater agreement [19]. K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 5 of 9 Similarly, Wongpakaran [22] found Gwet’s AC to pro- 28–30] and also pointed out the inadequacies in KAP vide a more stable inter-rater reliability coefficient than in both health providers as well as the travellers [31– Cohen’s Kappa and recommended to use for inter-rater 34]. In order to build any specific intervention program reliability analysis. A more detailed discussion on each of to increase knowledge regarding travel medicine in the agreement coefficients may be found elsewhere [19, healthcare practitioners, it becomes necessary to assess 22, 25]. In our study, we estimated these agreement coef- the existing knowledge of the health providers. ficients along with the percent agreement for each of the Earlier KAP studies in travel medicine are either dis- three above mentioned components. ease-specific [31, 35] or conducted amongst travellers [32, 33, 35, 36]. None of these studies have elucidated on the development process of their tools, and valida- Results tion data on the same is often missing. Very few stud- Content validity indices ies have been published which attempted to develop Table 1 shows the I-CVIs and S-CVI/Ave for each of the and validate the questionnaire regarding travel medi- component of content validity. Polit and Beck recom- cine among medical practitioners. Ratnam et.al. devel- mended an I-CVI ≥ 0∙78 for inclusion of an item [17]. oped and validated a questionnaire to assess the risk of But, we adopted a less strict cut-off of I-CVI < 0∙60 for developing viral infections in Australian Travellers [37]. deletion of the items from the pool [26]. We removed the The study covers only a particular domain (viral infec - items which had an I-CVI < 0∙6. The I-CVIs for neces - tions) of travel related problems among travellers and sity ranged from 0∙625 to 1∙000. Six items had a necessity does not establish the content validity through estima- I-CVI of 0∙625 whereas five items had 0∙750. Rest of the tion of content validity indices (I-CVI and S-CVI). items had an I-CVI ≥ 0∙78 where out of total 106 items The major strength of this study is the develop - 85 items had an I-CVI of 1∙000. This reflects satisfac - ment and validation of a travel medicine tool, which tory ranges for necessity in terms of I-CVIs. For clarity, will enable the researchers to assess the KAP among we observed a slightly better I-CVIs which ranged from health care providers. The content collection through 0∙875 to 1∙000 with six items having an I-CVI of 0∙875 and thorough literature review as well as several rounds rest of the items had 1∙000. Likewise, for relevance the of discussion with the experts ensured the quality and I-CVIs ranged from 0∙625 to 1∙000 where four items had coverage. Further, the establishment of content valid- an I-CVI of 0∙625. The overall scale level content valid - ity through expert evaluation and measures of con- ity index (S-CVI/Ave) was observed to be above 0∙900 for tent validity and agreement coefficients made the tool each of the dimension of content validation. robust and scientifically validated. The final set of 106 questions had satisfactory content validity indices Agreement among the experts (I-CVI > 0∙6 and S-CVI/Ave > 0∙9). The agreement coef - The final version of questionnaire had 106 items after ficients (Brennan and Prediger AC > 0∙7, p < 0∙01 and removal of items with an I-CVI < 0∙6 (Supplementary Gwet’s AC > 0∙8, p < 0∙01) among the raters with regard Table  1). For the remaining items, we estimated agree- to necessity, clarity and relevance of the travel medicine ment indicators. The results of these agreement indica - KAP assessment tool were observed to be high. tors with regard to the three dimensions of overall quality This study is not free from limitations. The experts of the tool has been depicted in Table  2. We observed chosen for reviewing the travel medicine tool are from a high and statistically significant percentage agree - internal medicine, infectious disease programme and ment among experts with regard to the overall validity allied branches who are involved in operating clinics of of the travel medicine tool. For each of the dimensions, travel medicine since dedicated travel medicine branch the overall percent agreement among the experts was is yet to evolve in India. One who has completed a above 90 percent. The cut-offs of agreement according certificate course in Travel Health from International to Gwet’s AC as categorized by Tammaa [27] is as fol- Society of Travel Medicine (ISTM) was actively involve lows: < 0∙2 = poor; 0∙21–0∙4 = fair; 0∙41–0∙6 = moderate; as an expert. Although, we have taken utmost care to 0∙61–0∙8 = substantial; and 0∙81–1∙0 = almost perfect. cover every aspect of travel medicine, since it is a vast For each of the dimensions, we observed Gwet’s AC > 0∙8 discipline there is always a prospect of modification showing high levels of agreement among raters (Table 3). and improvement of this tool. Due to limited resources available for the study, only experts from India were Discussion involved to review the travel medicine KAP tool. How- With the increasing number of international travellers, ever, AIIMS, New Delhi being an apex health care travel medicine has gained new significance. Studies center of India has specialists from all clinical domains have highlighted that the prevalence of travel related of human health. Therefore, their expertise was used problems is surprisingly high among the travellers [7, Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 6 of 9 Table 2 Item level content validity index (I-CVI) for each item and scale level content validity index for travel medicine questionnaire I-CVI I-CVI I-CVI Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) 1 1∙000 1∙000 1∙000 41 1∙000 1∙000 1∙000 81 1∙000 1∙000 0∙875 2 1∙000 1∙000 1∙000 42 1∙000 1∙000 1∙000 82 1∙000 0∙875 1∙000 3 0∙625 1∙000 0∙625 43 1∙000 1∙000 1∙000 83 0∙875 0∙875 1∙000 4 0∙875 1∙000 1∙000 44 1∙000 1∙000 1∙000 84 1∙000 1∙000 1∙000 5 1∙000 1∙000 1∙000 45 1∙000 1∙000 1∙000 85 1∙000 1∙000 1∙000 6 1∙000 1∙000 1∙000 46 1∙000 1∙000 1∙000 86 1∙000 1∙000 1∙000 7 1∙000 1∙000 1∙000 47 0∙625 1∙000 0∙625 87 1∙000 1∙000 1∙000 8 0∙875 1∙000 1∙000 48 1∙000 1∙000 1∙000 88 1∙000 1∙000 1∙000 9 1∙000 1∙000 1∙000 49 1∙000 1∙000 1∙000 89 1∙000 1∙000 1∙000 10 1∙000 1∙000 1∙000 50 0∙625 0∙875 0∙750 90 1∙000 1∙000 1∙000 11 1∙000 1∙000 1∙000 51 0∙875 0∙875 1∙000 91 0∙750 1∙000 0∙625 12 1∙000 1∙000 1∙000 52 0∙875 1∙000 1∙000 92 1∙000 1∙000 1∙000 13 1∙000 1∙000 1∙000 53 1∙000 1∙000 1∙000 93 1∙000 1∙000 1∙000 14 1∙000 1∙000 1∙000 54 1∙000 1∙000 1∙000 94 1∙000 1∙000 1∙000 15 1∙000 1∙000 1∙000 55 0∙875 1∙000 0∙875 95 1∙000 1∙000 1∙000 16 1∙000 1∙000 1∙000 56 1∙000 1∙000 1∙000 96 1∙000 1∙000 1∙000 