Journal of Nursing Measurement. Volume 12. Number 3, Winter 2004

Psychometric Testing and Refinement ofthe Support Needs Inventory for Parents

of Asthmatic Children

Christine ToyeLinda J. KristjansonEdith Cowan UniversityChurchlands, Australia

Mardhie E. ColemanMurdoch UniversityMandurah, Australia

Hendrika MaltbyEdith Cowan University

Churchlands, Australia, andUniversity of Vermont

Burlington, VT

Glenda JacksonEdith Cowan University

Joondalup, Australia

This study refined the Support Needs Inventory for Parents of Asthmatic Children (SNI-PAC) (Coleman, Maltby, Kristjanson, & Robinson, 2001) to produce a more parsimonioustool to assess the importance and meet the support needs of parents of children with asth-ma. The original tool was completed by 145 parents of 199 children with asthma, and 74of these also provided test-retest responses. Internal consistency reliability, constructvalidity, and stability over time were assessed and refinements were made. Internal con-sistency reliability of the revised 20-item tool ranged from .77 to .95 for the three subscalesof the Parent's Priority Scale (PPS), and .92 for the full PPS. Cronbach's alphas rangedfrom .74 to .90 for the three subscales of the Parent's Fulfillment Scale (PFS) and was .91for the full scale. Factor analysis results of the PPS were compatible with the tool's con-ceptual framework. The revised 20-item tool demonstrated adequate psychometric proper-ties in most areas. This tool may be used for research or clinical screening without imposingundue burden on parents. Further work is required to establish the tool's stability over time.

Keywords: assessment tool; asthma; parents; reliability; support; validity

Asthma is a complex disease process involving biochemical, immune, infectious,endocrine, and psychological factors (Anderson, Anderson, & Glanze, 1994). It isan episodic, reversible, obstructive airway disease that results in smooth muscle

contraction of the airways, characterized by mucous hyper-secretion, mucosal edema, cellinfiltration, and epithelial desquamation (National Asthma Campaign, 1993). However,asthma is a phenomenon that is more complex than its medical definition suggests. As is

© 2004 Springer Publishing Company 179

180 Toye et al.

true with many other diseases, asthma has a social dimension. There is increasing recogni-tion among researchers and clinicians that the social and medical dimensions of the illnessare linked (Nocon & Booth, 1991). Juniper and associates (1996) have reported that chil-dren with asthma are troubled not only by symptoms, but by the physical, social, educa-tional, and emotional impairments that they experience in response to their asthma as well.The impact of this illness on parents, and the extent to which they are able to help theirchildren respond to demands of the illness, are critical components in understanding thesocial dimension of this disease. Parental needs for support merit investigation because itis known that feeling well supported by others (i.e., perceiving social support to be ade-quate) can minimize the negative impact upon health during a stressful situation (Turner,1992). If parental support needs are not met, the child's needs are less likely to beaddressed, increasing the possibility that they will experience exacerbations of the diseaseprocess. In addition to the suffering associated with this scenario, economic and socialcosts to the community, accrued because of the provision of care to these children, wouldalso increase.

Before health care providers can address the support needs of parents of children withasthma, it is important that these needs be systematically assessed. A search of the literaturehas revealed no published instruments specifically designed for assessing either the relativeimportance of the support needs of this parent group or the extent to which these needs aremet. Tools designed for use with different parent groups may not be appropriate for use withthis population. For example, the Family Support Scale (Dunst, Jenkins, & Trivett, 1984)measures how helpful various sources of social support are to families of young childrenwith or at risk of developmental delay. Similarly, the Support Functions Scale (Dunst &Trivette, 1988) and the Parent Needs Inventoty (Robinson & DeRosa, 1980) are tools pri-marily designed to assess support needs of children with a disability. Parents of disabledchildren tend to provide constant high levels of care and may risk social isolation because ofthis (Britner, Morog, Pianta, & Marvin, 2003). The scenario for parents of children withasthma is different. These parents are likely to provide a lower level of ongoing care but alsoneed to respond to acute, and sometimes life-threatening, exacerbations of the disease.Family assessment tools for use when children are ill, rather than disabled, were reviewedin 2000 by Neabel, Fothergill-Bourbonnais, and Dunning. The nine tools examined assessedeither family functioning or family needs for support, but only one addressed family needswhen there are chronically ill children (i.e., the Family Needs Tool developed by Rawlins,Rawlins, and Homer in 1990). Whereas this tool can (appropriately) be used with parents ofchildren with asthma, some items, such as those addressing bowel/bladder problems and sur-gery, are clearly irrelevant for this parent group. Moreover, a tool designed specifically toassess the support needs of parents of children with asthma might be expected to cover theassessment of these needs more comprehensively.

