Journal of Education and Health Promotion

: 2020  |  Volume : 9  |  Issue : 1  |  Page : 116-

Awareness and attitude of students and professors of medical sciences universities toward social determinants of health: Design and preliminary psychometrics of a questionnaire

Farzaneh Mohammadi1, Mahmoud Keyvanara2, Rahele Samouei2,  
1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Correspondence Address:
Dr. Rahele Samouei
Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan


BACKGROUND AND AIM: Considering the important role of universities in advancing educational, social, cultural, economic, and political affairs and given the significant and effective role of social determinants of health (SDH) in personal and social life, this study aimed to design a preliminary questionnaire to assess the awareness and attitude of students and professors of relevant medical sciences departments toward the SDH. METHODS: This is a descriptive survey study of the instrumentation type and is done on the students and professors of Isfahan and Kashan medical sciences universities in 2019. The content and face validity of the questionnaire were assessed. Cronbach's alpha coefficient and the correlation coefficient for each question as well as the total score of the questionnaire were reported for this attitude measurement questionnaire. The difficulty coefficient, optimum difficulty level, discrimination coefficient, and the relevant variance were calculated for every question in the awareness measurement questionnaire. RESULTS: The internal consistency of the questionnaire for the awareness toward the SDH for 15 questions was 0.742. This consistency was acceptable for 18 questions in the attitude measurement questionnaire after omitting two questions with not appropriate distinguishing ability. The difficulty level of the questions was relatively high. CONCLUSION: Given that no tool was observed in the search strategy to measure the SDH, therefore, the design and psychometrics of such a tool can be used to measure the awareness and attitude of the target audiences; since this tool had an acceptable validity and reliability at its initial stages, researchers are suggested to apply it for standardization in different academic societies.

How to cite this article:
Mohammadi F, Keyvanara M, Samouei R. Awareness and attitude of students and professors of medical sciences universities toward social determinants of health: Design and preliminary psychometrics of a questionnaire.J Edu Health Promot 2020;9:116-116

How to cite this URL:
Mohammadi F, Keyvanara M, Samouei R. Awareness and attitude of students and professors of medical sciences universities toward social determinants of health: Design and preliminary psychometrics of a questionnaire. J Edu Health Promot [serial online] 2020 [cited 2020 Sep 21 ];9:116-116
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In recent decades, there has been an increasing interest in the social determinants of health (SDH) as a basic concept in the health sector.[1] The World Health Organization defines the SDH as the conditions in which people born, grow up, live, work, and get old.[2] These conditions are shaped by political, social, and economic powers.[3],[4] SDH includes a wide range of factors such as income, education, housing, food security, job and job security, social safety net, gender, race, early childhood factors, access to health care, and being indigenous and disability [5] which can affect the health outcomes.[6] Some aspects of socioeconomic factors are directly related to health. For instance, exposure of children to lead used in nonstandard houses results in their low cognitive performance and poor physical development.[7],[8] Pollution and allergy are also more common in deprived areas and can aggravate asthma.[9] Certain groups of the population, especially those with low socioeconomic status, live and work in inappropriate environments and as a result are exposed to higher disease risk factors as well as physiological effects of chronic stress.[10] In addition, socioeconomic factors can worsen people's health condition in a relatively short period of time. For example, exposure to violence increases the likelihood of violence growth among youth [11] and alcohol availability in disadvantaged areas could affect its usage among youth and its harms.[12] Socioeconomic factors could affect people's sleep and have short-term health impacts under the influence of work environment, home, and environmental conditions.[13] Lower intake of fresh foods, lower physical activity, and consuming fast foods could lead to poorer nutrition and less physical activity.[14],[15] Children who grow up in socially disadvantaged areas face challenges in their health condition and health-improving behaviors. Moreover, they often experience stressors and physiological factors including family conflicts and instability caused by inappropriate resources.[16] It seems that not only the poverty-related material deprivation but also childhood chronic stress explains the relationship between the childhood poverty time period and adults cognitive performance.[17] In addition to these relatively quick impacts on health, the effects of health-related socioeconomic factors could influence the outcomes of diseases that appear later in life. The poor socioeconomic condition of surroundings had a direct relationship with smoking even after considering and modifying for several personality traits such as educational achievement and family income.[18]

Proper planning and taking required actions can lower the resulted damages of neglecting SDH and improve health indicators. Therefore, making necessary investments with the SDH approach must be at the forefront of all affairs. Since higher education is one of the main social, economic, political, and cultural elements in any society and a center of training and educating specialized and efficient human capital, therefore, it is of special importance to contribute to the comprehensive development of the country. Having the appropriate awareness and attitude toward the SDH among university students and professors would be a way to create major changes in the attitude and awareness of the society.