17 0∙625 1∙000 0∙875 57 1∙000 1∙000 1∙000 97 1∙000 1∙000 1∙000 18 1∙000 1∙000 1∙000 58 1∙000 1∙000 1∙000 98 1∙000 1∙000 1∙000 19 1∙000 1∙000 1∙000 59 1∙000 1∙000 1∙000 99 1∙000 1∙000 1∙000 20 1∙000 1∙000 1∙000 60 1∙000 1∙000 1∙000 100 1∙000 1∙000 1∙000 21 1∙000 1∙000 1∙000 61 1∙000 1∙000 1∙000 101 1∙000 1∙000 1∙000 22 1∙000 1∙000 1∙000 62 1∙000 1∙000 1∙000 102 1∙000 1∙000 1∙000 23 1∙000 1∙000 1∙000 63 1∙000 1∙000 1∙000 103 1∙000 1∙000 1∙000 24 0∙875 1∙000 1∙000 64 1∙000 1∙000 1∙000 104 1∙000 1∙000 1∙000 25 0∙875 1∙000 0∙875 65 1∙000 0∙875 1∙000 105 1∙000 1∙000 1∙000 26 0∙750 1∙000 0∙625 66 1∙000 1∙000 1∙000 106 1∙000 1∙000 1∙000 27 0∙750 1∙000 0∙750 67 1∙000 1∙000 1∙000 S-CVI/Ave 0∙955 0∙994 0∙968 28 1∙000 1∙000 1∙000 68 1∙000 1∙000 1∙000 29 1∙000 1∙000 1∙000 69 1∙000 1∙000 1∙000 30 1∙000 1∙000 1∙000 70 0∙750 1∙000 0∙875 31 1∙000 1∙000 1∙000 71 1∙000 1∙000 1∙000 32 1∙000 1∙000 1∙000 72 1∙000 1∙000 1∙000 33 0∙875 1∙000 1∙000 73 0∙625 1∙000 0∙750 34 1∙000 1∙000 1∙000 74 0∙875 1∙000 0∙750 K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 7 of 9 Table 2 (continued) I-CVI I-CVI I-CVI Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) 35 1∙000 1∙000 1∙000 75 0∙750 1∙000 1∙000 36 1∙000 1∙000 1∙000 76 1∙000 1∙000 1∙000 37 1∙000 1∙000 1∙000 77 0∙875 0∙875 0∙875 38 1∙000 1∙000 1∙000 78 1∙000 1∙000 1∙000 39 0∙625 1∙000 0∙875 79 1∙000 1∙000 1∙000 40 1∙000 1∙000 1∙000 80 1∙000 1∙000 1∙000 Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 8 of 9 Authors’ contributions Table 3 Details of agreement among experts for travel medicine AK- Conceptualization, development of tool, finalization of draft; AR-Devel- tool with regard to necessity, clarity and relevance opment of tool, data collection and analysis; MU- Review of literature, data analysis, drafting of manuscript, editing of manuscript; JA-Conceptualization Indicator Necessity Clarity Relevance and development of tool; SS, AM and UB-Development of tool and review of literature; PR and PG-Review of literature, editing of final draft NW- Overall % Agreement 96∙8*** 91∙4*** 90∙8*** supervision and editing of final draft. The author(s) read and approved the Brennan and Prediger AC 0∙9148*** 0∙7258*** 0∙7042*** final manuscript. Gwet’s AC 0∙9656*** 0∙8445*** 0∙8336*** Funding *** p < 0∙01 This research work has not received any funding from any of the funding sources. for the development of initial pool of items and revised Availability of data and materials version of the tool. The dataset supporting the conclusions of this article is available by taking prior approval of the corresponding author. The patterns of infectious diseases vary by geo - graphic region and population [38] and differences Declarations in the climate of various regions also impact the pat- terns of infectious diseases [39] and therefore require Ethics approval and consent to participate special attention by health care providers. We sug- Study was ethically approved by All India Institute of Medical Sciences (AIIMS) research ethics committee (Ref. No.: IECPG-326/22.07.2020, RT-34/26.08.2020). gest that the definition of travel medicine should be This study has not been conducted on human participants, and therefore con- expanded in such a way that it covers the health prob- sent to participate do not apply. lems of domestic travellers and repatriates, to prevent Consent for publication the spread of infectious diseases especially various Not applicable. kinds of respiratory tract infections (RTIs) which may be highly contagious and can give rise to a pandemic. Competing interests The authors declare that they have no competing interests. So, comprehensive attempts should be made to make the definition more exhaustive and the possible inclu - Author details 1 2 sion of this aspect should be the point of consideration Department of Medicine, AIIMS, New Delhi, India. Infectious Diseases & Travel Health Specialist, Indraprastha Apollo Hospital, New Delhi, India. in future. Received: 16 February 2022 Accepted: 4 May 2022 Conclusions The pre-travel consultation has become a necessary part of the travellers’ checklist. Considering this issue, present References 1. Aw B, Boraston S, Botten D, Cherniwchan D, Fazal H, Kelton T, et al. study is a significant contribution in the field of travel Travel medicine: What’s involved? When to refer? Can Fam Physician. medicine and provides the basis for the assessment of the 2014;60:1091–103. knowledge, attitude and practices among medical prac- 2. Treadwell TL. Trends in travel. In: Zuckerman JN, editor. Princ Pract Travel Med. 2nd ed. United Kingdom: John Wiley & Sons, Ltd; 2013. p. 3–4. titioners so that adequate intervention programs may 3. Kozarsky PE, Keystone JS. Introduction to Travel Medicine. In: Keystone JS, be developed to enhance the knowledge of travel medi- Kozarsky PE, Bradley A. Connor, Hans D. Nothdurft, Mendelson M, Leder K, cine among health care providers. This tool covers a wide editors. Travel Med. 4th ed. United States: Elsevier; 2019. p. 1–2. 4. Torresi J, McGuinness S, Leder K, O’Brien D, Ruff T, Starr M, et al. Non- range of questions and is scientifically validated. The final infectious Problems. Man Travel Med. 4th ed. Singapore; 2019. p. 265–96. version of the tool can be used globally for the assess- 5. WHO. Injuries and violence. In: Poumerol G, Wilder-Smith A, editors. Int ment of knowledge, attitude and practices among medi- Travel Heal. 1st ed. Switzerland: World Health Organization; 2012. p. 51–3. 6. Flaherty GT, Chen B, Avalos G. Individual traveller health priorities and the cal practitioners. This is instrumental to build targeted pre-travel health consultation. J Travel Med. 2017;24:1–4. intervention programs to enhance the knowledge regard- 7. Farnham A, Furrer R, Blanke U, Stone E, Hatz C, Puhan MA. The quantified ing travel medicine among health care providers. self during travel: mapping health in a prospective cohort of travellers. J Travel Med. 2017;24:1–8. 8. Grieve S, Steffen R. Epidemiology: Morbidity and Mortality in Travelers. In: Supplementary Information Keystone JS, Kozarsky PE, Connor BA, Nothdurft HD, Mendelson M, Leder The online version contains supplementary material available at https:// doi. K, editors. Travel Med. 4th ed. Elsevier; 2019. p. 3–14. org/ 10. 1186/ s40794- 022- 00170-w. 9. Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: Guidelines by the infectious diseases society of America. Clin Infect Dis. 2006;43:1499–539. Additional file 1. Questionnaire toEvaluate the Knowledge, Attitude and 10. CDC. CDC Yellow Book 2018: Health Information for International Travel. Practices Regarding Travel MedicineAmongst Physicians. Brunette GW, editor. United States: Oxford University Press; 2018. 