HomeAboutusEditorial BoardCurrent issuearchivesSearch articlesInstructions for authorsSubscription detailsAdvertise

  Login  | Users online: 2497

   Ahead of print articles    Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size  

 Table of Contents    
Year : 2020  |  Volume : 45  |  Issue : 4  |  Page : 458-462

Development and validation of a tool to assess perceptions and practices regarding hypertension and associated comorbidities among primary health care providers of a rural community in India

1 Department of Community Medicine, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India
2 ID and Beliaghata Hospital, Kolkata, West Bengal, India

Date of Submission29-Nov-2019
Date of Acceptance25-Jun-2020
Date of Web Publication28-Oct-2020

Correspondence Address:
Dr. Indira Dey
A, Kali Kumar Banerjee Lane, Kolkata - 700 002, West Bengal
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcm.IJCM_490_19

Rights and Permissions



Background: Primary health-care providers can play a crucial role in the prevention and early detection of non-communicable diseases. Knowledge, attitude, and practice (KAP) survey of primary health-care providers is needed to assess their gaps in knowledge, and identify barriers for effective implementation of the national program. However, such KAP instruments are lacking. Objective: The aim of this study is to develop, validate and assess the reliability of a questionnaire to determine the KAPs of primary health-care providers about hypertension and associated comorbidities Materials and Methods: This study was conducted in the following steps: item construction and psychometric testing, by validity and reliability analysis. Results: The final KAP questionnaire comprised 25 knowledge items, 12 attitude items, and 8 practice items. Exploratory factor analysis using principal axis factoring with varimax rotation revealed four dimensions in the attitude section explaining 35.93% and two dimensions in practice sections explaining 65.96% of the total variance. Cronbach's alpha coefficient for attitude and practice session measured 0.65 and 0.85, respectively. A Kuder Richardson value of 0.70 was obtained for the knowledge section. ICC coefficients were 0.56 (P < 0.00) for knowledge, 0.77 (P < 0.00) for attitude and 0.88 (P < 0.00) for practice sections indicating moderate-to-good correlations. Overall, the instrument developed had acceptable validity and reliability. Conclusion: Overall, the instrument developed had acceptable validity and reliability to assess the perceptions and practices of primary healthcare providers about prevention and control of hypertension and associated comorbidities in the community.

Keywords: Hypertension, primary health care providers, questionnaire, validation

How to cite this article:
Mukhopadhyay P, Dey I, Haldar A. Development and validation of a tool to assess perceptions and practices regarding hypertension and associated comorbidities among primary health care providers of a rural community in India. Indian J Community Med 2020;45:458-62

How to cite this URL:
Mukhopadhyay P, Dey I, Haldar A. Development and validation of a tool to assess perceptions and practices regarding hypertension and associated comorbidities among primary health care providers of a rural community in India. Indian J Community Med [serial online] 2020 [cited 2022 May 21];45:458-62. Available from: https://www.ijcm.org.in/text.asp?2020/45/4/458/299437

   Introduction Top

Rising levels of obesity and unhealthy lifestyle choices with South Asian ethnicity, has resulted in an alarming rise in noncommunicable diseases (NCDs).[1],[2],[3],[4] Cardiovascular diseases and diabetes together comprise one-fourth of all leading causes of mortality in India.[5],[6] The majority remain undetected in the community despite the availability of effective preventive and therapeutic measures. Lack of resources and personnel make their detection an even bigger challenge.[7],[8] Primary health-care providers working at the grassroots level can play an important role in their prevention and early detection after adequate training.[8],[9],[10],[11],[12],[13]

The ongoing National Programme (NPCDCS) to prevent and control NCDs is still in its early stages. Knowledge, attitude, and practice (KAP) survey of primary health-care providers who form the backbone of this program are useful to identify gaps in knowledge, their needs, problems, and barriers. However, there is a lack of such validated and reliable KAP instruments. This study aims to develop and validate a questionnaire used to determine the knowledge and attitude of primary health-care providers about hypertension and associated comorbidities and to assess their practices toward its prevention and control in the community.