The Support Needs Inventory for Parents of Asthmatic Children (SNIPAC) (Colemanet al., 2001) was developed as a tool to specifically assess the support needs of parents ofchildren with asthma. The development of this tool is summarized in this article, prior todetailing a study conducted to further test and refine the instrument, conducted at EdithCowan University in Westem Australia. The aims of the study were to (a) produce a moreparsimonious tool that adequately covered the conceptual domain identified during earli-er, qualitative work, and (b) ensure that the tool demonstrated satisfactory psychometricproperties. The refined tool could then be used without burdening parents unduly, eitherfor research in the area or for screening parents to assess requirements for a more thor-ough needs assessment.

Testing and Refining the SNIPAC 181

BACKGROUND AND CONCEPTUAL FRAMEWORK

Coleman and colleagues (2001) initially undertook a descriptive phenomenological studyto examine the experiences of parents of children with asthma and their consequent sup-port needs. These data provided a basis for questionnaire development. Interviews with 15families who had asthmatic children were conducted. Data analysis indicated that parentsexperience economic hardships, lack of support by extended family, worries about safety,and uncertainty about the future. The support needs of parents varied according to theindividual; age of the child; length of time since diagnosis; type, amount, level, and paceof information provided; and support from family, friends, and the community. Six cate-gories of support needs emerged from this early phase of the work: economic support,extended family support, health professional support, community support, educational sup-port, and internal family support.

Coleman and colleagues (2001) validated the thematic analysis through focus groupswith mothers to determine if the interpretation of the interview data accurately reflectedtheir original experiences. During these focus groups, the mothers identified additionalsupport needs, so the analysis was revisited. Six, more inclusive, categories replaced theoriginal ones derived only from the family interviews. The newly identified categories ofsupport needs were for

1. support bolstering the parent's spirit;2. informational support assisting the parent in the caregiver role;3. knowledge of care available for the child in the community, outside the home or

healthcare setting (e.g., from teachers);4. partnering by health care professionals in the provision of health care for the child;5. support allowing the parent to meet his or her own care needs; and6. support allowing lifestyle planning, including financial support.

A broader overarching conceptual framework was also subsequently defined, entitled"Leaming to Be a Parent of a Child With Asthma," based upon the results of this descrip-tive phenomenological study. The conceptual framework described the phases of chal-lenges to competency that parents experience as they learned to care for their asthmaticchildren (Maltby, Kristjanson, & Coleman, 2003). The impact of this illness on parentsand the extent to which they were able to help their children respond to demands of asth-ma were critical components in understanding the effect of this disease on parentalcompetency. The framework is shown in Figure 1 and demonstrates relationships among

Parenting competence challenged:"NAMING ASTHMA"

Parentmg competence uncertamty:"TAKING ON THE REALITY"

Parenting competence reclaimed:"GETTING ON WITH IT"

Figure 1. Leaming to be a parent of a child with asthma.

182 Toye et al.

three main concepts: "Parenting Competence Challenged: Naming Asthma," "ParentingCompetence Uncertainty: Taking on the Reality," and "Parenting Competence Reclaimed:Getting on With It."

The six categories of support needs that shaped the questionnaire were viewed as con-sistent with potential support needs that parents may have at any stage as they learn tobecome a parent of a child with asthma. These support needs may vary in priority and indegree of fulfillment. Therefore, the questionnaire was structured in two scales (the Parents'Priority Scale [PPS] and the Perceived Fulfillment Scale [PFS]) and based upon the sixcategories of support needs.

PROCEDURES FOR INSTRUMENT DEVELOPMENT

Items related to each of the six categories designated after the focus groups were generat-ed from the qualitative data. These items used the informants' words wherever possible toincorporate content validity into the developing instrument. Results were shared with par-ticipants who provided confirmation of the categories and the emerging conceptualframework.

To ensure that the tool was clearly written, that items were clustered appropriately, andthat content validity was demonstrated, a panel of experts, six parents of children withasthma, were mailed the SNIPAC (Coleman et al., 2001), instructions, and a response for-mat. Percent agreement was used to determine if items were acceptable. A preset agree-ment of five of six parents was used (at least 83% agreement) as the decision rule forretaining an item. The panel members were asked to evaluate each item and indicate if itwas clear. They were also asked to determine whether the items belonged together andwhether each item belonged in the selected subscale set. Space was provided for the panelmembers to comment further. All items met the preset criterion of 83% agreement for clar-ity and agreement that the item belonged in the subscale set.