11. Tessier D. Fitness to travel. In: Jane N Zuckerman, editor. Princ Pract Travel Med. 2nd ed. United Kingdom: John Wiley & Sons, Ltd; 2013. p. 27–36. Acknowledgements 12. Torresi J, McGuinness S, Leder K, O’Brien D, Ruff T, Starr M, et al. Manual of Authors are thankful to the experts who provided that ratings of the questions Travel Medicine. 4th ed. Singapore: Springer Nature Singapore; 2019. in terms of Necessity, Clarity and Relevance. K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 9 of 9 13. Kozarsky PE, Steffen R. Travel medicine education-what are the needs? J 35. Flaherty GT, Leong SW, Finn Y, Sulaiman LH, Noone C. Travellers with Travel Med. 2016;23:1–3. type 1 diabetes: Questionnaire development and descriptive analysis of 14. Shrotryia VK, Dhanda U. Content Validity of Assessment Instrument for knowledge and practices. J Travel Med. 2021;27:1–8. Employee Engagement. SAGE Open [Internet]. 2019;9:1–7. Available 36. Goesch JN, Simons De Fanti A, Béchet S, Consigny PH. Comparison of from: https://doi.org/10.1177/2158244018821751 knowledge on travel related health risks and their prevention among 15. Halek M, Holle D, Bartholomeyczik S. Development and evaluation of the humanitarian aid workers and other travellers consulting at the Institut content validity, practicability and feasibility of the Innovative dementia- Pasteur travel clinic in Paris France. Travel Med Infect Dis. 2010;8:364–72. oriented Assessment system for challenging behaviour in residents with 37. Ratnam I, Torresi J, Matchett E, Pollissard L, Luxemburg C, Lemoh CN, et al. dementia. BMC Health Serv Res. 2017;17(1):554. Development and validation of an instrument to assess the risk of devel- 16. Rodrigues IB, Adachi JD, Beattie KA, MacDermid JC. Development and oping viral infections in Australian travelers during international travel. J validation of a new tool to measure the facilitators, barriers and prefer- Travel Med. 2011;18:262–70. ences to exercise in people with osteoporosis. BMC Musculoskelet Disord. 38. Wilson ME. Geography of Infectious Diseases. In: Jonathan Cohen, William 2017;18:1–9. G. Powderly, Opal SM, editors. Infect Dis (Auckl). 4th ed. United States: 17. Polit DF, Beck CT. The content validity index: Are you sure you know Elsevier; 2017. p. 1055–64. what’s being reported? Critique and recommendations. Res Nurs Heal. 39. Wu X, Lu Y, Zhou S, Chen L, Xu B. Impact of climate change on human 2006;29:489–97. infectious diseases: Empirical evidence and human adaptation. Environ 18. Kovacic D. Using the Content Validity Index to Determine Content Valid- Int. 2016;86:14–23. ity of an Instrument Assessing Health Care Providers’ General Knowledge of Human Trafficking. J Hum Traffick. 2018;4:327–35. Available from: Publisher’s Note https:// doi. org/ 10. 1080/ 23322 705. 2017. 13649 05 (Routledge). Springer Nature remains neutral with regard to jurisdictional claims in pub- 19. Klein D. Implementing a general framework for assessing interrater lished maps and institutional affiliations. agreement in stata. Stata J. 2018;18:871–901. 20. de Raadt A, Warrens MJ, Bosker RJ, Kiers HAL. A Comparison of Reliability Coefficients for Ordinal Rating Scales. J Classif. 2021;1–25. Available from: https:// link. sprin ger. com/ artic le/ 10. 1007/ s00357- 021- 09386-5 . Springer; [cited 29 Jul 2021]. 21. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20:37–46. Available from: http:// epm. sagep ub. com 22. Wongpakaran N, Wongpakaran T, Wedding D, Gwet KL. A comparison of Cohen’s Kappa and Gwet’s AC1 when calculating inter-rater reliability coefficients: A study conducted with personality disorder samples. BMC Med Res Methodol. 2013;13:1–7. 23. Brennan RL, Prediger DJ. Coefficient kappa: Some uses, misuses, and alternatives. Educ Psychol Meas. 1981;41:687–99. 24. Gwet KL. Computing inter-rater reliability and its variance in the presence of high agreement. Br J Math Stat Psychol. 2008;61:29–48. 25. Gwet KL. Handbook of Inter-Rater Reliability: the definitive guide to meas- uring the extent of agreement among raters. 4th ed. 2014. Adv. Anal. 26. Solans-Domènech M, MV Pons J, Adam P, Grau J, Aymerich M. Develop- ment and validation of a questionnaire to measure research impact. Res Eval. 2019;28:253–62. 27. Tammaa A, Fritzer N, Lozano P, Krell A, Salzer H, Salama M, et al. Interobserver agreement and accuracy of non-invasive diagnosis of endometriosis by transvaginal sonography. Ultrasound Obstet Gynecol. 2015;46:737–40. 28. Buss I, Genton B, D’Acremont V. Aetiology of fever in returning travellers and migrants: A systematic review and meta-analysis. J Travel Med. 2020;27:1–12. 29. Angelo KM, Kozarsky PE, Ryan ET, Chen LH, Sotir MJ. What proportion of international travellers acquire a travel-related illness? A review of the literature. J Travel Med. 2017;24:1–8. 30. Liu W, Hu W, Dong Z, You X. Travel-related infection in Guangzhou, China, 2009–2019. Travel Med Infect Dis. 2021;43:102106 (Elsevier Ltd). Available from: https:// doi. org/ 10. 1016/j. tmaid. 2021. 102106 31. Pavli A, Lymperi I, Katerelos P, Maltezou HC. Knowledge and practice of malaria prophylaxis among travel medicine consultants in Greece. Travel Med Infect Dis. 2012;10:224–9. Elsevier Ltd Available from: http:// dx. doi. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : org/ 10. 1016/j. tmaid. 2012. 09. 006 32. Namikawa K, Kikuchi H, Kato S, Takizawa Y, Konta A, Iida T, et al. Knowl- fast, convenient online submission edge, attitudes, and practices of Japanese travelers towards malaria thorough peer review by experienced researchers in your field prevention during overseas travel. Travel Med Infect Dis. 2008;6:137–41. 33. Al-Abri SS, Abdel-Hady DM, Al-Abaidani IS. Knowledge, attitudes, and rapid publication on acceptance practices regarding travel health among Muscat International Airport support for research data, including large and complex data types travelers in Oman: Identifying the gaps and addressing the challenges. J • gold Open Access which fosters wider collaboration and increased citations Epidemiol Glob Health. 2016;6:67–75. Available from: https:// doi. org/ 10. 1016/j. jegh. 2016. 02. 003 (Ministry of Health, Saudi Arabia). maximum visibility for your research: over 100M website views per year 34. Della Polla G, Pelullo CP, Napolitano F, Lambiase C, De Simone C, Angelillo IF. Knowledge, attitudes, and practices towards infectious diseases related At BMC, research is always in progress. to travel of community pharmacists in italy. Int J Environ Res Public Learn more biomedcentral.com/submissions Health. 2020;17(6):2147. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png "Tropical Diseases, Travel Medicine and Vaccines" Springer Journals

Development and validation of a questionnaire to evaluate the knowledge, attitude and practices regarding travel medicine amongst physicians in an apex tertiary hospital in Northern India

Loading next page...