   Materials and Methods Top

An observational type of study with a cross-sectional design was used to develop and measure the validity and reliability of the above questionnaire.

Study population and sample size

All primary health-care providers enlisted under the district CMOH office chosen from three purposively selected blocks in the North 24 Parganas district in West Bengal, India. Anganwadi workers, Village Health Guides, refusal to give consent, on leave or reporting sick were excluded. A total of 200 eligible participants were enrolled in the study for psychometric analysis. The sample size was consistent with the recommended minimum sample size for exploratory factor analysis (EFA) as most studies of questionnaire validation use 2–20 “subjects to item ratio” for factor analysis.[14]

Questionnaire development

A questionnaire was developed to collect data on perceptions and practices regarding hypertension and its risk factors, associated comorbidities, caregivers current role in patient counseling activities, and control of hypertension and diabetes besides sociodemographic characteristics.

Item pool generation

The conceptual framework for the English questionnaire was prepared after a review of the literature using journal databases. A qualitative study by Focus group discussions with primary health-care providers and in-depth interviews of Medical Officers of 3 Primary health centers in the selected blocks were done. This was followed by the Delphi technique among a group of experts from various disciplines such as Community Medicine, Medicine, Endocrinology, and Cardiology. Based on those results, a consensus on the items to be included in the questionnaire was obtained. The questionnaire was then translated to the local language, i.e., Bengali, by forward-translation and back-translation by experienced translators. Each step after the translation was followed up by a review of experts, and revision was incorporated.

Content and face validity

The questionnaire was then rated individually by a team of 3 public health experts for content relevance, clarity, and accuracy using 3 point Likert scale and content validity was calculated based on Lawshe's formula using a cut-off score of 0.99 when retaining a specific item. Opinion of five public health nurses was taken regarding feasibility, formatting, and comprehensiveness of the questionnaire.

Finally, a questionnaire in Bengali, which comprised 12 sociodemographic questions, 34 knowledge items, 17 attitude items, and 10 practice items was developed and was tested to determine construct validity and reliability.

Construct validity

An EFA with principal axis factoring (PAF) and varimax rotation was used for questions in the attitude and practice domains, to identify the dimensionality of the items. Kaiser–Meyer–Olkin (KMO) test value of >0.6 and Barlett's test of sphericity (P < 0.001) was used to check for sampling adequacy.[12],[13]

The number of factors to retain was determined by considering the Eigenvalues (>1) and the Scree plot.[14] Items with factor loadings >0.3 were considered acceptable and remained in the constructs.[15]


Reliability assessment was made by measurement of internal consistency and stability over time was assessed using test-retest method.

Internal consistency

For the knowledge section of the questionnaire item difficulty index (IDI) and discrimination index (DI) were determined. The acceptable range for IDI was set between 20% and 80% with DI value >0.3 which is generally considered good.[16],[17]

Kuder Richardson (KR-20) coefficient with scores >0.60 was used to determine the reliability of the knowledge section.[18]

For the attitude and practice sections item to total correlations were determined and a cutoff of 0.2 was used.[16],[19]

The reliability of the questionnaire was analyzed by Cronbach's alpha coefficient, coefficients >0.60 were acceptable for exploratory research.[20]

Test-retest reliability

The test-retest reliability of the questionnaire was initially assessed on a sample of 50 providers selected purposively from a different Block (Amdanga). The retest was administered after 3 weeks to avoid any recall bias using the same questionnaire, wherein 28 participants returned and completed the retest.

Description of questionnaire

Questions evaluating knowledge were 34 items were analyzed as “correct-1” or “incorrect-0.” Questions in the attitude domain comprised 17 items and 10 items in the Practice domain with 5-point Likert type responses. Negatively phrased items were scored reversely.