Content validity of items was determined by asking panel members to read each itemand the title of the subscale to determine whether the title of the subscale was appropriatefor the set of items. Panel members also rated whether each item was a type of supportneed, defined as a requirement for assistance by parents in response to their efforts to carefor their child with asthma, using a Yes/NoAJnsure response option with space for com-ment. Items all met the preset criterion of 83% acceptability. Finally, raters indicated ifany items on the scale were redundant and if any were missing from the scale and shouldbe added, again using a Yes/No/Unsure response option with space for comments. A fewminor suggestions for wording improvements were mentioned, the preset criterion was met,and no evidence of redundancy was noted.

DESCRIPTION, ADMINISTRATION, AND SCORINGOE THE INSTRUMENT

The first draft of the SNIPAC (Coleman et al., 2001) comprised 48 items, each a statementdescribing a support need. The tool was formatted as two scales (i.e., two sets of responseoptions were listed beside each item), the PPS and the PFS.

The PPS measured the relative importance of each of the support needs. Responseswere Not Important (scored as 1), Somewhat Important (2), Average Importance (3), Very

Testing and Refining the SNIPAC 183

Important (4), and Extremely Important (5). These ratings were explained at the beginningof the questionnaire, as a heading to the responses for the PPS. Ratings (i.e., numbers 1-5)were listed beside each item and respondents were asked to circle the appropriate number.

The PFS measured the extent to which each of the needs was met. PFS responses wererequired to be ticks placed in blank columns headed Met (scored 3), Partly Met (2), andUnmet (1). These columns were to the right of the columns used for the PPS so that par-ents would read each item, assess the priority of the need first, and then indicate the extentto which it was met.

The proposed subscales contained the same items for the PPS and the PFS. These sub-scales corresponded to the six categories of support needs identified after the focus groups:Personal Support Needs (8 items). Information Support Needs (22 items). CommunitySupport Needs (4 items), Medical Support Needs (6 items). Self Care Support Needs (5items), and Lifestyle Support Needs (3 items). Summed overall scores for the PPS demon-strated the importance attributed to these support needs overall. Summed PPS subscalescores demonstrated the importance attributed to the different categories of support needs.Summed scores for the PFS identified the extent to which the overall support needs rele-vant to parents of children with asthma were met. Summed PFS subscale scores demon-strated the extent to which the categories of needs were met.

Whether used in the research or the clinical context, subscale and total scale scoreswould be useful overall indicators of the importance of needs and of the extent to whichthey were met. In both instances, individual item scores might also be examined to inter-pret findings.

METHODS EOR TESTING AND REFINING THE TOOL

Following the receipt of ethical approval from the institutional ethics committee of theadministering university for all procedures, and from the ethics committee of a children'shospital for the distribution of some questionnaires by staff of the emergency department,we conducted a survey to obtain data for assessment of the psychometric properties of thetool. Parents of children with asthma were recruited throughout Western Australia viamedia; notices sent to schools and swimming clubs; questionnaires distributed by commu-nity nurses, school nurses, and the emergency department nurses; and directly from swim-ming pools hosting the statewide swimming program for children with asthma. On eachoccasion, access to parents was negotiated via the official contact person. Each survey packincluded a demographic data collection form, information sheets about the study, SNIPACquestionnaire (Coleman et al., 2001), and the consent form required by one of the ethicscommittees. To allow assessment of the stability of the instrument over time, two question-naires were included in initial questionnaire packs with two return envelopes and a letterexplaining the test-retest process.

Initial exploratory analyses included the documentation of sample characteristics. Thedata analysis process for tool reliability and validity testing used only time 1 (Tl) dataexcept when stability over time was assessed. Validity and reliability testing used PPS datain preference to PFS data because the PPS was theoretically more likely to elicit consis-tent responses (i.e., the extent to which needs are met may vary from day to day, dependingupon contact with others, but the relative importance of needs is likely to be a more endur-ing construct). As it was desirable to obtain a parsimonious tool, refinement involved itemdeletions. Initial decisions to delete items took into account items with exceptionally high

184 Toye et al.

rates of missing PPS or PFS responses. Thereafter, all deletions were prompted by thefindings of PPS analyses but were automatically made from both scales. Although the con-struct validity of the PFS was not assessed, the affect of any deletions on the conceptualdomain of this scale was evaluated throughout the refinement process, with a view to ensur-ing that this domain remained intact.

Approaches to Reliability Assessment

Internal Consistency. A baseline assessment of the internal consistency reliability ofboth scales was carried out at the beginning of the data analysis process. We calculatedinternal consistency reliability estimates using Cronbach's alpha coefficient. Internal con-sistency reliability assessment was also conducted (for the PPS) as a part of tool refine-ment, a coefficient of greater than or equal to .70 being preset as the acceptable criterionfor reliability of the scale (Nunnally & Bernstein, 1994). As suggested by Carmines andZeller (1979), the criterion set for item-to-total correlations demanded that at least 50%of retained item scores correlated with total subscale scores in the range .30 to .70. Forinter-item correlations, the criterion was that scores of retained items should correlatewith 50% or more of other item scores in the range .30 to .70. At the end of the refine-ment process, we again assessed the internal consistency reliability of both the PPS andPFS.

