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Validation and psychometric properties of the commitment to hip protectors (C-HiP) index in long-term… Korall, Alexandra M; Godin, Judith; Feldman, Fabio; Cameron, Ian D; Leung, Pet-Ming; Sims-Gould, Joanie; Robinovitch, Stephen N May 3, 2017

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RESEARCH ARTICLE Open AccessValidation and psychometric properties ofthe commitment to hip protectors (C-HiP)index in long-term care providers of BritishColumbia, Canada: a cross-sectional surveyAlexandra M.B. Korall1,2*, Judith Godin3, Fabio Feldman1,4, Ian D. Cameron5, Pet-Ming Leung4,6,Joanie Sims-Gould2,7 and Stephen N. Robinovitch1,2AbstractBackground: If worn during a fall, hip protectors substantially reduce risk for hip fracture. However, a major barrierto their clinical efficacy is poor user adherence. In long-term care, adherence likely depends on how committedcare providers are to hip protectors, but empirical evidence is lacking due to the absence of a psychometricallyvalid assessment tool.Methods: We conducted a cross-sectional survey in a convenience sample of 529 paid care providers. Wedeveloped the 15-item C-HiP Index to measure commitment, comprised of three subscales: affective, cognitiveand behavioural. Responses were subjected to hierarchical factor analysis and internal consistency testing.Eleven experts rated the relevance and clarity of items on 4-point Likert scales. We performed simple linearregression to determine whether C-HiP Index scores were positively related to the question, “Do you think ofyourself as a champion of hip protectors”, rated on a 5-point Likert scale. We examined whether the C-HiPIndex could differentiate respondents: (i) who were aware of a protected fall causing hip fracture from thosewho were unaware; (ii) who agreed in the existence of a champion of hip protectors within their home fromthose who didn’t.Results: Hierarchical factor analysis yielded two lower-order factors and a single higher-order factor,representing the overarching concept of commitment to hip protectors. Items from affective and cognitivesubscales loaded highest on the first lower-order factor, while items from the behavioural subscale loadedhighest on the second. We eliminated one item due to low factor matrix coefficients, and poor expertevaluation. The C-HiP Index had a Cronbach’s alpha of 0.96. A one-unit increase in championing wasassociated with a 5.2-point (p < 0.01) increase in C-HiP Index score. Median C-HiP Index scores were4.3-points lower (p < 0.01) among respondents aware of a protected fall causing hip fracture, and 7.0-points higher (p < 0.01) among respondents who agreed in the existence of a champion of hip protectorswithin their home.Conclusions: We offer evidence of the psychometric properties of the C-HiP Index. The development of avalid and reliable assessment tool is crucial to understanding the factors that govern adherence to hipprotectors in long-term care.Keywords: Hip fracture, Hip protector, Adherence, Commitment, Long-term care* Correspondence: akorall@sfu.ca1Injury Prevention and Mobility Laboratory (IPML), Simon Fraser University,8888 University Drive, Burnaby, BC V5A 1S6, Canada2Centre for Hip Health and Mobility, 7th Floor, 2635 Laurel Street, VancouverV5Z 1M9, BC, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Korall et al. BMC Geriatrics  (2017) 17:103 DOI 10.1186/s12877-017-0493-5BackgroundFalls persist as the leading cause of injury-related hospi-talizations and deaths among individuals aged 65 yearsand older [1–4]. Second only to traumatic brain injuries,hip fractures are the most debilitating injury caused byfalls, associated with morbidity, compromised quality oflife, fear, delirium, depression and even death [5–11].Older people residing in long-term care (LTC) are gener-ally frail [12, 13] and are up to 10-times more likely tosuffer a hip fracture during a fall than community dwell-ing seniors [14–16]. In the event of a hip fracture, 1 in 3residents in LTC will die by six months, after whichtime, about a third of survivors will lose the ability towalk independently [7]. In Canada, the direct cost totreat a single hip fracture is estimated at $40,000, and asapproximately 28,000 Canadian elders are hospitalizedfor hip fractures each year, the collective financial bur-den of hip fractures in terms of direct costs exceeds $1.1billion annually [3, 17].Hip fractures arise from a combination of intrinsic,situational, and environmental factors. Although thestrength and integrity of bone play an important role indetermining risk for hip fracture, the strongest singlepredictor of hip fracture is a sideways landed fall, withrisk increasing 32-fold if direct impact occurs to thelateral aspect of the pelvis [18–21]. According to analysisof real life video footage of 520 falls in LTC by 160residents, hip impact occurs in about 40% of falls, usuallyonto hard flooring [22].Consisting of soft padding or hard shield domes embed-ded in garments or undergarments, hip protectors repre-sent a non-pharmaceutical, and potentially cost-effectiveapproach for hip fracture prevention (e.g., [23–27]). Ra-ther than preventing the fall itself, which has provedchallenging in LTC [28], the rationale behind hip protec-tors is to minimize the risk of hip fracture associated withfalling, by absorbing and diverting impact energyaway from the proximal femur during a sidewayslanding [29, 30]. If worn at the time of a fall, certainmodels of hip protectors have been found in clinicaltrials to reduce the risk of hip fracture between 69and 80% [31–33]. When assessed solely on an intention-to-treat basis, however, the clinical value of hip protectorsis compromised by rather poor adherence in the wearingof these devices, ranging from 20% (e.g., [34]) to 80% (e.g.,[35]), and often below 50% in clinical trials [36]. Thus,poor user adherence in wearing hip protectors is a majorbarrier to their effectiveness.Determinants of adherence with hip protectors spandifferent socio-ecological levels [37]. Because the major-ity of residents in LTC have some form of cognitiveimpairment (e.g., [38]) and all require at least partial as-sistance performing activities of daily living, the attitudesand subsequent behaviour of care providers is believedto be important