The purpose of the study was explained to the study participants and their written informed consent was obtained. This was followed by administering the questionnaires to them.

All data were analyzed using Statistical Package for the Social Sciences version 16 (SPSS Inc., SPSS for Windows, Chicago, USA).

   Results Top

The mean age of participants was 44.72 ± 8.41 years, and mean years in service was 18.17 ± 11.39 years. 43.5% were graduates, followed by 30.5% educated up to higher secondary level with 95.0% being married.

Content and face validity

All items were contextually relevant, and no item was deleted. All items in the questionnaire were comprehended easily after minor modifications. The time spent to complete the questionnaire was 45 min.

Construct validity

EFA was carried out using PAF with varimax rotation to determine the underlying constructs of each section. For the attitude section, KMO measured 0.69, and Bartlett's test significance was <0.000, indicating that the sample was adequate for factor analysis.

The scree plot revealed four dimensions with reported eigenvalue ≥1 in the attitude section, with 12 items retained from the initial 17 items in the attitude scale. The four factors together explained 35.93% of the total variance in the scale. [Table 1] shows the item loadings of the four factors identified in the attitude domain.
Table 1: Exploratory factor analysis of items in attitude domain (n=200)

Click here to view

In the practice section, assumptions to conduct EFA were also met as the KMO score measured 0.81, and Bartlett's test significance was <0.000.

EFA of the Practice section revealed two dimensions in the Scree plot with eigenvalue ≥1 following which eight items were retained from the initial ten items in the Practice scale. The two factors together accounted for 65.96% of the total variance in the scale. [Table 2] shows the item loadings of the two factors identified in practice domain.
Table 2: Exploratory factor analysis of items in practice domain (n=200)

Click here to view

Internal consistency

Item analysis was conducted on the knowledge domain. Out of 34 items, 25 items were retained in the knowledge domain. The difficulty index ranged from 0.25 to 0.79 and the DI ranged from 0.15 to 0.66 [Table 3].
Table 3: Difficulty index and discrimination index of knowledge items (n=200)

Click here to view

The item-total correlations for each item in the attitude and practice sections were above cut-off 0.2 and no items were removed.

A KR value of 0.70 was obtained for the knowledge section, whereas the overall Cronbach's alpha coefficient for attitude and practice session measured 0.65 and 0.85, respectively.

Test-retest reliability

The test-retest reliability assessed by intra class correlation coefficients were 0.56 (P < 0.00) for knowledge, 0.77 (P < 0.00) for attitude, and 0.88 (P < 0.00) for practice sections indicating moderate-to-good correlations.

   Discussion Top

The questionnaire was assessed for face validity, content validity, and construct validity. Although content validity alone, does not measure an instrument's validity by itself, demonstration of content validity is a fundamental requirement of all assessment instruments.[21] For content validity, consensus of an expert panel was analyzed using Lawshe's formula to calculate the content validity ratio, and all items in the original format were retained.[22]

For construct validity, commonly used methods for factor extraction include-principal components analysis, PAF, maximum likelihood, unweighted least squares, etc., however, maximum likelihood or PAF will give the researcher the best results.[19],[23] EFA of the Attitude and Practice sections indicated only two attitude items showing slightly lower factor loadings between 0.3 and 0.4, which was acceptable (>0.3). For practice items, all factor loadings were >0.4. Thus, it was decided to retain 12 items in the attitude section and 8 items in the practice section of the KAP questionnaire for further data analysis.

The knowledge items were constructed in a manner that assessed the primary health-care providers' awareness about general questions on risk factors to more specific questions about hypertension and its comorbidities such as diabetes, obesity, cardiovascular diseases, and its complications. In item analysis, the difficulty of an item measures the proportion of the persons who answer a test item correctly with higher proportion, indicating lower difficulty.[24]

Item discrimination compares the extent to which items discriminate among high and low scorers groups with a score >0.2 regarded as acceptable.[17],[25]

In item analysis, 21 knowledge items were in the category of the middle level of difficulty and acceptable DI and was thus able to distinguish between high scoring and low scoring respondents. Four items with DI <0.2 were retained as they assessed knowledge about comorbidities.