Stability. The time interval between the completion of the two copies of the question-naire was to be 24 hours, a brief interval to prevent contaminadon of assessment ofstability of the tool by changes in the child's illness. It is essential when testing the sta-bility of an instrument over time that the researchers select a time interval that does notallow for changes in the phenomenon during this fime interval (De Vellis, 1991; Streiner& Norman, 2000). The 24-hour time interval between test and retest time points hasbeen used previously with this type of tool without association with a memory effect(Kilpatrick, Kristjanson, & Tataryn, 1998) and was judged to be appropriate given poten-tial changes in parents' perceptions over a short time period. We computed correlationsbetween time 1 and time 2 PPS and PFS data to assess the stability of the instrument overtime, using the intraclass correlation coefficient (ICC) and only including items retainedin the refined instrument. Nunnally and Bernstein (1994) suggest that a correlation of atleast .70 may be considered to be satisfactory in such an assessment.

Approaches to Validity Assessment

We needed to assess the construct validity of the SNIPAC (Coleman et al., 2001), establish-ing whether the categories of items designated during the construction of the tool did, infact, demonstrate its true (subscale) structure. We also needed to re-cluster the items appro-priately if an alternate structure became evident and to delete items that were not essentialto the conceptual domain in the given structure. To do this, we conducted a factor analysisof the PPS using principal components analysis. Criteria for factor analysis estimates werethat factors included should have eigenvalues of greater than one and be supported by resultsof a scree plot analysis. The scree plot would show a gradual decrease in eigenvaluesbefore a plateau and only factors identified prior to the plateau would be considered valid(Cattell, 1966). Factor loadings should be of at least .40 with differences of at least .15 foritems loading on different factors. Missing responses were not imputed for the purpose ofthe analysis process; rather, the reasons underlying missing responses were carefully con-sidered as part of the decision-making process around the retention or deletion of items.

Testing and Refining the SNIPAC 185

RESULTS

Sample

We obtained a convenience sample of 145 parents of children with asthma at time 1. Ofthese parents, 74 also provided time 2 responses. Although a case-to-variable ratio of 5 to1 is recommended, according to Aleamoni (1973, 1976), a sample size of at least 100 issufficient to allow the required statistical preliminary examination of the properties of theinstrument and should provide reasonably stable results.

Parents participating in the study were predominantly mothers (n - 134, 92.4%).Seventy-three participants (50.3%) reported completing post-secondary education cours-es, and 41 of these (28.3% of the sample) indicated that they held baccalaureate degrees.Nine participants (6.1%) had not progressed past Grade 8 in their formal education.Parents' ages varied widely and are summarized in Table 1. Fifty-three (36.6%) parentsreported having more than one child in the family with asthma. The highest number of chil-dren with asthma in any one family was four.

There were 199 children with asthma referred to by their parents in the questionnaires(5 being aged older than 20 years). These children included 92 (46.2%) females and 107(53.8%) males. Thirty-five (18.4%) of these children were said by their parents to havesevere asthma, 68 (35.8%) moderate asthma, and 90 (47.4%) mild asthma. The general prac-titioner (GP) was considered to be the main medical provider for the asthmatic child(ren)in the family in 114 cases (78.6%). Respiratory consultants were identified as the mainmedical providers in 14 cases (9.7%), and pediatricians were nominated in 11 cases (7.6%).There was a wide range both in the number of years these children had suffered with asth-ma and in their ages (Table 1).

We collected information about children's medication using the demographic data col-lection form. Medications used to treat asthma in children were categorized as "puffer"bronchodilators, bronchodilators administered via a nebulizer, long-acting (oral) bron-chodilators, preventative medications, antihistamines, and oral steroids. Approximately50% of the children were taking preventative medication, and almost all of them wereusing bronchodilators in puffer form. Five percent of the children were taking long-actingbronchodilators and 9.5% were taking oral steroids. More than 25% of the children weretaking combinations of bronchodilators and preventatives, but only 2.5% were taking anti-histamines (Table 2).