in determining whether a resident willwear hip protectors on a regular basis (e.g., [39–46]).For example, care providers are responsible for identify-ing residents likely to benefit and tolerate hip protectors,educating residents and family about the benefits of hipprotectors, monitoring for signs of discomfort and pain,implementing interventions to optimize adherence, andcontinuously reassessing for eligibility [47]. In a recentsystematic review on factors affecting use of hip protec-tors among residents in LTC, the commitment of careproviders to hip protectors emerged as a facilitator ofacceptance and/or adherence in nearly half of studies(46%) [37]. However, our understanding of the nature ofcommitment, along with its associated antecedents andoutcomes, is constrained by the absence of a psychomet-rically valid assessment tool, and subsequently, relianceon relatively low-level evidence, namely expert opinion.Therefore, our aim is to develop a valid and reliable toolto measure commitment to hip protectors among paidcare providers in LTC.Theoretical frameworkOver the past few decades, researchers have conceptualizedcommitment to many different workplace foci, includingwork organizations (e.g., [48, 49]), work teams and leaders(e.g., [50, 51]), occupations and professions (e.g., [52]),organizational change (e.g., [53]) and technological change(e.g., [54]). And yet, there remains considerable uncertaintysurrounding how to define and measure commitment inthe workplace, how commitment in the workplace develops,and how commitment subsequently affects organizationalbehaviour [55]. However, what is largely undisputed is thatcommitment to any workplace foci should be conceived asa strictly attitudinal phenomenon (e.g., [49, 56, 57]).According to prevailing theoretical frameworks in so-cial psychology (e.g., ABC model), attitudes have threedifferent components: an affective component reflectingan individual’s feelings and emotions about a target, acognitive component reflecting an individual’s knowledgeand beliefs about a target, and a behavioural componentreflecting an individual’s readiness to act or behave in acertain way (e.g., [58, 59]). Thus, it follows that com-mitment is also reflected by a combination of affective,cognitive, and behavioural components, whereby: affectivecommitment refers to an emotional attachment to andidentification with one or more targets; cognitive commit-ment refers to an internalization of the targets’ goals,norms, and values; behavioural commitment refers toa generalized behavioural pledge to serve and enhancethe targets’ interests [57]. Summarized nicely by Solin-ger, van Olffen and Roe [57], “…thus, commitmentdoes not come cheap: it is a binding vow, a general-ized behavioural pledge to act in the interest of the[target]” (pg. 80).Korall et al. BMC Geriatrics  (2017) 17:103 Page 2 of 13Consistent with extant research conceptualizing com-mitment in the workplace as a purely attitudinal phenom-ena, we defined commitment to hip protectors as a careprovider’s attachment to and behavioural intentions to-wards hip protectors, reflected by three components: (i) abelief in the value of hip protectors (affective commit-ment), (ii) acceptance of the clinical efficacy of hip protec-tors (cognitive commitment), and (iii) a willingness to actor modify their behaviour to generally support the use ofhip protectors (behavioural commitment).MethodsAim, design, and settingOur aim was to develop and test the psychometric proper-ties of a tool to measure commitment to hip protectorsamong paid care providers in LTC, named the Commit-ment to Hip Protectors (C-HiP) Index. To achieve this,we conducted a cross-sectional survey within thirteennon-profit, publically subsidized LTC homes situatedin Metro Vancouver and the Fraser Valley, of BritishColumbia (BC), Canada. Homes ranged from 50 to234 beds, and all were owned and operated by theFraser Health Authority.Context: Hip protector policy in Fraser healthFraser Health does not provide hip protectors free ofcharge to residents living in owned and operated LTChomes, nor are hip protectors reimbursed throughnational health care coverage (e.g., Medical ServicesPlan). A single pair of hip protectors costs between$70–$120 CAD.In 2013, Fraser Health released a clinical practiceguideline (CPG) endorsing the use of hip protectorsamong residents of LTC: (1) with more than 2 falls inthe previous 6 months, (2) who were admitted to thehome in the past month, (3) with impaired mobility, bal-ance or gait, and (4) who are agitated, restless, or unableto follow instructions. The CPG states that educationabout hip protectors should be provided to residentswho meet this criterion, and if applicable, their family,and any refusal to adhere should be clearly documentedin health records.SampleWe recruited a convenience sample of 541 paid careproviders from publically subsidized LTC homes, whoreported working for at least one full month on theirfloor/neighbourhood/unit, and for at least 8 h per week.We excluded carers who indicated they were unaware ofhip protectors (n = 5, 0.9%), and one respondent wholeft this question blank and did not answer any items inthe C-HiP Index. An additional six (1.1%) respondentswere excluded because they indicated they worked mostof their time at privately owned or contracted LTChomes. Another six (1.1%) respondents indicated theyworked most of their time at a LTC home owned andoperated by the Fraser Health Authority that did not par-ticipate in data collection, but as they met our criteria forinclusion, they were included anyway. Of the remaining529 respondents, the majority were female (90%) andmost were health care assistants (55%). About half werefull-time (53%), one-quarter were part-time (28%), and theremainder were casual (16%) or unknown. More respond-ent characteristics are provided in Table 1.C-HiP index development and scoringFour items were written to measure affective commit-ment to hip protectors, modified from the affectivecommitment subscale of Herscovitch and Meyer’s [53]Commitment to Change scale. An example being, “Ibelieve in the value of hip protectors.” Seven items werewritten to measure behavioural commitment to hip pro-tectors, modified from Mowday, Steers and Porter’s [49]Organizational Commitment Questionnaire (OCQ) andthe Compliance and Cooperation subscales of Herscov-itch and Meyer’s [53] Measures of Behavioural Supportfor Change questionnaire. An example being, “I amwilling to put in a great deal of effort, above and beyondwhat is normally expected, to work with hip protectors.”These eleven items were pretested in a conveniencesample of 119 paid care providers from two privatelyowned LTC homes within Fraser Health, and the resultswere subjected to exploratory factor analysis and in-ternal reliability testing. Two behavioural items were re-moved due to low pattern matrix and structure matrixcoefficients. After pre-testing, six items were addedbased on qualitative feedback from respondents, consti-tuting the cognitive subscale of the C-HiP Index, anexample being, “I am convinced that, when worn, hipprotectors reduce risk for injury from falls.” All itemsused Likert-type response scales ranging from 1 (stronglydisagree) to 5 (strongly agree); however, one cognitiveitem, “I doubt the effectiveness of hip protectors”, usedreverse scoring (e.g., a response of 1 is scored as 5-points).Although scores for the C-HiP Index can be calculated ei-ther by summing or averaging responses to individualitems, we elected to sum responses.ProtocolIn May 2015, an email message was sent to managers ofLTC homes owned and operated by Fraser Health, alert-ing them of the upcoming study and inviting them toparticipate. In homes where managers expressed interestin participating, a member of the research team (AMBK)scheduled the launch of data collection.We developed five different versions of the paper survey.In each, we kept the location of the C-HiP Index the same,but we randomized the order in which individual itemsKorall et al. BMC Geriatrics  (2017) 17:103 Page 3 of 13were presented within the scale. We also randomized theorder in which LTC homes were assigned versions of thepaper survey. However, each version was assigned to atleast two LTC homes, and all participants from a givenTable 1 Demographic characteristics of 529 paid caregiverswho completed the C-HiP IndexCharacteristics No. (%)GenderFemale 474 (89.6)Male 40 (7.6)Missing/unknown 15 (2.8)Age20–29 years 42 (7.9)30–39 years 87 (16.4)40–49 years 149 (28.2)50–59 years 187 (35.3)60–69 years 46 (8.7)Missing/unknown 18 (3.4)Highest level of educationLess than high school 5 (0.9)High school or equivalent 43 (8.1)College or professional certification 312 (59.0)Bachelor’s degree 119 (22.5)Master’s degree 36 (6.8)Missing/unknown 14 (2.6)Race/ethnicity – mark all that applyBlack CanadianYes 17 (3.2)Missing/unknown 24 (4.5)CaucasianYes 261 (49.3)Missing/unknown 24 (4.5)ChineseYes 23 (4.3)Missing/unknown 24 (4.5)FilipinoYes 69 (13.0)Missing/unknown 25 (4.7)South Asian (E.g., East Indian, Pakistani, Sri Lankan)Yes 95 (18.0)Missing/unknown 24 (4.5)Role/occupation – mark all that applyHealth care assistant/resident care aideYes 290 (54.8)Missing/unknown 17 (3.2)Licensed practical nurseYes 84 (15.9)Missing/unknown 17 (3.2)Registered nurseYes 40 (7.6)Table 1 Demographic characteristics of 529 paid caregiverswho completed the C-HiP Index (Continued)Missing/unknown 17 (3.2)Resident care coordinatorYes 13 (2.4)Missing/unknown 17 (3.2)ManagerYes 14 (2.6)Missing/unknown 17 (3.2)Recreational/occupational/physiotherapistYes 24 (4.5)Missing/unknown 17 (3.2)Unit/program clerkYes 18 (3.4)Missing/unknown 17 (3.2)Employment statusPart-time 149 (28.2)Casual 86 (16.2)Full-time 282 (53.3)Missing/unknown 12 (2.3)ShiftDay shifts 237 (44.8)Evening shifts 61 (11.5)Night shifts 11 (2.1)Combination 206 (38.9)Missing/unknown 14 (2.6)Clinical experienceLess than 1 year 15 (3.0)1–5 years 98 (18.5)5–10 years 121 (22.9)10–20 years 148 (28.0)20–30 years 94 (17.8)30 or more years 38 (7.2)Missing/unknown 15 (2.8)Organizational tenureLess than 1 year 36 (6.8)1–5 years 159 (30.1)5–10 years 120 (22.7)10–20 years 129 (24.4)20–30 years 57 (10.8)30 or more years 13 (2.5)Missing/unknown 15 (2.8)Korall et al. BMC Geriatrics  (2017) 17:103 Page 4 of 13LTC home received the same version (i.e., stratifiedrandomization). This method of randomization ensuredwe received an adequate and relatively equal number ofresponses to each version of the survey.During data collection, AMBK offered multiple informa-tion sessions within each home to explain the overall aimsand objectives of the study and to distribute invitation let-ters and paper surveys to eligible participants. Additionalcopies of the invitation letter and paper survey were leftbehind for those unable to attend sessions (e.g., night shiftemployees). Once completed, respondents were asked toplace paper surveys in a sealed envelope and to leave themin a secured collection box. The return of completedpaper surveys was interpreted as implied consent. Datacollection lasted between 9 and 10 days in each participat-ing LTC home, and took place between June and Decem-ber 2015. The Fraser Health Authority Research EthicsBoard and the Simon Fraser University Office of ResearchEthics approved the study protocol.Double data entryThirteen volunteers entered the data from returned papersurveys into spreadsheets, including one physiotherapist,five undergraduate students, five graduate students, andtwo postdoctoral fellows. Paper surveys underwent first andsecond keying, respectively, each by different volunteers.To facilitate high quality data entry, volunteers wereprovided with a protocol, adapted from the WHO STEPSSurveillance Manual [60], outlining general rules and guide-lines for data entry, including how and when to assignmissing data codes and resolutions to common difficulties(e.g., surplus data). All difficulties, and their associated reso-lutions, were logged on data tracking forms.The overall error rate was low (1.02%). However, 369(83.7%) surveys had at least one discrepancy betweenfirst and second keying, 197 (44.7%) had at least two er-rors, and 100 (22.7%) had three or more errors. The dataentry supervisor (AMBK) resolved discrepancies bycomparing entries to original responses.Statistical MethodsUnless otherwise stated, statistical testing was performedusing IBM SPSS Statistics version 22.0 (SPSS Inc.,Chicago, IL, USA) and significance was defined at thelevel p < 0.05.Missing dataTable 2 describes the amount (count, %) of missing datafor each item of the C-HiP Index. 