Reliability reflects consistency and replicability over time with more measurement errors making the test less reliable.[26] The internal consistency of the knowledge domain was assessed using KR-20 as the items were scored dichotomously, and it was found to be satisfactory. The Cronbach alpha reliability coefficient of both attitude and practice sections were similarly found to be acceptable. Although Cronbach's alpha coefficient of >0.7 is used most commonly, reliabilities as low as 0.50 are satisfactory for short tests of 10–15 items, tests with >50 items should have reliabilities of 0.80 or higher.[27]

The results indicate that the practice section of the questionnaire had a high-reliability coefficient of 0.85, while the attitude section had a relatively lower reliability coefficient of 0.65, which was, however, within the acceptable threshold for exploratory research (>0.6).[18] Further research can be done to improve reliability by increasing the number of items in the attitude domain and increasing the sample size. Overall, the instrument showed good test-retest reliability.

   Conclusion Top

The strength of this study is the development of a validated and reliable instrument that can identify primary health-care providers' gaps in knowledge and practices and advocate measures towards improving their role in prevention and control of NCDs. This tool simultaneously measures the promotion of preventive measures as well as delivering services towards control of hypertension. Most tools focus on preventive and control measures individually. However, all aspects of KAP regarding prevention and control of hypertension could not be covered in detail. It is possible that some of the knowledge questions could have been answered by guessing. Further evaluation of this instrument in urban and different rural settings is necessary.


The study was conducted under the ICMR extramural project research grant. The authors would like to express their gratitude towards CMOH and Deputy CMOH II of North 24 parganas, CMOH Bashirhat and all allied administrative officials. The authors would also like to thank all medical experts, Consultants and doctors who have helped in providing their valuable opinion regarding content validation. Special mention must be made of all the BPHNs, PHNs, Health assistants, supervisors, ANMs, ASHAs and other field staff of North 24 parganas for their extensive support and cooperation.

Financial support and sponsorship

This study was part of a Project with research grant sponsored by ICMR. Grant No: Adhoc /2014 /80 / HSR.

Conflicts of interest

There are no conflicts of interest.

