Desenvolvimento e validação de conteúdo do instrumento ADHERE: avaliação de barreiras e facilitadores para adesão a medidas de prevenção e controle de infecções respiratórias transmissíveis no Brasil

Abstract

Background: The COVID-19 pandemic highlighted the issue of individual and population adherence to recommended measures for the prevention and control of infectious respiratory diseases. However, the low compliance with recommended preventive behaviors and the scarcity of tools that assess this construct in the same population have challenged managers and researchers. Given all the possible clinical, economic, and psychosocial implications, prevention measures at a population level need to be guided by assertive decision-making. Aims: Develop and validate the content of an instrument for the Brazilian population, capable of measuring barriers and facilitators of adherence to recommended measures for the prevention and control of infectious respiratory diseases. Methods: To contemplate the objectives, two studies were carried out. Study 1 included a systematic review (SR) that followed the Cochrane recommendations for the global qualitative synthesis of themes and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The themes emerging in the SR elicited the content for the initial generation of instrument items. These items were classified into two frameworks: the Health Beliefs Model (HBM) and the Capacity, Opportunity, and Motivation Model (COM-B). Study 2 comprised the development and content validation of the ADHERE questionnaire. For the initial construction of the items, in addition to the SR results, in-depth interviews were conducted with representatives of the target population, following the recommendations of the PRO Good Research Practices Task Force Report (ISPOR 1). The items were evaluated by a panel of judges and the questionnaire was submitted to a pre-test with the target population in the Survey format, following the modified e-Delphi Method, as well as the recommendations of the COSMIN methodology for content validity and the PRO Good Research Practices Task Force Report (ISPOR 2). The reduction of items occurred from an Exploratory Factor Analysis (EFA) considering the varimax rotation model and factor loading ≥ 0.45. The internal consistency of the data was evaluated using Cronbach's Alpha Coefficient. The items retained in the factorial analysis were submitted to a qualitative pre-test in the format of cognitive interviews (debriefing) following the recommendations of the PRO Good Research Practices Task Force Report: Part 2 - Assessing Respondent Understanding (ISPOR 2). Results: The systematic review included 71 studies and their qualitative synthesis identified 37 findings of barriers and 23 of facilitators, classified into 10 coded themes and 10 dimensions of the frameworks used (COM-B and HBM). These stages resulted in 68 preliminary items that were judged by a panel of judges, following the modified e-Delphi method, anonymously in three rounds. Items were judged on clarity, objectivity, relevance, feasibility, and comprehensiveness. After the panel of judges, the remaining 61 items were pre-tested on 138 representatives of the target audience, in the Survey format via Jotform®. The respondents evaluated the clarity, relevance, and comprehensiveness dichotomously and anonymously and in this phase, 12 items were eliminated. The results of the Kaiser-Meyer-Olkin test (KMO=0.80) and the Barlett sphericity test (χ²= 3488.09; p<0.001) indicated an adequate fit of the data, allowing the EFA of 49 items. Cronbach's alpha coefficient indicated high internal consistency (α=0.94) for the scale, and after EFA, 34 items were retained, explaining 42% of the total variance. In the cognitive interviews, 16 representatives of the target audience recommended maintaining these 34 items through adjustments and changes in the operationalization of the response scales. Conclusions: The development and content validation of the ADHERE questionnaire ensured semantic and cultural adequacy to evaluate, throughout Brazil, the barriers, and facilitators of the population's adherence to measures to prevent and control emerging and re-emerging infectious respiratory diseases. Its use could generate reliable reports and help policymakers plan, monitor, review, modify, and implement health policies to prevent and control respiratory infections in Brazil.