TABLE 1. Participants' and Children's Demographic Characteristics

Characteristic M SD Range

Age of participantAge of child 1 with asthmaAge of child 2 with asthmaAge of child 3 with asthmaNumber of years with asthma (child 1)Number of years with asthma (child 2)Number of years with asthma (child 3)

37.26 7.00 21-57 1398.787.576.515.685.416.23

4.453.966.934.113.896.59

1-251-220-210-250-220-21

14343

713743

8

186 Toye et al.

ocu

IPU

TS

.a

o

"3

dai

C3

•a

-3I

p p p p p >oci22222^ o o o o --<

p p P IT) pO O —< O O

O O CN -^ O

OON

pvd O CN

IT) v q

CN

ON CN O0 0 —• ^

j2 22.-S

ca

1uo

OS

•a xio o

O X)

X> No ^ - 2 g o

00 Sd -S 㤠1 ' ^ ^(2 z J (i: < o u

T3

I

lU

o

oe n

II

•2

I

Testing and Refining the SNIPAC 187

Preliminary Internal Consistency Assessment

In the case of the 48-itetn instrument, Cronbach's alpha coefficients for the proposed sub-scales ranged from .67 to .91 for the PPS (.96 for the whole scale) and from .75 to .93 forthe PFS (.95 for the whole scale). The high levels of some of these coefficients suggestedlikely redundancies. Missing data for the PPS ranged from a single response (.68%) to 12responses (8.28%); for the PFS it ranged from 1 response (.68%) to 17 responses (11.72%).Missing responses for the PPS totaled 262 (3.76% of a possible 6,960 responses).

Detailed and painstaking examination of items included in the tool resulted in theshort-listing of items for possible deletion with reference to time 1 responses and the fol-lowing concerns:

• the percentage of responses missing in either scale and whether these responses werelikely inapplicable to some participants (e.g., when the item referred to siblings of thechild with asthma);

• the relative importance of the need to which the item referred, as shown by PPSresponses;

• the possibility that consistently low inter-item PPS correlations might indicate that anitem did not belong in the questionnaire; and

• the possibility that highly correlated PPS responses to items might mean that these itemswere subsumable or redundant.

The level of item-to-total correlations was not considered at this stage of the analysisbecause the structure of the tool had not yet been assessed.

Eighteen items were deleted at this stage. Reasons for deletions were as follows:

• more than 10% missing data, poorly correlated with other items, and rated in the sixleast important needs (3 items);

• insufficiently correlated with other items and rated in the six least important needs (1item);

• highly correlated and redundant or subsumable (total of 14 items, one with more than10% missing data).

Correlations of items that were deleted because they were highly correlated and redun-dant or subsumable are summarized as follows: .76, one item; from .80 to .89, eleven items;.90 or above, two items.

Construct Validity Assessment

After the initial 18 item deletions, a factor analysis was conducted. The 30-item PPS wasexamined using principal components analysis. Oblique rotations provided the most inter-pretable solutions. In the first instance, a six-factor solution was requested, because sixsubscales had been designated by the researchers based on theoretical and practical knowl-edge. The six-factor structure was not confirmed. This lack of confirmation indicated tothe researchers that family members might not view their support needs in the ways orig-inally clustered by the researchers based on the early qualitative results.

The next approach was to discover a possible alternate subscale construction. When werepeated the analysis without entering a predetermined number of factors, examination ofthe scree plot suggested a two-, three-, or four-factor solution. The three-factor solutionwas the most interpretable. The variables with the highest loadings were used to help todefine the factors, which were named Reliable Alliance (support assisting the parent to workwith others to provide the best possible care for the child). Parent Assistance (support

188 Toye et al.

allowing the parent to meet his or her own needs in the context of having a child with asth-ma), and Support Addressing Family and Peripheral Issues. Eigenvalues were 13.28, 2.71,and 1.91, respectively. The three factors accounted for 59.68% of the variance. Twenty-seven items loaded clearly onto the factors, 17 items on Factor 1, 7 on Factor 2, and 3 onFactor 3. Three items were deleted at this stage because they were not separated by mar-gins of at least .15; the highest loadings for these were .38, .41, and .42.

We then deleted further items after examination of inter-item and item-to-total correla-tions, considering qualitative implications of deletions carefully. A summary of reasonsfor deletions is as follows: more than 50% of inter-item correlations and of item-to-totalcorrelations exceeding .70 (4 items), more than 50% of inter-item correlations less than.30 (2 items, item-to-total correlations .45 and .47), and item not fitting conceptually withother items (1 item). As a result of one of these deletions. Factor 3 was clarified andrenamed "Family Role Assistance," the support needed to help the parent fulfill his or herrole in parenting the siblings of the child with asthma.