Among the available studies, no previous comprehensive study has measured the awareness and attitude toward the SDH. A number of these studies have only addressed some of these factors. Aluko et al. assessed the knowledge, attitude, and performance of the Nigerian health-care personnel towards occupational hazards and safety procedures. This was a descriptive cross-sectional study and used the stratified sampling method to identify 290 respondents. The results showed a high level of knowledge of respondents, but there was a difference in performance.[19]

In a cross-sectional study with 1634 participants, Hu et al. assessed the knowledge, attitude, and relevant behaviors of eating out among university students in China using a questionnaire tool. The results revealed that when the knowledge level increases, the high satisfaction percentage with attitude and behaviors increases too. Only 10% of participants had not eaten out their lunch and dinner over the past week and month. The gender, ethnicity, mothers' training, monthly costs, living place during education, and frequency of eating breakfast out were correlated with the scores of awareness, attitude, and behaviors. Overall, the Chinese students had a poor knowledge and behavior in relation to eating out and they repeated this several times.[20]

El-Nmer et al. examined the effect of nutritional knowledge, attitude, and performance of parents on the nutritional behaviors of their children. The stochastic sampling method was undertaken in this study. The results of this study showed that there is no relationship between the knowledge, attitude, and performance of parents and healthy food consumption by children. Parental education and their socioeconomic status were among the most important determinants of healthy food consumption by children.[21]

Al-Haqwi et al. in a cross-sectional study which based on a self-administrated questionnaire evaluated the knowledge, attitude, and performance of medical students in tobacco smoking in two universities in Riyadh in Saudi Arabia. The results suggested that despite having the knowledge of dangers of tobacco smoking, about 25% of the medical students smoke. They mentioned tobacco smoking as one of the solutions to overcome stress.[22]

Soleymani et al. evaluated the status of awareness, attitude, and declared performance of elderly people in Ahram in association with nutrition-related behaviors. Two hundred elderly people aged 60–75 years from Ahram (capital of Tangestan County, Bushehr Province, Iran) participated in this study. The instrument used was a 4-section questionnaire which contained demographic, awareness, attitude, and nutritional behavior questions. Given the low level of awareness of the elderly people about nutrition, a comprehensive and accurate educational planning to enhance the awareness level of these people appears to be necessary.[23]

Given the important role of universities in advancing the country's educational, social, cultural, economic, and political affairs in one hand and considering the important and effective role of SDH, and moreover, due to the lack of information on the awareness and attitude of individuals and society, especially in the relevant areas, and the need to measure them on the other hand, this study aimed to develop a tool and psychometrics undertaken on it to measure the awareness and attitude of students and professors in medical sciences universities relevant to the SDH.


This descriptive-survey study was done on students and professors of medical sciences universities in Iran in 2019. The study population was all the students and professors in medical sciences universities in Isfahan and Kashan. The disciplines of choice were those related to the SDH and in different educational levels. The data collection tool was the self-determined questionnaire and contained three sections. The first section contained information on demographic variables of the participants including age, gender, marital status, discipline, and education level; the second section contained questions related to measurement of awareness level of the participants (20 questions); and the third section contained questions to measure the attitude of participants (20 questions using Likert scale) toward the SDH. At the first stage, 10 individuals from experts and professors in the disciplines related to SDH were selected to evaluate the content validity and face validity of the questionnaire. The necessary changes were made to the questionnaire based on their corrections. The validity of the attitude measurement questionnaire was evaluated too. The pilot study was conducted with 83 questionnaires distributed among the participants. The questionnaires were collected and the data were entered into SPSS 20 software for descriptive and statistical analysis. Cronbach's alpha coefficient and correlation coefficient of each question and the total score were reported for the attitude measurement questionnaire. Moreover, in the awareness questionnaire, the technical characteristics of each question were assessed to determine its accuracy and deficiencies, and for this purpose, difficulty coefficient, optimal difficulty level, discrimination coefficient, and the relevant variance for each question were calculated. One of the criteria to analyze the questionnaire questions is the difficulty coefficient. The percentage of total participants that correctly answer a question is the difficulty coefficient of that question which is indicated by the letter P:


The difficulty coefficient is a number between 0 and 1. If it is close to 0, it indicates a difficult question, and if it is close to 1, it indicates a simple question. The best difficulty coefficient ranges from 0.3 to 0.7 because it provides the most information about the difference between the participants. In this study, the scores of individuals were ranked from low to high to define the high group and the low group. Twenty-seven percent who received lower scores and 27% who received higher scores were selected to represent the low and the high groups.

To calculate the optimal difficulty level of questions, the formula below was used. P in calculating the optimal difficulty level is the percentage of those who positively answered a question. The optimal difficulty level was between 0.5 and 1 and the most optimal level was 62.5.

Optimal difficulty level=(1+P)/2

Discrimination coefficient identifies the power of question in distinguishing between strong and weak groups of participants. The formula below was used to calculate the discrimination coefficient:


The discrimination coefficient is between +1 and −1. The negative coefficient indicates that the respondents with lower awareness answered the question to a greater extent compared to respondents with more awareness, which implies that the question does not have an appropriate ability to discriminate and is misleading or ambiguous. A coefficient close to 0 does not have the discrimination ability too.