484 (91.5%) respon-dents answered the C-HiP Index completely. The behav-ioural item, “When it comes to hip protectors, I amwilling to accept changes in the roles and responsibilitiesof my job”, had the most missing data, with 14 (2.6%)respondents leaving this question blank, while thecognitive item, “I am convinced that, when worn, hipprotectors reduce risk for injury from falls”, had the leastmissing data, with no respondents refusing to answer.We used a combination of single and multiple imput-ation (MI) procedures to handle missing data. MI is thegold standard of missing data procedures, and is pre-ferred over many commonly used approaches, such aslistwise deletion, for its ability to produce unbiased par-ameter estimates, reasonable estimates of uncertainty (i.e.,standard errors and confidence intervals), and maximalstatistical power [61, 62]; however, when preparing data-sets for preliminary statistical analyses that do not involvestandard errors, such as exploratory factor analysis (EFA)and coefficient alpha analyses, the Maximum-Likelihood,single imputation technique known as the Expectation-Maximization (EM) algorithm can be just as useful as MIprocedures [62, 63].Accordingly, we first implemented the EM algorithmto generate a single imputed dataset, from which we: (i)derived means (SD) of individual items within the C-HiPIndex; (ii) conducted EFA and alpha coefficient analyses,described in the following sections entitled ‘constructvalidity’ and ‘internal consistency’, respectively. The EMalgorithm contained age, sex, all fifteen items belongingto the C-HiP Index, and single items probing their famil-iarity with hip protectors, their familiarity with protocolsconcerning hip protectors at their LTC home, whetherthey identify as a champion of hip protectors, andwhether there is at least one other person in their LTChome that is a champion of hip protectors.We then used the MI procedures implemented in themice package [64] of R [65] to prepare for statistical ana-lyses involving hypothesis testing, such as simple linearregression and Mann-Whitney U tests, described in thefollowing sections entitled ‘convergent validity’ and ‘con-current validity’, respectively. We used a multilevel ap-proach and included all variables from our statisticalanalyses, along with age, sex and facility code as the Level2 identifier. We imputed m = 5 different datasets. Eachstatistical test (e.g., simple linear regression) was repeatedon all five datasets, and the results from each dataset werepooled to generate a single population estimate, confi-dence interval, and p-value. We pooled population esti-mates by averaging across the five imputed datasets. Wepooled standard errors using the method proposed byEnders (2010), which considers within and betweenimputed dataset variation [61]. There is currently noestablished method to pool p-values generated from non-parametric tests (i.e., Mann-Whitney U tests) on multiplyimputed datasets; however, all p-values were p < 0.01.Construct validityBecause we conceptualized commitment to hip protec-tors as subsuming affective, cognitive and behaviouralKorall et al. BMC Geriatrics  (2017) 17:103 Page 5 of 13components, with each component subsuming severalindividual items of the C-HiP Index, we elected to per-form hierarchical (i.e., higher order) factor analysis.Individual C-HiP Index items were first subjected to aseries of exploratory factor analysis (EFA) with obliquerotation (i.e., Oblimin with Kaiser Normalization) toidentify lower-order factors (i.e., components of commit-ment). To determine the number of factors to retain ineach EFA, we conducted Velicier’s minimum averagepartial (MAP) tests and parallel analyses [66]. Items wereonly retained if they had coefficients of .6 or higher oneither the pattern matrix or the structure matrix, andthey loaded onto the same factor in both matrices. Ifitems did not meet these criteria, they were removed,and a subsequent EFA was performed. This procedurewas repeated until all items met the criterion for reten-tion. We then subjected lower-order factors to EFA toidentify higher order factors.For each EFA performed, we report eigenvalues(ranging from 0 to the number of items), which rep-resent the variance in the original data matrix that isreproduced by each of the factors, the percentage ofvariance explained by each of the factors, and whereapplicable, factor matrix coefficients, pattern matrixcoefficients and/or structure matrix coefficients. Wehypothesized hierarchical factor analysis would yieldthree lower-order factors, representing the three com-ponents of commitment, and a single higher-orderfactor, representing the overarching concept of com-mitment to hip protectors.Content validityTo assess content validity, a completely anonymoussample of eleven experts, consisting of directors ofcare and members of the Fraser Health AuthorityPatient Safety and Injury Prevention Program, ratedthe relevance and clarity of C-HiP items on Likertscales ranging from 1 (e.g., “Not at all relevant”) to 4(e.g., “Extremely relevant”). For each item, we computed acontent validity index (CVI), taken as the percentageof experts giving a rating of 3 or 4, for both clarityand relevance (e.g., [67]). We hypothesized that eachitem in the C-HiP Index would have a CVI greaterthan 0.79 (>79% agreement) for both relevance andclarity, which has been recommended as a thresholdof adequate content validity [67]. However, in linewith extant research [67], only those items with aCVI less than 0.70 (<70% agreement) for both rele-vance and clarity were considered unacceptable, andwere deleted from the C-HiP Index.Table 2 Missingness, means (SD) and content validity index scores for C-HiP Index itemsItem Missingness Meana SD Content validity indexNo. % Clarity RelevanceAffective commitment subscaleAFF01 I believe in the value of hip protectors. 2 0.4 4.18 0.88 0.91 1.00AFF02 Hip protectors are necessary. 6 1.1 4.11 0.93 1.00 0.91AFF03 Hip protectors are needed. 10 1.9 4.16 0.92 0.91 1.00AFF04 Hip protectors serve an important purpose. 2 0.4 4.20 0.89 1.00 1.00Cognitive commitment subscaleCOG01 I believe in the effectiveness of hip protectors. 3 0.6 4.16 0.91 0.91 1.00COG02 I am convinced that, when worn, hip protectors help to protect myresidents from injury.1 0.2 4.17 0.92 1.00 1.00COG03 I think that hip protectors work. 2 0.4 4.12 0.91 1.00 1.00COG04 I think that hip protectors are useful. 