The final version of the tool has 13 items in the Reliable Alliance subscale, 5 in theParent Assistance subscale, and 2 in the Family Role Assistance subscale. Table 3 showsthese items along with factor loadings. The eigenvalue for Factor 1 (Reliable Alliance)was 9.10, and this factor accounted for 45.51% of the variance. The eigenvalue for Factor2 (Parent Assistance) was 2.21; this factor accounted for 11.05% of the variance. The eigen-value for Factor 3 (Family Role Assistance) was 1.50; this factor accounted for 7.52% of thevariance.

Items in the Reliable Alliance subscale are from the previously nominated PersonalSupport Needs, Information Support Needs, and Medical Support Needs subscales. Itemsloading on this factor cover the parent's knowledge of the care and treatment provided forthe child by others, including that the care is the best possible, and of the parent's role inthe child's care. These items address the concept of the child's parents being part of thehealth care team working, with the support of others, in the child's best interests, hence thesubscale title. The items in the Parent Assistance subscale are almost all from the previous-ly nominated Self-Care Support Needs and Lifestyle Support Needs subscales and addressthe needs of the parent to maintain their own health and well-being. The two items in theFamily Role Support subscale are both from the previous Information Support Needs sub-scale and address the need of the parent to know how to support any other children in thefamily relevant to having a sibling who has asthma.

Further Internal Consistency Assessment

To confirm the internal consistency reliability of the instrument's structure as demonstratedby the analysis, we assessed Cronbach's alpha coefficients for the revised PPS and therevised PFS, plus all the subscales. Table 4 shows the estimates of internal consistency reli-ability for the PPS subscales and Table 5 shows those of the PFS. Cronbach's alpha coef-ficient for the full PPS was .92 (N =113), for the full PFS it was .91 (A = 97).

Assessment of the 18-Item Instrument's Stability Over Time

Tables 6 and 7 document ICCs for the time 1 and time 2 scores for the PPS and the PFS,respectively. Whereas all correlations between time 1 and time 2 subscale scores were sig-nificant, those for the Reliable Alliance subscale of the PPS were significant at the .05level and the remainder was significant at the .001 level. In the case of the PPS, the recom-mended criterion of a correlation of at least .70 was only achieved in the Parent Assistance

Testing and Refining the SNIPAC 189

TABLE 3. Items Retained in the Support Needs Inventory for Parents of AsthmaticChildren

Factor Loading Item

Reliable Alliance0.570.99

0.63

0.800.630.560.940.940.68

0.580.89

0.71

0.58

Parent Assistance0.580.840.870.63

0.48

Family Role Support0.90

0.94

Feel there is help and supportBe assured that the best possible health care is being given tomy childKnow that the health care professionals see me as the centralperson in my child's careKnow the long-term issues of my child's illnessKnow to whom I should direct my questionsKnow to whom to tum if conflict situations ariseKnow what treatment my child is receivingKnow what side effects the treatment can causeKnow what information to give to my child with asthma (appro-priate to his/her age)Know how environmental factors can affect my childKnow that my child's teachers have the knowledge to supportmy child at school/daycare/after-school careKnow that my child's sporting associations are able to act appro-priately in times of acute episodesKnow what situations I can and cannot control while my child isin hospital

Be told about people who could help with my concernsHave someone to be concerned with my healthHave time to myselfFeel encouraged by health care professionals to maintain a nor-mal lifestyleHave financial assistance to help cope with costs of my child'sillness

Know what information to give to my other children (appropri-ate to their ages)Know how to handle the feelings of my other children

TABLE 4. The 20-Item Parents' Priority Scale: Estimates of Internal ConsistencyReUahility for Suhscales

Subscales

One (13 items)Two (5 items)Three (2 items)

Inter-ItemCorrelations

M Range

0.58 0.35-0.870.41 0.30-0.73

Item-to-TotalCorrelations

M Range

0.74 0.63-0.860.54 0.41-0.64

Cronbach'sAlpha

0.950.77

». n 0"

N

ni129133

190 Toye et al.

TABLE 5. The 20-Item Perceived Fulfillment Scale: Estimates of InternalConsistency Reliahility for Suhscales

Inter-Item Item-to-TotalCorrelations Correlations Cronbach's

Subscales M Range M Range Alpha N

One (11 items) 0.34 0.09-0.57 0.55 0.38-0.67 0.87 111Two (5 items) 0.36 0.15-0.59 0.50 0.35-0.43 0.74 118Three (2 items)

TABLE 6. Test-Retest Correlations for the 20-Item

Reliable AllianceSubscale

Intraclass 0.26*

Parent AssistanceSubscale

0.86*"

>-

Parents' Priority

0.90

Scale

Family Role AssistanceSubscale

0.60***

128

WholeScale

0.53***

Note. V < . 0 5 . ***/7<.OOl.

TABLE 7.