 
/lp/springer-journals/development-and-validation-of-a-questionnaire-to-evaluate-the-n4tmq5P83o

References (44)

Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2022
eISSN
2055-0936
DOI
10.1186/s40794-022-00170-w
Publisher site
See Article on Publisher Site

Abstract

Objectives: Travel medicine focuses primarily on pre-travel preventive care and the conditions and diseases acquired during or after travel. There is a paucity of validated tools to assess the knowledge, attitude and practises of physicians with regard to travel medicine. We attempted to develop a tool to assess existing expertise among Medicine and Infectious Diseases resident doctors with respect to travel medicine. Methods: Item level content validity index (I-CVI) and scale level content validity index (S-CVI/Ave) were estimated for each of the items to establish the content validity. Refined measures of inter-rater agreement (Brennan and Predi- ger Agreement Coefficient and Gwet’s Agreement Coefficient) were estimated for the tool. Results: The final version of the questionnaire had satisfactory content validity (I-CVI > 0∙6 and S-CVI/Ave > 0∙9) and possessed high agreement among the raters (Brennan and Prediger AC > 0∙7, p < 0∙01 and Gwet’s AC > 0∙8, p < 0∙01) with regard to necessity, clarity and relevance of the scale. Conclusions: This tool covers a wide range of questions and is scientifically validated. The final version of the tool can be used largely for the assessment of knowledge, attitude and practices among medical practitioners. This is instru- mental to build targeted intervention programs to enhance the knowledge regarding travel medicine among health care providers. Keywords: Travel Medicine, Knowledge, Practice, Questionnaire, Development, Validation care system should be geographically inclusive and not be Introduction confined to a region or a country because a pandemic like After a long gap of the Spanish flu pandemic, the emer - this has no boundaries. Travel medicine globalizes health gence of COVID-19 has taught many lessons to human- care in terms of providing preventive and curative health ity. One of the key message is to realize the importance across boundaries. of public health from a global perspective. The health Travel medicine or emporiatrics is the field of medi- cine which is concerned with the promotion and *Correspondence: linktoarvind@gmail.com protection of health of travellers. It aims to prevent Department of Medicine, AIIMS, New Delhi, India diseases and other adverse health outcomes among Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 2 of 9 international travellers. It requires up-to-date informa- Material and methods tion on the global epidemiology of the non-infectious Development and validation of the travel medicine and infectious health risks, health regulations and vac- questionnaire cination necessities in various countries along with the Step I: Conceptualization and identification of domains emerging patterns of medication-resistant infections and sub‑domains for the travel medicine knowledge, attitude [1]. As international travel becomes more accessible, and practices assessment tool knowledge of this field is likely to become essential For conceptualizing and identification of domains and for a physician [2, 3]. Although derived from the tradi- sub-domains to develop the initial pool of items, multi- tional medicine disciplines, this branch of medicine is ple round table discussions and focus group discussions a newly emerging field given the increasing number of (FGDs) were held among experts from different fields of international travellers and reporting of various infec- medicine, infectious diseases and travel medicine from tious and non-infectious diseases [4], injuries [5] and five tertiary care centers in different parts of India. This other health risks among international travellers [6–8]. included subject experts with certifications in travel Since travel medicine is a new discipline, expert opin- medicine from the International Society of Travel Medi- ion and experience still dominate many areas in this cine (ISTM) and physicians currently practicing in travel branch, highlighting the need for continuous investi- clinics across the country (Fig. 1). gation in the field [9]. International travellers are at higher risk of devel- Step II: Literature review to identify domains oping various health threats, which depend on both and sub‑domains and generating preliminary item pool the health needs of the traveller and on the type of for the tool travel to be undertaken. The traveller’s triad includes An extensive literature review was carried out to ana- the three major components that influence the risk lyse the existing evidence on travel medicine. The litera - associated with a specific travel plan i.e. place, time ture search aimed to identify domains and sub-domains and person. The region of the world being visited required to develop the travel medicine KAP assessment determines the altitude, humidity, temperature and tool. We used the standard textbooks, journals, and inter- infection profile etc. The travellers’ vulnerability to net databases for the identification of relevant concepts. these exposures may be determined by their age, gen- The internet search engines used were Google Scholar, eral well-being, the trip’s length, and the diversity of PubMed, Scopus and JSTOR using the keywords string: planned activities [10]. Pre-travel health education, (Travel Medicine) AND (Knowledge) AND (Attitude) vaccination and prophylactic drugs may serve to miti- AND (Practices) published in or after year 2000. Table  1 gate these risks [10–12]. shows the details of some of the sources used to identify With rapidly evolving travel regulations, there is a the domains and sub-domains and to generate a prelimi- need to provide training to practicing physicians to nary item pool for our travel medicine tool. predict travel-associated health risks and recognise untoward exposures. As travel medicine gains promi- Step‑III: Developing the structure of the questionnaire nence worldwide, we recognise the dearth of ade- through expert review quately trained field experts. In the absence of subject The initial pool of 157 questions was again reviewed by specialists, general physicians must be provided formal the experts, and the number of items was reduced to 143. training to ensure adequate care [13]. In this regard, This set of identified items was organized into the form of an assessment of the existing knowledge among health a questionnaire. The questionnaire was constructed in a care practitioners is necessary to develop interventions