3 0.6 4.16 0.87 0.91 1.00COG05 I am convinced that, when worn, hip protectors reduce risk for injury from falls. 0 0 4.17 0.98 1.00 1.00COG06 I doubt the effectiveness of hip protectors. 7 1.3 2.29 1.19 0.36 0.36Behavioural commitment subscaleBEH01 I am always willing to work with hip protectors. 5 0.9 4.28 0.77 0.91 1.00BEH02 I try to remain positive about hip protectors, even under challenging circumstances. 1 0.2 4.21 0.74 0.91 0.91BEH03 When it comes to hip protectors, I am willing to accept changes in the roles andresponsibilities of my job.14 2.6 4.11 0.82 0.55 0.73BEH04 I am willing to put in a great deal of effort, above and beyond what is normallyexpected, to work with hip protectors.5 0.9 3.98 0.84 0.73 0.82BEH05 I am willing to adjust the way I do my job, as required to use hip protectors. 4 0.8 4.13 0.80 0.91 0.91aExpectation-Maximization (EM) imputed means; responses ranged from 1 (strongly disagree) to 5 (strongly agree)Korall et al. BMC Geriatrics  (2017) 17:103 Page 6 of 13Convergent validityAnother method to test the validity of scales is to deter-mine whether variables that ought to be related to theoutcome measure of interest are indeed related. An indi-vidual’s commitment to hip protectors should ultimatelyaffect how they behave (e.g., [59]). The stronger theircommitment, the more likely they should be to engagein a form of discretionary behaviour known as cham-pioning (e.g., [53]). A champion is defined as an em-ployee who exhibits considerable personal sacrifice, andgoes above and beyond what is explicitly required toserve and enhance the interests of one or more targetswithin and outside their organization [53]. In general,champions are known for their achievement, persuasive-ness, persistence, innovativeness, charisma, enthusiasm,assertiveness, and/or risk-tolerance [68].Thus, we hypothesized C-HiP Index scores are posi-tively associated with championing. To test this hypoth-esis, we performed simple linear regression to examinethe association between scores on the entire C-HiP Indexand responses to the single question, “Do you think ofyourself as a champion of hip protectors”, with responsesranging from 1 (strongly disagree) to 5 (strongly agree).We also examined the association between each lowerorder factor, taken as the sum of items loading onto eachfactor (e.g., Factor 1) extracted from EFA, and responsesto the single question, “Do you think of yourself as achampion of hip protectors”. To minimize interpretationbias, respondents were provided with a definition ofchampioning before being asked to answer.Concurrent validityTo test concurrent validity, we examined the ability ofthe two lower-order factors and the entire C-HiP Indexto distinguish between subgroups of respondents that itshould theoretically be able to distinguish between. Al-though hip protectors substantially reduce risk of hipfracture if worn during a fall, they cannot prevent hipfracture on every occasion, including cases of spontan-eous fracture without any obvious external impact (e.g.,[69]), when the hip breaks from impact to the buttocksduring of a backwards landed fall or a fall to the knees(e.g., [22, 70]), or when the hip protector is not positionedcorrectly over the greater trochanter (e.g., [71, 72]). Forsenet al. [73] reported that it became increasingly difficult toconvince residents of the benefits of hip protectors aftereach time a hip fracture occurred while wearing a hipprotector. Furthermore, an important facilitator of adher-ence in LTC is the existence of a leader within the hometo act as a champion of hip protectors and to convinceothers of their efficacy [74, 75].Therefore, we hypothesized that responses to the C-HiP Index should be: (i) lower among paid caregiverswho responded ‘Yes’ to the question, “Are you aware ofa resident breaking their hip during a fall while wearinga hip protector”, compared to those who responded ‘No’;(ii) higher among paid caregivers who agreed (responded‘4’ or ‘5’ on a 5-point Likert scale) with the statement,“Would you say there is at least one other person inyour residential care facility that is a champion of hipprotectors”, compared to those who did not agree(responded ‘1’, ‘2’ or ‘3’). As C-HiP Index responses wererightward skewed, we performed Mann-Whitney U teststo determine whether there were differences in medianresponses to lower-order factors and the entire C-HiPIndex between these subgroups of respondents.Internal consistencyTo assess internal consistency, we computed Cronbach’salpha coefficients for lower-order factors and the entire C-HiP Index. We hypothesized alpha coefficients would beabove 0.70, indicating acceptable internal consistency [76].ResultsTable 2 describes mean (SD) responses to individualitems of the C-HiP Index derived from the EM imputeddataset.Construct validityContrary to expectation, both Velicier’s MAP test andparallel analysis indicated the presence of only twolower-order factors. The eigenvalues of Factor 1 and Fac-tor 2 were 9.225 and 1.078, respectively. Accordingly,lower-order factors explained 68.7% of the variance inresponses. One cognitive item (i.e., COG06) – “I doubtthe effectiveness of hip protectors” – had poor patternmatrix and structure matrix coefficients for both Factor1 (−.597, −.508, respectively) and Factor 2 (.136, −.250,respectively), and was removed. After removal ofCOG06, EFA yielded two lower-order factors, with ei-genvalues of 9.002 and 1.033, respectively. Lower-orderfactors now explained 71.7% of the variance in re-sponses. Items from the affective and cognitive subscalesloaded highest on Factor 1, whereas items from the be-havioural subscale loaded highest on Factor 2 (Table 3).Higher-order factor analysis supported a hierarchicalfactor structure (Fig. 1). Both Factor 1 (affective/cogni-tive subscale) and Factor 2 (behavioural subscale) loadedonto a single higher-order factor, “commitment to hipprotectors,” having an eigenvalue of 1.386 and account-ing for 69.3% of the variance in responses. Factor 1(affective/cognitive subscale) and Factor 2 (behaviouralsubscale) each had factor matrix coefficients of .833.Content validityTwelve items had a CVI above 0.79 for both clarity andrelevance. A single