Another variable which was calculated for each question was the variance. The variance of a question was calculated using the formula below:

Variance = P(P - 1)

where P shows the percentage of those who positively answered a question. The variance is between 0 and 0.25, and the higher its value, the better. In fact, each question with higher variance and higher correlation with other questions helps the total variance of the test.


In this study, the information of 83 individuals from students and professors in disciplines relevant to SDH were collected, of whom 71 people (85.5%) were female and 12 people (14.5%) were male, 73 people (88%) were single and 10 people (12%) were married, and 66 people (79.6%) were undergraduates, and their average age was 25.64 ± 2.68 years.

The results of preliminary psychometrics of the attitude measurement questionnaire of students and professors about the social determinants of health

To measure the internal consistency of the attitude measurement questionnaire of students and professors toward the SDH, Cronbach's alpha was calculated and it indicated that by eliminating some of the questions, the value of alpha considerably increases. Given that 5 questions adversely affected the internal consistency of the questionnaire, it was decided to delete questions 2, 12, 17, 18, and 19 from the attitude measurement questionnaire. In [Table 1], the reliability of the attitude measurement questionnaire toward the SDH with 15 questions was calculated.{Table 1}

According to the results in [Table 1], Cronbach's alpha of all questionnaire questions was more than 0.7 and Cronbach's alpha for all questions was 0.742. The value of alpha of 0.7 and higher is desirable and approved.

According to the results in [Table 2], all the questions except question 8 had a positive and significant correlation with the total score of the attitude measurement questionnaire. As there were not many questions in the questionnaire, this question was not eliminated at this stage and was left to be evaluated by psychometrics again in the main run.{Table 2}

The results of preliminary psychometrics of the awareness measurement questionnaire of students and professors about the social determinants of health

Some of the indices of psychometrics tests of knowledge and awareness including difficulty coefficient and discrimination coefficient of questions are reported in [Table 3].{Table 3}

According to the results in [Table 3], the difficulty coefficient of question 10 in the awareness measurement questionnaire was 0.146 and as it is close to 0, therefore, it is considered to be a very difficult question. The difficulty coefficient for other questions is around average or slightly higher than average. The analysis of the discrimination coefficient of the questions revealed that question 10 had a negative discrimination coefficient of −0.05. The discrimination coefficient for question 20 was 0. The questions 10 and 20 were excluded from the questionnaire due to the lack of discriminatory power. On the other hand, despite a positive discrimination coefficient of questions 1 and 11, as they were not powerful enough to discriminate the two groups, they required a revise. It can be seen from the other parts of the results that the variances of all questions of the questionnaire were acceptable and approved. The optimal difficulty level of the questions was also acceptable which can be found in the appendix. The lowest optimal level was related to question 10 with a value of 0.573 which was removed from the questionnaire along with question 20.


This study designed and reported initial psychometrics of awareness and attitude measurement questionnaire of SDH of students and professors of Iran's medical sciences universities. The results of the validity test of the awareness questionnaire indicated some minor and editorial changes that were mostly related to editing questions, changing some words which were difficult or ambiguous for the participants in the study. Some professors also believed that some negative words or adverbs such as “completely” or “always” needed to be changed.

In examining the internal consistency of the questionnaire, if some questions cause this consistency to decline, these questions do not fit in that set. After excluding 5 inappropriate questions, the second stage reliability test reported an appropriate level of internal consistency which indicated the reliability and usability of the questionnaire. Moreover, the positive and significant correlation of each question with the total score of the questionnaire reflected this appropriate capability; however, the only question that was not correlated with the total score was not eliminated at this stage considering the lack of questions in the questionnaire and left to be evaluated in the main rerun.

Assessment of the psychometric properties of the awareness measurement questionnaire showed that the difficulty coefficient of the questionnaire was generally higher than the average which was adjusted after eliminating some questions; however, as the discussions related to the SDH are more of interpretive nature and less frequently deal with true and false answers, there were difficulties in designing the questionnaire. As the right answers in social content questions are generally clear answers among other choices, therefore, it requires more study and analysis to design the wrong choices so that the designed questions have the overall power to distinguish between aware and less aware individuals; however, the reality of the study population is that they generally had little information and awareness about the SDH, and the motivation to design the questionnaire was to measure the awareness and knowledge of academics.

The reader should bear in mind that as this was a pilot study, the number of participants was suitable for the initial preparation of the questionnaire rather than standardization. Another limitation of the study was that the respondents were from different disciplines, levels, and universities and were very highly diverse and dispersed. SDH has many diverse domains, and naturally, the questions would have less consistency to cover different domains.


The results of the psychometrics of the awareness measurement questionnaire for students and professors of medical sciences students of SDH indicated acceptable psychometric properties and validity. This tool can be used in scientific and academic environments to measure the awareness and attitude of professors, students, and researchers to do required targeting and planning based on the measurement results.


We thank all the students and professors who participated in this study.

Financial support and sponsorship

This project was funded by the National Agency for Strategic Research in Medical Education. Tehran. Iran. Grant No. 960440.

Conflicts of interest

There are no conflicts of interest.


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