simple and lucid language, and the flow of the questions for targeting gaps in knowledge. was maintained, keeping in mind the purpose of assess- With this objective in mind, an attempt was made at ment of KAP. our tertiary care facility to develop a comprehensive tool covering major aspects of travel medicine. Cur- Step‑IV: Establishing face and content validity and estimation rently, no widely disseminated, valid instrument for of agreement coefficients assessing travel medicine’s knowledge, attitude, and Face validity is the lowest level of validity and repre- practices is available in India. This tool assesses the sents the assumption of an expert and acceptance that a knowledge, attitude and practices (KAP) regarding test represents the domain being assessed. After prepar- travel medicine in the form of a questionnaire. We also ing the first draft, the questionnaire was reviewed by the attempted to validate this tool in primary care physi- experts in the field for face validity (by assessing for read - cians, internist, infectious disease specialists, and other ability, comprehensibility, feasibility, completeness and health care providers. layout and style). K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 3 of 9 Fig. 1 Flow chart of the development and validity of the travel medicine tool The purpose of content validation is to reduce the bias question relevant as far as branch of travel medicine is associated with the operationalization of the instrument concerned with respect to knowledge/attitude/prac- in the initial stages [14]. To establish the content validity tice?). Each question was evaluated by the experts for of the travel medicine tool, we chose three components these components separately. The rating protocol was to judge the overall content validity. Studies estimate the designed into the form of a Likert scale as- content validity indices with a single validity parameter. However, a few studies adopted a different approach and 1) Necessity (N): Each item was rated as: 1 (neither decomposed the overall validity into its components [15, useful nor necessary), 2 (useful but not necessary) and 16]. We adopted this technique and judged the over- 3 (essential). all content validity in terms of—Necessity (Is the ques- 2) Clarity (C): Rate each item as 1(not clear), tion necessary to be asked to the resident to assess their 2(slightly clear/needs major revision), 3 (clear/ knowledge/attitude/practices of travel medicine?), Clar- needs minor revision), 4 (very clear). ity (Is the question wording/structure/options given convey the meaning effectively?) and Relevance (Is the Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 4 of 9 Table 1 List of various books/journals used to identify the domains and sub-domains and to develop the preliminary pool of items for travel medicine tool Name of the Journal/Book Name of the author(s)/editor(s) Name of the Publisher Publication year/reference period 1.Principles and Practice of Travel Medicine Jane N. Zuckerman John Wiley & Sons 2013 2.Travel Medicine Jay S. Keystone Elsevier 2019 Phyllis E. Kozarsky Bradley A. Connor Hans D. Nothdurft Marc Mendelson Karin Leder 3.Manual of Travel Medicine Joseph Torresi Springer 2019 Sarah McGuinness Karin Leder Daniel O’Brien Tilman Ruff Mike Starr Katherine Gibney 4.CDC Health Information for International Gary W. Brunette Oxford University Press 2018 Travel 2018. The Yellow Book 5.Manual of Travel Medicine and Health Robert Steffen BC Decker Inc 2003 Herbert L. DuPont Annelies Wilder-Smith 6.Journal of Travel Medicine Annelies Wilder-Smith Oxford University Press 2000 or later 7.Travel Medicine and Infectious Disease Patricia Schlagenhauf-Lawlor Elsevier 2000 or later 8.International Travel and Health Gilles Poumerol World Health Organization ( WHO) 2012 Annelies Wilder-Smith 3) Relevance (R): Each item was rated as: 1 (not rel- Likewise, for clarity and relevance the dichotomous vari- evant), 2 (slightly relevant/needs major revision), 3 ables were generated as ‘1’ for experts giving a rating of (relevant/needs minor revision), 4 (very relevant). 3 or 4 and ‘0’ otherwise. These dichotomous variables were then used to estimate the content validity indices The idea behind decomposing the overall quality judge - (I-CVI and S-CVI/Ave) for each of these characteristics. ment into its components (N, C and R) was to give more The item-level CVI (I-CVI) is computed by dividing the freedom to the experts to judge and to provide more total number of ‘1’s by the total number of experts [17, strength to the validation process. Furthermore, we also 18]. The S-CVI/Ave is then calculated by averaging the looked for any lack of consistency between experts for I-CVIs estimated for each item of the instrument. This travel medicine questionnaire in terms of three above exercise was repeated for each of the parameters of con- mentioned parameters. tent validity (necessity, clarity and relevance). Polit and Beck [17] recommended an S-CVI/Ave of 0∙90 or above Measures as excellent. We chose several measures of inter-rater agreement as well as indices of validity to validate the travel medicine Agreement Coefficients (AC) tool. The most popular method of quantification of inter- rater agreement among researchers has been the Cohen’s Content validity indices (CVI) Kappa [19–22]. Recent published literature discussed the Two indices have been proposed by researchers for judge- limitations of kappa statistic and proposed other meas- ment of content validity of a tool. This includes-item level ures of inter-rater agreement [19, 22]. Klein [19] has content validity index (I-CVI) and scale level content pointed out the limitations of Cohen’s Kappa and sug- validity index (S-CVI)[17]. The eight experts rated each gested that the Brennan and Prediger [23] coefficient and of the item in terms of N, C and R as mentioned above. Gwet’s [24, 25] agreement coefficient arguably represent In the next step, these scores were dichotomized. For the data more accurately. Further, he suggested that these necessity, the dichotomous variable was categorized as two agreement measures are found to be more robust ‘1’ if the item was rated as ‘3’ (essential) or ‘0’ otherwise. than any other measure of inter rater agreement [19]. K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 5 of 9 Similarly, Wongpakaran [22] found Gwet’s AC to pro- 28–30] and also pointed out the inadequacies in KAP vide a more stable inter-rater reliability coefficient than in both health providers as well as the travellers [31– Cohen’s Kappa and recommended to use for inter-rater 34]. In order to build any specific intervention program