item, BEH04 (“I am willing to put ina great deal of effort, above and beyond what is normallyKorall et al. BMC Geriatrics  (2017) 17:103 Page 7 of 13expected, to work with hip protectors”), had a CVI of0.82 (‘adequate’) for relevance, but a CVI of 0.73 (‘ques-tionable’) for clarity. Another item, BEH03 (“When itcomes to hip protectors, I am willing to accept changesin the roles and responsibilities of my job”), had a CVIof 0.73 (‘questionable’) for relevance, and a CVI of 0.55(‘unacceptable’) for clarity. Finally, a single item, COG06(“I doubt the effectiveness of hip protectors”) had a CVIbelow 0.70 for both clarity and relevance, and therefore,was eliminated from the C-HiP Index (Table 2).Convergent validityAfter removal of COG06, a 1-unit increase in champion-ing (responses to the single question, “Do you think ofyourself as a champion of hip protectors”, scored from 1to 5) was associated with 3.6-point (95% CI: 2.9–4.2;p < 0.01), 1.6-point (95% CI: 1.4–1.9; p < 0.01) and 5.2-point (95% CI: 4.4–6.1; p < 0.01) increases in theaffective/cognitive subscale (scored from 9 to 45), thebehavioural subscale (scored from 5 to 25) and the en-tire C-HiP Index (scored from 14 to 70), respectively.Concurrent validityWe observed significantly lower median responses to theaffective/cognitive subscale (estimated difference = 4.0-points; p < 0.01), the behavioural subscale (estimated dif-ference = 1.0-point; p < 0.01), and the entire C-HiPIndex (estimated difference = 4.3-points; p < 0.01) amongpaid care providers who were aware of a resident breakingtheir hip during a fall while wearing a hip protector com-pared to those who were unaware (Table 4).We also observed significantly higher median re-sponses to the affective/cognitive subscale (estimated dif-ference = 5.0-points; p < 0.01), the behavioural subscale(estimated difference = 2.0-points; p < 0.01), and the entireC-HiP Index (estimated difference = 7.0-points; p < 0.01)among paid care providers who agreed that there is atleast one other person in their LTC home that is a cham-pion of hip protectors compared to those who did notagree (Table 4).Internal consistencyAfter removal of COG06, Cronbach’s alpha coefficientsfor the affective/cognitive subscale, the behavioural sub-scale, and the entire C-HiP Index were 0.97, 0.87, and0.96, respectively.DiscussionHip protectors represent a promising technology for theprevention of hip fractures in one of society’s frailest andmost cognitively impaired cohorts of older adults, resi-dents of LTC. However, a major barrier to the clinicaleffectiveness of hip protectors in LTC is poor user ad-herence in the wearing of hip protectors, often droppingTable 3 Pattern and structure matrix coefficients for each item retained in exploratory factor analysisItem Pattern matrix Structure matrixFactor 1 Factor 2 Factor 1 Factor 2Affective commitment subscaleAFF01 I believe in the value of hip protectors. .861 .058 .902 .656AFF02 Hip protectors are necessary. .847 .015 .857 .602AFF03 Hip protectors are needed. .825 .040 .853 .612AFF04 Hip protectors serve an important purpose. .853 .063 .897 .655Cognitive commitment subscaleCOG01 I believe in the effectiveness of hip protectors. .933 −.025 .915 .622COG02 I am convinced that, when worn, hip protectors help to protect myresidents from injury..908 −.035 .884 .595COG03 I think that hip protectors work. .926 −.019 .913 .624COG04 I think that hip protectors are useful. .898 .027 .917 .650COG05 I am convinced that, when worn, hip protectors reduce risk for injury from falls. .891 −.030 .870 .588Behavioural commitment subscaleBEH01 I am always willing to work with hip protectors. .202 .620 .633 .761BEH02 I try to remain positive about hip protectors, even under challenging circumstances. .248 .488 .587 .660BEH03 When it comes to hip protectors, I am willing to accept changes in the roles andresponsibilities of my job.−.070 .760 .457 .711BEH04 I am willing to put in a great deal of effort, above and beyond what is normallyexpected, to work with hip protectors..137 .653 .589 .747BEH05 I am willing to adjust the way I do my job, as required to use hip protectors. −.100 .935 .549 .866Korall et al. BMC Geriatrics  (2017) 17:103 Page 8 of 13below 50% in clinical trials [36]. Within LTC, care pro-viders are believed to play a particularly important rolein influencing a resident’s decision to wear hip protec-tors on a regular basis (e.g., [39–46]). The overall com-mitment of paid care providers towards hip protectorshas been identified as an important determinant of ad-herence, but empirical evidence is lacking [37]. Toaddress this knowledge gap, our aim was to develop avalid and reliable tool to measure commitment to hipprotectors among paid caregivers in LTC.Fig. 1 Conceptual model of commitment to hip protectors determined using hierarchical (higher-order) factor analysisTable 4 Concurrent validity of the C-HiP IndexCharacteristic Affective/Cognitivea Behavioural C-HiP indexaMedian P-value Median P-value Median P-valueAware of padded hip fractureYes (n = 203, 38%) 36.0 p < 0.01* 20.0 p < 0.01* 56.0 p < 0.01*No (n = 326, 62%) 40.0 21.0 60.3Existence of a championYes (n = 397, 75%) 40.0 p < 0.01* 21.0 p < 0.01* 61.0 p < 0.01*No (n = 132, 25%) 35.0 19.0 54.0* p < 0.01 in each multiply imputed dataset; Mann-Whitney U testsaAfter removal of the cognitive item (COG06), “I doubt the effectiveness of hip protectors”Korall et al. BMC Geriatrics  (2017) 17:103 Page 9 of 13Consistent with extant research, we defined commit-ment to hip protectors as an individual’s attachment toand behavioural intentions towards hip protectors,reflected by three components: (i) a belief in the valueand importance of hip protectors (affective commit-ment), (ii) acceptance of the clinical efficacy of hip pro-tectors (cognitive commitment), and (iii) a willingness toact or modify their behaviour to generally support theuse of hip protectors (behavioural commitment). Weadapted existing metrics of workplace commitment todevelop the C-HiP Index, originally containing the 4-item affective subscale, the 6-item cognitive subscale,and the 5-item behavioural subscale. However, one nega-tive item was removed from the cognitive subscale, as itdid not meet our criteria for retention in EFA and it hada CVI less than 0.70 (<70% agreement) for both