Intraclass

Test-Retest Correlations for the 20-Item

Reliable Alliance 1Subscale

0.87***

Parent AssistanceSubscale

0.81***

Perceived Fulfillment

Family Role AssistanceSubscale

0.81***

Scale

WholeScale

0.86***

Note.

subscale. The same criterion was achieved in all subscales and the total scale in the caseof the PFS. Further exploration of correlations between the test and retest scores for indi-vidual items in the Reliable Alliance subscale of the PPS was undertaken to endeavor toexplain the low levels of these correlations. We found that the lowest correlations occurredin the case of the two items describing a need for information about treatment and sideeffects (ICC = .03 in both instances).

DISCUSSION

This study has built upon the previous work of Coleman and colleagues (2001). Theseresearchers developed a tool to measure the importance and fulfillment of the needs ofparents of children with asthma from individual and focus group interviews with 15 fam-ilies. To further test the tool, survey data were obtained from an additional 145 parents.Using these data, we were able to identify an abbreviated version of the SNIPAC that hasdemonstrated internal consistency reliability and construct validity. The new, shorter versionminimizes the burden for participants, but has been revised with extreme caution so thatthe conceptual domain covered by the questionnaire remains intact.

Testing and Refining the SNIPAC 191

For both clinical and research purposes, it is important that the tool is quick to com-plete. In research studies, the tool may be used in conjunction with other tools, for example,to assess the need for a support intervention at pre-test and demonstrate its effectivenessat post-test, also measuring a likely outcome of increased support, such as reduced psycho-logical stress. A large number of items to complete is likely to equate with a low responserate. In the clinical setting, the likely scenario is that a busy health professional will ask aparent to complete the questionnaire when he or she is already experiencing time pressuresbecause of the added burden of caring for a sick child. A brief questionnaire is, therefore,likely to get used more often in the clinical setting than a longer version and will identifysupport issues that can subsequently be explored in more depth.

The subscales identified in the final version are slightly different from those pro-posed based on the initial subscale classifications. The items are now clustered accord-ing to the purpose underlying support needs, based upon the factor analysis resultsobtained from this study's data. Information support needs are now included in theReliable Alliance subscale. This reflects the need of the parent for information thatallows him or her to work with others to support the child with asthma. Likewise, theinclusion of medical support needs in this subscale reflects the need of the parent for thesupport of the physician as a partner in the care of the child. Personal support is alsoincluded in this cluster of items, reflecting the parent's need for support as a partnerwith others in caregiving. The Family Role Support subscale comprises items describ-ing informational support also, but the information required in this instance is thatwhich will help a parent to deal with the impact of a child's asthma on siblings. The ParentAssistance subscale has items that are almost exclusively concerned with self-care andlifestyle support, needed so that the parent may maintain his or her own health to carefor the child.

The overarching conceptual framework that describes the process that parents experi-ence as they learn to live with a child with asthma provides a helpful conceptual structure.Use of the SMPAC can examine the extent to which support needs change at differentphases of the parent's response to having a child with asthma.

Limitations

We acknowledge the limitations of this study. Firstly, we have only, as yet, completed pre-liminary testing of the tool. Clearly, much additional work is required. Secondly, althoughwe predicted that the PPS would produce more stable findings than the PFS, stability overtime was actually a concem for the PPS, perhaps because the dynamic nature of asthmaaffected the importance that parents attributed to the various kinds of support. Parents mayprioritize their needs differently when their child is acutely ill, and a child who was ill attime 1 may have been comparatively well even 24 hours later, and vice versa. The fact thatthe lowest correlations from test to retest were in items concerning a need for informationabout treatment (part of the Reliable Alliance subscale) tends to support this assertion.However, we did not collect data about acute illness in children so, in further work toassess the tool's stability, this information will need to be collected. Thirdly, we have onlyaddressed the construct validity of the PPS in this study, not that of the PFS. Having twosets of responses for parents to choose for each item is likely to focus their thoughts aboutthe item. However, whether items should be grouped in the same way for the PPS and thePFS for analysis purposes merits further investigation than has occurred in the studyreported here.

192 Toye et al.

Conclusions

The SNIPAC, developed by Coleman and colleagues (2001), is a tool that has been testedand refined during this study. The fact that the stability over time of one scale of the toolwas not well demonstrated is most likely due to the dynamic nature of the disease, and allremaining documented psychometric properties of the tool are satisfactory. Further test-ing over an even shorter time frame may be associated with a memory effect; one optionwould be, therefore, to repeat stability testing over a time frame of about 2 weeks but doc-umenting the illness status of the child at the two time-points. Data from parents whosechildren's illness status differed from time 1 to time 2 would be excluded from the stabil-ity assessment of the tool. Another priority for the testing of the tool is to discover if itemsin the PFS should be grouped differently for analysis purposes. The final priority for fur-ther testing of the tool is to assess its validity with a tool that assesses a related concept,for example, one measuring parental coping. In this kind of validation exercise it might behypothesized that parents whose greatest support needs were met would cope better withcaring for a child who has asthma than those whose greatest needs were unmet. Our 18-itemtool is one that will not be burdensome for busy parents to complete and should be a valu-able aid to those wishing to assess the support needs of parents of children with asthma.