reliability analysis. A more detailed discussion on each of to increase knowledge regarding travel medicine in the agreement coefficients may be found elsewhere [19, healthcare practitioners, it becomes necessary to assess 22, 25]. In our study, we estimated these agreement coef- the existing knowledge of the health providers. ficients along with the percent agreement for each of the Earlier KAP studies in travel medicine are either dis- three above mentioned components. ease-specific [31, 35] or conducted amongst travellers [32, 33, 35, 36]. None of these studies have elucidated on the development process of their tools, and valida- Results tion data on the same is often missing. Very few stud- Content validity indices ies have been published which attempted to develop Table 1 shows the I-CVIs and S-CVI/Ave for each of the and validate the questionnaire regarding travel medi- component of content validity. Polit and Beck recom- cine among medical practitioners. Ratnam et.al. devel- mended an I-CVI ≥ 0∙78 for inclusion of an item [17]. oped and validated a questionnaire to assess the risk of But, we adopted a less strict cut-off of I-CVI < 0∙60 for developing viral infections in Australian Travellers [37]. deletion of the items from the pool [26]. We removed the The study covers only a particular domain (viral infec - items which had an I-CVI < 0∙6. The I-CVIs for neces - tions) of travel related problems among travellers and sity ranged from 0∙625 to 1∙000. Six items had a necessity does not establish the content validity through estima- I-CVI of 0∙625 whereas five items had 0∙750. Rest of the tion of content validity indices (I-CVI and S-CVI). items had an I-CVI ≥ 0∙78 where out of total 106 items The major strength of this study is the develop - 85 items had an I-CVI of 1∙000. This reflects satisfac - ment and validation of a travel medicine tool, which tory ranges for necessity in terms of I-CVIs. For clarity, will enable the researchers to assess the KAP among we observed a slightly better I-CVIs which ranged from health care providers. The content collection through 0∙875 to 1∙000 with six items having an I-CVI of 0∙875 and thorough literature review as well as several rounds rest of the items had 1∙000. Likewise, for relevance the of discussion with the experts ensured the quality and I-CVIs ranged from 0∙625 to 1∙000 where four items had coverage. Further, the establishment of content valid- an I-CVI of 0∙625. The overall scale level content valid - ity through expert evaluation and measures of con- ity index (S-CVI/Ave) was observed to be above 0∙900 for tent validity and agreement coefficients made the tool each of the dimension of content validation. robust and scientifically validated. The final set of 106 questions had satisfactory content validity indices Agreement among the experts (I-CVI > 0∙6 and S-CVI/Ave > 0∙9). The agreement coef - The final version of questionnaire had 106 items after ficients (Brennan and Prediger AC > 0∙7, p < 0∙01 and removal of items with an I-CVI < 0∙6 (Supplementary Gwet’s AC > 0∙8, p < 0∙01) among the raters with regard Table  1). For the remaining items, we estimated agree- to necessity, clarity and relevance of the travel medicine ment indicators. The results of these agreement indica - KAP assessment tool were observed to be high. tors with regard to the three dimensions of overall quality This study is not free from limitations. The experts of the tool has been depicted in Table  2. We observed chosen for reviewing the travel medicine tool are from a high and statistically significant percentage agree - internal medicine, infectious disease programme and ment among experts with regard to the overall validity allied branches who are involved in operating clinics of of the travel medicine tool. For each of the dimensions, travel medicine since dedicated travel medicine branch the overall percent agreement among the experts was is yet to evolve in India. One who has completed a above 90 percent. The cut-offs of agreement according certificate course in Travel Health from International to Gwet’s AC as categorized by Tammaa [27] is as fol- Society of Travel Medicine (ISTM) was actively involve lows: < 0∙2 = poor; 0∙21–0∙4 = fair; 0∙41–0∙6 = moderate; as an expert. Although, we have taken utmost care to 0∙61–0∙8 = substantial; and 0∙81–1∙0 = almost perfect. cover every aspect of travel medicine, since it is a vast For each of the dimensions, we observed Gwet’s AC > 0∙8 discipline there is always a prospect of modification showing high levels of agreement among raters (Table 3). and improvement of this tool. Due to limited resources available for the study, only experts from India were Discussion involved to review the travel medicine KAP tool. How- With the increasing number of international travellers, ever, AIIMS, New Delhi being an apex health care travel medicine has gained new significance. Studies center of India has specialists from all clinical domains have highlighted that the prevalence of travel related of human health. Therefore, their expertise was used problems is surprisingly high among the travellers [7, Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 6 of 9 Table 2 Item level content validity index (I-CVI) for each item and scale level content validity index for travel medicine questionnaire I-CVI I-CVI I-CVI Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) 1 1∙000 1∙000 1∙000 41 1∙000 1∙000 1∙000 81 1∙000 1∙000 0∙875 2 1∙000 1∙000 1∙000 42 1∙000 1∙000 1∙000 82 1∙000 0∙875 1∙000 3 0∙625 1∙000 0∙625 43 1∙000 1∙000 1∙000 83 0∙875 0∙875 1∙000 4 0∙875 1∙000 1∙000 44 1∙000 1∙000 1∙000 84 1∙000 1∙000 1∙000 5 1∙000 1∙000 1∙000 45 1∙000 1∙000 1∙000 85 1∙000 1∙000 1∙000 6 1∙000 1∙000 1∙000 46 1∙000 1∙000 1∙000 86 1∙000 1∙000 1∙000 7 1∙000 1∙000 1∙000 47 0∙625 1∙000 0∙625 87 1∙000 1∙000 1∙000 8 0∙875 1∙000 1∙000 48 1∙000 1∙000 1∙000 88 1∙000 1∙000 1∙000 9 1∙000 1∙000 1∙000 49 1∙000 1∙000 1∙000 89 1∙000 1∙000 1∙000 10 1∙000 1∙000 1∙000 50 0∙625 0∙875 0∙750 90 1∙000 1∙000 1∙000 11 1∙000 1∙000 1∙000 51 0∙875 0∙875 1∙000 91 0∙750 1∙000 0∙625 12 1∙000 1∙000 1∙000 52 0∙875 1∙000 1∙000 92 1∙000 1∙000 1∙000 13 1∙000 1∙000 1∙000 53 1∙000 1∙000 1∙000 93 1∙000 1∙000 1∙000 14 1∙000 1∙000 1∙000 54 1∙000 1∙000 1∙000 94 1∙000 1∙000 1∙000 15 1∙000 1∙000 1∙000 55 0∙875 1∙000 0∙875 95 1∙000 1∙000 1∙000 16 1∙000 1∙000 1∙000 56 1∙000 1∙000 1∙000 96 1∙000 1∙000 1∙000 17 0∙625 1∙000 0∙875 57 1∙000 1∙000 1∙000 97 1∙000 1∙000 1∙000 18 1∙000 1∙000 1∙000 58 1∙000 1∙000 1∙000 98 1∙000 1∙000 1∙000 19 1∙000 1∙000 1∙000 59 1∙000 1∙000 1∙000 99 1∙000 1∙000 1∙000 20 1∙000 1∙000 1∙000 60 1∙000 1∙000 1∙000 100 1∙000 1∙000 1∙000 21 1∙000 1∙000 