clarityand relevance. Despite expert ratings of unacceptableand questionable clarity, respectively, we retained BEH03and BEH04 in their original form as they met our criteriafor retention in EFA and did not have unacceptably lowCVI scores (<0.70) for relevance.We expected EFA to confirm a hierarchical factorstructure, yielding three lower-order factors, and a singlehigher-order factor. We hypothesized items from theaffective subscale would load onto a first lower-orderfactor, items from the cognitive subscale would loadonto a second lower-order factor, and items from the be-havioural subscale would load onto a third lower-orderfactor. We also hypothesized lower-order factors wouldsubsequently load onto a single higher-order factor.However, contrary to expectation, EFA supported a hier-archical factor structure with only two lower-order fac-tors, and a single higher-order factor. Items from theaffective and cognitive subscales loaded together onto afirst lower-order factor (i.e., ‘Factor 1’) and those fromthe behavioural subscale loaded onto a second lower-order factor (i.e., ‘Factor 2’). Both lower-order factorsthen loaded onto a single higher-order factor (i.e., ‘Com-mitment to Hip Protectors’).We have shown it is hard to separate affective com-mitment from cognitive commitment, and believe thisinconsistency is explained by empirical, rather than con-ceptual problems. Firstly, it is possible that these resultsare merely a by-product of our sampling strategy, inwhich we recruited participants from a single healthauthority in BC, Canada. Although excessive variability(i.e., noise) in any signal can interfere with our ability tomake statistical inferences, the same can be said whenthere is too little variability. For example, we need vari-ability in predictor variables to explain variability in out-comes. After conducting this study, it became apparentthat commitment to hip protectors among paid care-givers in participating LTC homes was higher and lessvariable than expected, with mean scores exceeding 4.00for most (93%) items of the C-HiP Index. Therefore, wemay not have been able to distinguish affective fromcognitive commitment because the majority of respon-dents believed in the value of hip protectors and theirclinical efficacy. To determine if affective commitmentand cognitive commitment truly are inseparable, futureresearch should include participants from LTC homeswhere hip protectors have not been embraced as a fall-related injury prevention strategy, and commitment tohip protectors is much lower.Alternatively, we might have failed to capture the trueessence of affective commitment to hip protectors in theC-HiP Index, and instead wrote 9-items to measure cog-nitive commitment. Solinger, van Olffen and Roe [57]defined affective commitment as an emotional attach-ment and identification with one or more targets, andcognitive commitment as the internalization of a target’sgoals, norms and values. Although we adapted affectiveitems from the well-validated affective commitmentsubscale of Herscovitch and Meyer’s [53] Commitmentto Change scale, in future research it might be fruitfulto revise and improve this subscale of the C-HiP Indexto better capture an individual’s emotional attachmentto and identification with hip protectors. Examplescould include, “I love the idea of hip protectors”, “I hatethe idea of hip protectors”, “I would consider wearinghip protectors if I was a senior residing in this long-term care home”, or perhaps, “I would put hip protec-tors on someone I love or care deeply for”.Despite the unexpected factor structure, we were ableto demonstrate the content, convergent and concurrentvalidity of the C-HiP Index. For example, after removingCOG06, 86% (12 of 14) of remaining C-HiP Index itemshad a CVI above 0.79 for both clarity and relevance. Fur-thermore, we saw a positive and significant associationof overall C-HiP Index scores with self-reported cham-pioning behaviours (estimated slope of the regressionline, β1 = 5.2-points). As theorized, respondents whowere aware of a resident breaking their hip during a fallwhile wearing a hip protector had lower median scorescompared to those who were unaware (estimated differ-ence = 4.3-points). Also, respondents who agreed withthe statement that there is at least one other person intheir LTC home that is a champion of hip protectorshad higher median scores compared to those who didnot agree (estimated difference = 7.0-points). These find-ings are in line with those from previous qualitative andquantitative studies examining resident and staff experi-ences using hip protectors, which suggest differencesshould exist in commitment between these subgroups ofrespondents [73–75].In general, the C-HiP Index demonstrated acceptableinternal consistency, having alpha values greater than0.70 [76]. Alpha values of the affective/cognitive subscaleKorall et al. BMC Geriatrics  (2017) 17:103 Page 10 of 13(9-items), the behavioural subscale (5-items), and theentire C-HiP Index (14-items) were 0.97, 0.87, and 0.96,respectively, thereby achieving high consistency, but alsosuggesting that some items could potentially be removedfrom the affective/cognitive subscale to reduce redun-dancies [77]. However, as Cronbach’s alpha coefficientsare sensitive to the number of the questions containedin a scale, with longer scales always demonstratingimproved reliability, these findings are not surprising,and thus, should be interpreted with some caution.We acknowledge some important limitations. First, werecruited a convenience sample of paid care providers,and did not adopt a random sampling strategy. Thus, it ispossible that those who chose to participate in our studyare more committed to hip protectors than those whodeclined, which could have introduced bias. However, weare fairly confident our sampling strategy has not favouredand/or excluded obvious groups within the target popula-tion in terms of gender, age, employment status, and occu-pation/role type, as distributions are consistent with thosereported in previous studies (e.g., [78]), including theNational Study of Long-Term Care Providers conductedby the National Center for Health Statistics in the UnitedStates [79]. Second, previous research has shown that atti-tudes towards hip protectors differ between caregiversworking