   References Top

World Health Organization. Regional Office for South-East Asia. Non-Communicable Diseases in the South-East Asia Region: Situation and Response. World Health Organization; 2011.  Back to cited text no. 1
Ramachandran A, Snehalatha C, Latha E, Satyavani K, Vijay V. Clustering of cardiovascular risk factors in urban Asian Indians. Diabetes Care 1998;21:967-71.  Back to cited text no. 2
Ramachandran A, Sathyamurthy I, Snehalatha C, Satyavani K, Sivasankari S, Misra J, et al. Risk variables for coronary artery disease in Asian Indians. Am J Cardiol 2001;87:267-71.  Back to cited text no. 3
Reddy KS, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in India. Lancet 2005;366:1746-51.  Back to cited text no. 4
World Health Organization. Global Status Report on Non Communicable Diseases 2010: Description of the Global Burden of NCDs, Their Risk Factors and Determinants. Geneva, Switzerland: World Health Organization; 2011.  Back to cited text no. 5
World Health Organization. Non-Communicable Diseases Country Profile. World Health Organization; 2011.  Back to cited text no. 6
Farzadfar F, Murray CJ, Gakidou E, Bossert T, Namdaritabar H, Alikhani S, et al. Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: A nationally representative observational study. Lancet 2012;379:47-54.  Back to cited text no. 7
Abegunde DO, Shengelia B, Luyten A, Cameron A, Celletti F, Nishtar S, et al. Can non-physician health-care workers assess and manage cardiovascular risk in primary care? Bull World Health Organ 2007;85:432-40.  Back to cited text no. 8
Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task shifting for non-communicable disease management in low and middle income countries-a systematic review. PLoS One 2014;9:e103754.  Back to cited text no. 9
Krieger J, Collier C, Song L, Martin D. Linking community-based blood pressure measurement to clinical care: A randomized controlled trial of outreach and tracking by community health workers. Am J Public Health 1999;89:856-61.  Back to cited text no. 10
Neupane D, Kallestrup P, McLachlan CS, Perry H. Community health workers for non-communicable diseases. Lancet Glob Health 2014;2:e567.  Back to cited text no. 11
Cerny BA, Kaiser HF. A study of a measure of sampling adequacy for factor-analytic correlation matrices. Multivariate Behav Res 1977;12:1, 43-7.  Back to cited text no. 12
Nunnally JC. Psychometric Theory. 2nd ed. New York: McGraw-Hill; 1978.  Back to cited text no. 13
Anthoine E, Moret L, Regnault A, Sébille V, Hardouin JB. Sample size used to validate a scale: A review of publications on newly-developed patient reported outcomes measures. Health Qual Life Outcomes 2014;12:176.  Back to cited text no. 14
Pallant J. SPSS survival manual: A step by step guide to data analysis using the SPSS program. 4th ed. Berkshire: Allen & Unwin; 2011.  Back to cited text no. 15
Kline P. The Handbook of Psychological Testing. London: Routledge; 1993.  Back to cited text no. 16
Hopkins KD. Educational and Psychological Measurement and Evaluation. 8th ed. USA: Allyyn and Bacon, Boston; 1998.  Back to cited text no. 17
Wasserman JD, Bracken BA. Fundamental psychometric considerations in assessment. In: Weiner IB, Graham JR, Naglieri JA, editors. Handbook of Psychology. Assessment Psychology. 2nd ed., Vol. 10. Hoboken, NJ: John Wiley & Sons; 2013. p. 50-81.  Back to cited text no. 18
Tabachnick BG, Fidell LS. Using Multivariate Statistics. 5th ed. Boston: Allyn & Bacon; 2007.  Back to cited text no. 19
Taber KS. The Use of Cronbach's Alpha When Developing and Reporting Research Instruments in Science Education. Res Sci Educ 2018;48:1273–1296. Available from https://doi.org/10.1007/s11165-016-9602-2 [Last accessed on 2019 Dec 22].  Back to cited text no. 20
Sireci SG. The construct of content validity. Soc Ind Res 1998;45:83.  Back to cited text no. 21
Awshe CH. A quantitative approach to content validity. Personnel Psychol 1975;28:563-75.  Back to cited text no. 22
Costello AB, Osborne JW. Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical Asses Res Evaluat 2005;10:1-9.  Back to cited text no. 23
Backhoff E, Larrazolo N, Rosas M. The Level of Difficulty and Discrimination Power of the Basic Knowledge and Skills Examination (EXHCOBA). Revista Electrónica de Investigación Educativa; 2000. p. 2. Available from: http://redie.uabc.mx/vol2no1/contents-backhoff.html. [ Last accessed on 2019 Dec22 ].  Back to cited text no. 24
Tilson JK. Validation of the modified Fresno test: Assessing physical therapists' evidence based practice knowledge and skills. BMC Med Educ 2010;10:38.  Back to cited text no. 25
Ebel RL, Frisbie, DA. Essentials of Educational Measurement (5th ed) NJ: PrenticeHall. Englewood Cliffs; 1991.  Back to cited text no. 26
Tavakol M, Dennick R. Making sense of cronbach's alpha. Int J Med Educ 2011;2:53-5.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3]


Print this article  Email this article


    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
  Related articles
    Article in PDF (325 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Tables

 Article Access Statistics
    PDF Downloaded87    
    Comments [Add]    

Recommend this journal

  Sitemap | What's New | Copyright and Disclaimer | Privacy Notice
  2007 - Indian Journal of Community Medicine | Published by Wolters Kluwer - Medknow
  Online since 15th September, 2007