1∙000 61 1∙000 1∙000 1∙000 101 1∙000 1∙000 1∙000 22 1∙000 1∙000 1∙000 62 1∙000 1∙000 1∙000 102 1∙000 1∙000 1∙000 23 1∙000 1∙000 1∙000 63 1∙000 1∙000 1∙000 103 1∙000 1∙000 1∙000 24 0∙875 1∙000 1∙000 64 1∙000 1∙000 1∙000 104 1∙000 1∙000 1∙000 25 0∙875 1∙000 0∙875 65 1∙000 0∙875 1∙000 105 1∙000 1∙000 1∙000 26 0∙750 1∙000 0∙625 66 1∙000 1∙000 1∙000 106 1∙000 1∙000 1∙000 27 0∙750 1∙000 0∙750 67 1∙000 1∙000 1∙000 S-CVI/Ave 0∙955 0∙994 0∙968 28 1∙000 1∙000 1∙000 68 1∙000 1∙000 1∙000 29 1∙000 1∙000 1∙000 69 1∙000 1∙000 1∙000 30 1∙000 1∙000 1∙000 70 0∙750 1∙000 0∙875 31 1∙000 1∙000 1∙000 71 1∙000 1∙000 1∙000 32 1∙000 1∙000 1∙000 72 1∙000 1∙000 1∙000 33 0∙875 1∙000 1∙000 73 0∙625 1∙000 0∙750 34 1∙000 1∙000 1∙000 74 0∙875 1∙000 0∙750 K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 7 of 9 Table 2 (continued) I-CVI I-CVI I-CVI Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) Item no∙ Necessity (N) Clarity (C) Relevance (R) 35 1∙000 1∙000 1∙000 75 0∙750 1∙000 1∙000 36 1∙000 1∙000 1∙000 76 1∙000 1∙000 1∙000 37 1∙000 1∙000 1∙000 77 0∙875 0∙875 0∙875 38 1∙000 1∙000 1∙000 78 1∙000 1∙000 1∙000 39 0∙625 1∙000 0∙875 79 1∙000 1∙000 1∙000 40 1∙000 1∙000 1∙000 80 1∙000 1∙000 1∙000 Kumar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 8 of 9 Authors’ contributions Table 3 Details of agreement among experts for travel medicine AK- Conceptualization, development of tool, finalization of draft; AR-Devel- tool with regard to necessity, clarity and relevance opment of tool, data collection and analysis; MU- Review of literature, data analysis, drafting of manuscript, editing of manuscript; JA-Conceptualization Indicator Necessity Clarity Relevance and development of tool; SS, AM and UB-Development of tool and review of literature; PR and PG-Review of literature, editing of final draft NW- Overall % Agreement 96∙8*** 91∙4*** 90∙8*** supervision and editing of final draft. The author(s) read and approved the Brennan and Prediger AC 0∙9148*** 0∙7258*** 0∙7042*** final manuscript. Gwet’s AC 0∙9656*** 0∙8445*** 0∙8336*** Funding *** p < 0∙01 This research work has not received any funding from any of the funding sources. for the development of initial pool of items and revised Availability of data and materials version of the tool. The dataset supporting the conclusions of this article is available by taking prior approval of the corresponding author. The patterns of infectious diseases vary by geo - graphic region and population [38] and differences Declarations in the climate of various regions also impact the pat- terns of infectious diseases [39] and therefore require Ethics approval and consent to participate special attention by health care providers. We sug- Study was ethically approved by All India Institute of Medical Sciences (AIIMS) research ethics committee (Ref. No.: IECPG-326/22.07.2020, RT-34/26.08.2020). gest that the definition of travel medicine should be This study has not been conducted on human participants, and therefore con- expanded in such a way that it covers the health prob- sent to participate do not apply. lems of domestic travellers and repatriates, to prevent Consent for publication the spread of infectious diseases especially various Not applicable. kinds of respiratory tract infections (RTIs) which may be highly contagious and can give rise to a pandemic. Competing interests The authors declare that they have no competing interests. So, comprehensive attempts should be made to make the definition more exhaustive and the possible inclu - Author details 1 2 sion of this aspect should be the point of consideration Department of Medicine, AIIMS, New Delhi, India. Infectious Diseases & Travel Health Specialist, Indraprastha Apollo Hospital, New Delhi, India. in future. Received: 16 February 2022 Accepted: 4 May 2022 Conclusions The pre-travel consultation has become a necessary part of the travellers’ checklist. Considering this issue, present References 1. Aw B, Boraston S, Botten D, Cherniwchan D, Fazal H, Kelton T, et al. study is a significant contribution in the field of travel Travel medicine: What’s involved? When to refer? Can Fam Physician. medicine and provides the basis for the assessment of the 2014;60:1091–103. knowledge, attitude and practices among medical prac- 2. Treadwell TL. Trends in travel. In: Zuckerman JN, editor. Princ Pract Travel Med. 2nd ed. United Kingdom: John Wiley & Sons, Ltd; 2013. p. 3–4. titioners so that adequate intervention programs may 3. Kozarsky PE, Keystone JS. Introduction to Travel Medicine. In: Keystone JS, be developed to enhance the knowledge of travel medi- Kozarsky PE, Bradley A. Connor, Hans D. Nothdurft, Mendelson M, Leder K, cine among health care providers. This tool covers a wide editors. Travel Med. 4th ed. United States: Elsevier; 2019. p. 1–2. 4. Torresi J, McGuinness S, Leder K, O’Brien D, Ruff T, Starr M, et al. Non- range of questions and is scientifically validated. The final infectious Problems. Man Travel Med. 4th ed. Singapore; 2019. p. 265–96. version of the tool can be used globally for the assess- 5. WHO. Injuries and violence. In: Poumerol G, Wilder-Smith A, editors. Int ment of knowledge, attitude and practices among medi- Travel Heal. 1st ed. Switzerland: World Health Organization; 2012. p. 51–3. 6. Flaherty GT, Chen B, Avalos G. Individual traveller health priorities and the cal practitioners. This is instrumental to build targeted pre-travel health consultation. J Travel Med. 2017;24:1–4. intervention programs to enhance the knowledge regard- 7. Farnham A, Furrer R, Blanke U, Stone E, Hatz C, Puhan MA. The quantified ing travel medicine among health care providers. self during travel: mapping health in a prospective cohort of travellers. J Travel Med. 2017;24:1–8. 8. Grieve S, Steffen R. Epidemiology: Morbidity and Mortality in Travelers. In: Supplementary Information Keystone JS, Kozarsky PE, Connor BA, Nothdurft HD, Mendelson M, Leder The online version contains supplementary material available at https:// doi. K, editors. Travel Med. 4th ed. Elsevier; 2019. p. 3–14. org/ 10. 1186/ s40794- 022- 00170-w. 9. Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: Guidelines by the infectious diseases society of America. Clin Infect Dis. 2006;43:1499–539. Additional file 1. Questionnaire toEvaluate the Knowledge, Attitude and 10. CDC. CDC Yellow Book 2018: Health Information for International Travel. Practices Regarding Travel MedicineAmongst Physicians. Brunette GW, editor. United States: Oxford University Press; 2018. 