day and night shifts, with night shift employeesreporting less favourable attitudes towards hip protectors[47]. For example, Milisen et al. [47] observed that nursesworking night shifts were more likely to rate a hip pro-tector policy in LTC as time-consuming, stressful, and ashaving a potentially negative impact on the independenceof residents compared to nurses working day shifts only.It is possible that care providers who work mostly night-shifts might respond to the C-HiP Index in a conceptuallydistinct manner to those working day or evening shifts. Aswe received only n = 11 responses from night shiftemployees, we could not examine whether the factorstructure of C-HiP Index items was equivalent betweenday/evening and night shift respondents. Third, we onlyrecruited participants from a single health authority,which limits the generalizability of our findings outsidethe Fraser Valley of BC, Canada. Regions located beyondthese borders might have differing policies on hip protec-tors, cultural norms, educational requirements, and use ofdialects and/or languages, which could affect responses tothe C-HiP Index and consequently, measures of validityand reliability obtained from psychometric testing. Fourth,although we conducted a comprehensive evaluation of theC-HiP Index, we did not explore face validity. Face validitycan be assessed by asking end-users to subjectively ratethe clarity/transparency and relevance of the instrumentas it appears to them at face value. Finally, when assessingcontent validity, we did not collect data on the first lan-guage of respondents, which might have provided valuableinsight into why experts rated the clarity of BEH03,BEH04 and COG06 as questionable (CVI = 0.70–0.79) orunacceptable (CVI < 0.70). An understanding of howclarity rankings may have associated with first languagecould aide future endeavours to improve the C-HiP Index.ConclusionsDespite these limitations, we offer novel insight into thepsychometric properties of a tool to measure commitmentto hip protectors among paid care providers in LTC. Wehave provided evidence of the content, construct, conver-gent, and concurrent validity, as well as the internalconsistency of the C-HiP Index. The development of a validand reliable assessment tool is a crucial first step in under-standing the relationship between care provider commit-ment and levels of reported adherence in the wearing ofhip protectors amongst residents of LTC. Downstream,findings have the potential to improve the safety and effi-ciency of care for institutionalized older adults, throughdeeper understanding of the factors governing adherence toa promising technology for the prevention of fall-relatedhip fractures, wearable hip protectors.AbbreviationsLTC: Long-Term Care; BC: British Columbia; CPG: Clinical Practice Guideline;MI: Multiple Imputation; EM: Expectation-Maximization; SD: StandardDeviation; EFA: Exploratory Factor Analysis; CVI: Content Validity Index;ICC: Intraclass CorrelationAcknowledgementsWe thank the staff of Bradley Centre, Baillie House, Carelife Fleetwood,Cottage-Worthington Pavilions, Czorny Alzheimer Centre, Delta ViewHabilitation and Life Enrichment Centres, Dr. Al Hogg and WeatherbyPavilions (Peace Arch Hospital), Eagle Ridge Manor, Fellburn Care Centre,Fraser Hope Lodge (Fraser Canyon Hospital), Langley Memorial HospitalResidential Services, Mountain View Manor, New Vista Care Home, Queen’sPark Care Centre, and The Residence in Mission, for volunteering to assistwith and/or participate in data collection. Also, we express our gratitude tothe members of the Injury Prevention and Mobility Laboratory (IPML) atSimon Fraser University for dedicating countless hours to data entry.FundingThis project was funded by AGE-WELL NCE Inc., a member of the Networksof Centres of Excellence program, and team grants from the Canadian Institutesof Health Research (AMG-100487 and TIR-103945 to SNR). AMBK was therecipient of a trainee award from AGE-WELL NCE Inc., and a CIHR FrederickBanting and Charles Best Canada Graduate Scholarship. Neither funding agencyinfluenced the experimental design, the collection, analysis and interpretationof the data, or the writing of the manuscript.Availability of data and materialsThe datasets generated during and/or analysed during the current study areavailable from the corresponding author on reasonable request.Authors’ contributionsAMBK contributed to the experimental design, data collection, data analysis,and preparation and review of the manuscript. JG contributed to dataanalysis and review of the manuscript. FF contributed to the experimentaldesign, data collection, and review of the manuscript. IDC contributed to theexperimental design and review of the manuscript. PML contributed to theexperimental design, data collection, and review of the manuscript. JSGcontributed to the experimental design and review of the manuscript. SNRcontributed to the experimental design, data analysis, and review of themanuscript. All authors read and approved the final manuscript.Korall et al. BMC Geriatrics  (2017) 17:103 Page 11 of 13Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateEthics approval was granted from the Simon Fraser University Office ofResearch Ethics (ORE) and the Fraser Health Authority Research EthicsBoard (REB). Informed consent was implied by the return of completedpaper surveys.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Injury Prevention and Mobility Laboratory (IPML), Simon Fraser University,8888 University Drive, Burnaby, BC V5A 1S6, Canada. 2Centre for Hip Healthand Mobility, 7th Floor, 2635 Laurel Street, Vancouver V5Z 1M9, BC, Canada.3Geriatric Medicine Research Unit, Nova Scotia Health Authority, 5955Veteran’s Memorial Lane, Halifax, NS B3H 2E1, Canada. 4Patient Safety andInjury Prevention, Fraser Health Authority, Suite 400, 13450 102nd Avenue,Surry, BC V3T 5X3, Canada. 5John Walsh Centre for Rehabilitation Research,Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW2065, Australia. 6New Vista Care Home, 7550 Rosewood Street, Burnaby, BCV5E 3Z3, Canada. 7Department of Family Practice, University of BritishColumbia, 5950 University Boulevard, Vancouver, BC V6T 1Z3, Canada.Received: 19 September 2016 Accepted: 25 April 2017References1. 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