REFERENCES

Anderson, K. N., Anderson, L. E., & Glanze, W. D. (Eds.). (1994). Mosby's medical, nursing, andallied health dictionary (4th ed.). St Louis: Mosby.

Aleamoni, L. (1973). Effects of size of sample on eigenvalues, observed communalities and factorloadings. Journal of Applied Psychology. 58, 266-269.

Aleamoni, L. (1976). Tlie relation of sample size to the number of variables using factor analysistechniques. Educational and Psychological Measurement. 36, 879-883.

Britner, P. A., Morog, M. C, Pianta, R. C , & Marvin, R. S. (2003). Stress and coping: A compari-son of self-report measures of functioning in families of young children with cerebral palsy orno medical diagnosis. Journal of Child and Eamily Studies, 12(3), 335-348.

Carmines, E. G., & Zeller, R. A. (1979). Reliability and validity assessment. Beverly Hills, CA: Sage.Cattell, R. B. (1966). The scree test for the number of factors. Multivariate Behavioral Research. 1,

245-276.Coleman, M. E., Maltby, H., Kristjanson, L. J., & Robinson, S. (2001). Supporting the needs of par-

ents of children with asthma. In C. Hernandez-Green, J. K. Singleton, & D. Z. Aronzon (Eds.),Primary care pediatrics (pp. 699-702). Philadelphia: Lippincott.

De Vellis, R. F. (1991). Scale development: Theory and applications. Newbury Park, CA: Sage.Dunst, C. J., Jenkins, V., & Trivette, C. M. (1984). The Family Support Scale: Reliability and valid-

ity. Journal of Individual. Family and Community Wellness. 1, 45-52.Dunst, C. J., & Trivette, C. M. (1988). Support Functions Scale. In C. J. Dunst, C. M. Trivette, & A.

G. Deal (Eds.), Enabling and empowering families: Principles and guidelines for practice (pp.143-146). Cambridge, MA: Brookline Books.

Juniper, E., Guyatt, G. H., Feeny, D. H., Ferrie, P. J., Griffith, L. E., & Townsend, M. (1996).Measuring quality of life in children with asthma. Quality of Life Research, 5(1), 35-46.

Kilpatrick, M., Kristjanson, L.J., & Tataryn, D. J. (1998). Measuring the information needs of hus-bands of women with breast cancer: Validity and reliability of the family inventory of needs-husbands. Oncology Nursing Forum. 25, 1347-1351.

Maltby, H., Kristjanson, L., & Coleman, M. (2003). The parenting competency framework:Leaming to be a parent of a child with asthma. International Journal of Nursing Practice. 9, 6.

National Asthma Campaign. (1993). Asthma management handbook. Melboume, Australia: NationalAsthma Council of Australia.

Neabel, B., Fothergill-Bourbonnais, F., & Dunnig, G. (2000). Family assessment tools: A review ofthe literature from 1978-1997. Heart and Lung: The Journal of Critical Care, 29(3), 196-209.

Testing and Refining the SNIPAC 193

Nocon, A., & Booth, T. (1991). The social impact of asthma. Family Practice. 8(I), 37-41.Nunnally, J. A., & Bemstein, 1. (1994). Psychometric theory. New York: McGraw-Hill.Rawlins, P. S., Rawlins, T. D., & Homer, M. (1990). Development of the Family Needs Assessment

tool. Westem Journal of Nursing Research. 12(2), 201-214.Robinson, L. E., & DeRosa, S. M. (1980). Parent Needs Inventory (Rev. ed.). Austin, TX: Parent

Consultants.Streiner, D. L., & Norman, G. R. (2000). Health measurement scales: A practical guide to their

development and use (2nd ed.). Oxford, UK: Oxford University Press.Tumer, R. J. (1992). Measuring social support: Issues of concept and method. In H. O. F. Veiel &

U. Baumann (Eds.), The meaning and measurement of social support (pp. 217-233). NewYork: Hemisphere.

Offprints. Requests for offprints should be directed to Christine Toye, RN, PhD, Edith CowanUniversity, School of Nursing, Midwifery, and Postgraduate Medicine, Pearson Street, Churchlands,Westem Australia, Australia 6018. E-mail: c.toye@ecu.edu.au