11. Tessier D. Fitness to travel. In: Jane N Zuckerman, editor. Princ Pract Travel Med. 2nd ed. United Kingdom: John Wiley & Sons, Ltd; 2013. p. 27–36. Acknowledgements 12. Torresi J, McGuinness S, Leder K, O’Brien D, Ruff T, Starr M, et al. Manual of Authors are thankful to the experts who provided that ratings of the questions Travel Medicine. 4th ed. Singapore: Springer Nature Singapore; 2019. in terms of Necessity, Clarity and Relevance. K umar et al. Tropical Diseases, Travel Medicine and Vaccines (2022) 8:13 Page 9 of 9 13. Kozarsky PE, Steffen R. Travel medicine education-what are the needs? J 35. Flaherty GT, Leong SW, Finn Y, Sulaiman LH, Noone C. Travellers with Travel Med. 2016;23:1–3. type 1 diabetes: Questionnaire development and descriptive analysis of 14. Shrotryia VK, Dhanda U. Content Validity of Assessment Instrument for knowledge and practices. J Travel Med. 2021;27:1–8. Employee Engagement. SAGE Open [Internet]. 2019;9:1–7. Available 36. Goesch JN, Simons De Fanti A, Béchet S, Consigny PH. Comparison of from: https://doi.org/10.1177/2158244018821751 knowledge on travel related health risks and their prevention among 15. Halek M, Holle D, Bartholomeyczik S. Development and evaluation of the humanitarian aid workers and other travellers consulting at the Institut content validity, practicability and feasibility of the Innovative dementia- Pasteur travel clinic in Paris France. Travel Med Infect Dis. 2010;8:364–72. oriented Assessment system for challenging behaviour in residents with 37. Ratnam I, Torresi J, Matchett E, Pollissard L, Luxemburg C, Lemoh CN, et al. dementia. BMC Health Serv Res. 2017;17(1):554. Development and validation of an instrument to assess the risk of devel- 16. Rodrigues IB, Adachi JD, Beattie KA, MacDermid JC. Development and oping viral infections in Australian travelers during international travel. J validation of a new tool to measure the facilitators, barriers and prefer- Travel Med. 2011;18:262–70. ences to exercise in people with osteoporosis. BMC Musculoskelet Disord. 38. Wilson ME. Geography of Infectious Diseases. In: Jonathan Cohen, William 2017;18:1–9. G. Powderly, Opal SM, editors. Infect Dis (Auckl). 4th ed. United States: 17. Polit DF, Beck CT. The content validity index: Are you sure you know Elsevier; 2017. p. 1055–64. what’s being reported? Critique and recommendations. Res Nurs Heal. 39. Wu X, Lu Y, Zhou S, Chen L, Xu B. Impact of climate change on human 2006;29:489–97. infectious diseases: Empirical evidence and human adaptation. Environ 18. Kovacic D. Using the Content Validity Index to Determine Content Valid- Int. 2016;86:14–23. ity of an Instrument Assessing Health Care Providers’ General Knowledge of Human Trafficking. J Hum Traffick. 2018;4:327–35. Available from: Publisher’s Note https:// doi. org/ 10. 1080/ 23322 705. 2017. 13649 05 (Routledge). Springer Nature remains neutral with regard to jurisdictional claims in pub- 19. Klein D. Implementing a general framework for assessing interrater lished maps and institutional affiliations. agreement in stata. Stata J. 2018;18:871–901. 20. de Raadt A, Warrens MJ, Bosker RJ, Kiers HAL. A Comparison of Reliability Coefficients for Ordinal Rating Scales. J Classif. 2021;1–25. Available from: https:// link. sprin ger. com/ artic le/ 10. 1007/ s00357- 021- 09386-5 . Springer; [cited 29 Jul 2021]. 21. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20:37–46. Available from: http:// epm. sagep ub. com 22. Wongpakaran N, Wongpakaran T, Wedding D, Gwet KL. A comparison of Cohen’s Kappa and Gwet’s AC1 when calculating inter-rater reliability coefficients: A study conducted with personality disorder samples. BMC Med Res Methodol. 2013;13:1–7. 23. Brennan RL, Prediger DJ. Coefficient kappa: Some uses, misuses, and alternatives. Educ Psychol Meas. 1981;41:687–99. 24. Gwet KL. Computing inter-rater reliability and its variance in the presence of high agreement. Br J Math Stat Psychol. 2008;61:29–48. 25. Gwet KL. Handbook of Inter-Rater Reliability: the definitive guide to meas- uring the extent of agreement among raters. 4th ed. 2014. Adv. Anal. 26. Solans-Domènech M, MV Pons J, Adam P, Grau J, Aymerich M. Develop- ment and validation of a questionnaire to measure research impact. Res Eval. 2019;28:253–62. 27. Tammaa A, Fritzer N, Lozano P, Krell A, Salzer H, Salama M, et al. Interobserver agreement and accuracy of non-invasive diagnosis of endometriosis by transvaginal sonography. Ultrasound Obstet Gynecol. 2015;46:737–40. 28. Buss I, Genton B, D’Acremont V. Aetiology of fever in returning travellers and migrants: A systematic review and meta-analysis. J Travel Med. 2020;27:1–12. 29. Angelo KM, Kozarsky PE, Ryan ET, Chen LH, Sotir MJ. What proportion of international travellers acquire a travel-related illness? A review of the literature. J Travel Med. 2017;24:1–8. 30. Liu W, Hu W, Dong Z, You X. Travel-related infection in Guangzhou, China, 2009–2019. Travel Med Infect Dis. 2021;43:102106 (Elsevier Ltd). Available from: https:// doi. org/ 10. 1016/j. tmaid. 2021. 102106 31. Pavli A, Lymperi I, Katerelos P, Maltezou HC. Knowledge and practice of malaria prophylaxis among travel medicine consultants in Greece. Travel Med Infect Dis. 2012;10:224–9. Elsevier Ltd Available from: http:// dx. doi. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : org/ 10. 1016/j. tmaid. 2012. 09. 006 32. Namikawa K, Kikuchi H, Kato S, Takizawa Y, Konta A, Iida T, et al. Knowl- fast, convenient online submission edge, attitudes, and practices of Japanese travelers towards malaria thorough peer review by experienced researchers in your field prevention during overseas travel. Travel Med Infect Dis. 2008;6:137–41. 33. Al-Abri SS, Abdel-Hady DM, Al-Abaidani IS. Knowledge, attitudes, and rapid publication on acceptance practices regarding travel health among Muscat International Airport support for research data, including large and complex data types travelers in Oman: Identifying the gaps and addressing the challenges. J • gold Open Access which fosters wider collaboration and increased citations Epidemiol Glob Health. 2016;6:67–75. Available from: https:// doi. org/ 10. 1016/j. jegh. 2016. 02. 003 (Ministry of Health, Saudi Arabia). maximum visibility for your research: over 100M website views per year 34. Della Polla G, Pelullo CP, Napolitano F, Lambiase C, De Simone C, Angelillo IF. Knowledge, attitudes, and practices towards infectious diseases related At BMC, research is always in progress. to travel of community pharmacists in italy. Int J Environ Res Public Learn more biomedcentral.com/submissions Health. 2020;17(6):2147.

Journal

"Tropical Diseases, Travel Medicine and Vaccines"Springer Journals

Published: Jun 1, 2022

Keywords: Travel Medicine; Knowledge; Practice; Questionnaire; Development; Validation

There are no references for this article.