Urban traffic-related determinants of health questionnaire

Original Article Medical Journal of the Islamic Reublic of Iran (MJIRI) Iran University of Medical Sciences Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 Urban traffic-related determinants of health questionnaire (UTDHQ): an instrument develoed for health imact assessments Haidar Nadrian, Saharnaz Nedjat, Mohammad Hossein Taghdisi Davoud Shojaeizadeh Received: November 0 Acceted: March 0 Published: August 0 Abstract Background: Traffic and transort is a substantial art of a range of economic, social and environmental factors distinguished to have imact on human health. This aer is a reort on a reliminary section of a Health Imact Assessment (HIA) on urban traffic and transort initiatives, being conducted in Sanandaj, Iran. In this reliminary study, the sychometric roerties of Urban Traffic related Determinants of Health Questionnaire (UTDHQ) were investigated. Methods: Multistage cluster samling was emloyed to recruit key informants in Sanandaj from Aril to June 0 to articiate in the study. The develoment of UTDHQ began with a comrehensive review of the literature. Then face, content and construct validity as well as reliability were determined. Results: Exloratory Factor Analysis showed otimal reduced solution including 0 items and factors. Three of the factors identified were Physical Environment, Social Environment, Public Services Delivery and Accessibility. UTDHQ demonstrated an aroriate validity, reliability, functionality and simlicity. Conclusion: Desite the need for further studies on UTDHQ, this study showed that it can be a ractical and useful tool for conducting HIAs in order to inform decision makers and stakeholders about the health influences of their decisions and measures. Keywords: Urban traffic, Health Imact Assessment, Social Determinants of Health, Factor Analysis, Questionnaire, Psychometric Proerties. Cite this article as: Nadrian H, Nedjat S, Taghdisi M.H, Shojaeizadeh D. Urban traffic-related determinants of health questionnaire (UTDHQ): an instrument develoed for health imact assess-ments. Med J Islam Reub Iran 0 ( August). Vol. :. Introduction Traffic and transort is a substantial art of a range of economic, social and environmental factors beyond the health care sector which are distinguished to have imact on human health (-). This imact may damage or romote health (). Examles of these otential health imacts may include air and noise ollution, health services delivery, enabling access, social suort, emloyment, economic develoment and road traffic injuries. Traffic congestion is a significant issue in almost every urban area around the world () and in Iran, as well. As a ublic health issue, it may be resulted from several causes including bad street layout, too many cars, oor driving behaviors and inefficient traffic control systems (). Whatever the reason is, it is clear that the imact of urban traffic and transort and their related olicies and rojects on health determinants are influential. Acheson in a seminal reort on inequalities in health in the UK had a secial emhasis on the association between urban traffic and health (). As he noted, urban. PhD student in Health Education and Promotion, Deartment of Health Education and Promotion, School of Health and Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran. nadrian@razi.tums.ac.ir. Associate Professor in Eidemiology, Deartment of Eidemiology and Biostatistics, School of Health, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran. s_nt@gmail.com. Associate Professor in Health Promotion, Deartment of Health Education and Promotion, School of Health, Iran University of Medical Sciences, Tehran, Iran. taghdisi_mh@gmail.com. (Corresonding author) Professor in Health Education, Deartment of Health Education and Promotion, School of Health and Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran. shojaei@yahoo.com

Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 Psychometric roerties of Urban Traffic-related Determinants of Health Questionnaire traffic and transort may have ositive and negative influences on health and so, there is a need to address these influences through relevant models such as Health Imact Assessment (HIA). Urban traffic and transort olicy is highly relevant to HIA, which is a combination of rocedures, methods and tools by which a olicy, rogram or roject may be judged as to its otential effects on the health of a oulation, and the distribution of those effects within the oulation (). HIA may comrise a broad definition of health; careful consideration of social, environmental or economic determinants of health; articiation of affected stakeholders; alication to a broad set of olicy sectors; and concerns about social equity (9). After collecting data and interreting evidence regarding otential urban trafficrelated health imacts and demonstrating the well-timed and relevant results and recommendations to decision- and olicymakers by HIA, it may be exected to include the obtained information into the urban traffic-related decision-making rocess to hel lessen harm and increase health advantages (0). Therefore, it was decided to conduct a HIA on urban traffic in Sanandaj, Iran, with a secial focus on traffic calming measures erformed by local government. To the best of our knowledge, this is the first HIA study conducted on urban traffic in Iran. In order to study any subject and, also, collect required information with the highest accuracy and the least mistakes, there is a need to reliable and valid instruments related to that subject (). Searching literature in the area of HIA, esecially on urban traffic and transort, showed that the number of reliable and valid instruments in this area is scarce. Also, the studies that conducted HIA on urban traffic, have not reorted the reliability and validity of the instruments used for data collection (, -). A reason for the rare number of instruments may be the novelty of HIA, which has not been well introduced and acceted as an imortant ublic health method () nor a tool for socially resonsible olicy and ractice, esecially in develoing countries like Iran. Thus, the researchers decided to develo a trustworthy instrument, as a first stage of HIA, in order to ensure obtaining comrehensive data on urban traffic-related health determinants in Sanandaj, Iran. One ositive oint of the resent study is roviding such an instrument for conducting retrosective HIAs on urban traffic. Because there are difficulties in accessing data and availability of certain data on the imacts of urban traffic on ublic health and its determinants () such as rimary health care and hosital admissions in almost every urban areas around the world and, articularly, in Iran. Moreover, there is a lack of timeliness of information in relation to urban traffic related mortality, morbidity () and health, as a whole, which is an obvious disadvantage necessitating the develoment of such instruments. The Urban Traffic-related Determinants of Health Questionnaire (UTDHQ) may be a useful tool for researchers working on HIA of urban traffic in collecting information regarding urban traffic related determinants of health. This aer reorts the sychometric roerties of UTDHQ in Sanandaj, Iran. Methods Poulation under study and Samling Multistage cluster samling was emloyed to recruit 00 key informants working in universities, schools, health care centers and traffic offices in Sanandaj, Iran, from Aril to June 0, to articiate in the study. The diverse key informants working in the above mentioned institutions and organizations ensured a broad reresentation of the target oulation. In this study, schools, universities, 0 health care centers, and 0 traffic offices were randomly selected. Clusters were samled with likelihood roortional to the target oulation coverage (i.e., the higher coverage of the institution/organization, the higher recruitment). The urose of the study, which included their rights as human MJIRI, Vol... August 0

Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 H. Nadrian, et al. subjects for a research study, was exlained to articiants and all signed informed consent forms. As the number of questions in the questionnaire was somewhat high and answer to the questions needed a high attention, some of the resondents refused to articiate in the study; therefore, the resonse rate was about 9%. items), Public Services ( items) and Public Policy ( items). As noted above, A oint Likert-tye scaling was used (= very low, = low, = moderate, = high and = very high) for section. The theoretical range for this section was -, in which the higher scores indicate more negative imact. Along with UTDHQ a Demograhic Da t a Form included questions has been develoed by researchers to obtain dat a related to the socio-demograhic characteristics of the resondents, such as age, gender, education, occuation, being motor vehicle (car/motorcycle) owner, history of having accident resulted in bodily injury or motor vehicle damage in the city since 0 years ago and in the case of having accident resulted in bodily injury, if he/she was aboard or edestrian. The consensus anel discussed the difficulty level of items. Ten key informants ( university teachers, school teacher and health care roviders) were interviewed face to face to examine the difficulty level of items. They were asked to reort the level of imortance of each item. Finally, the items with Imact Score. () were considered for the next analysis. In order to determine the content validity of UTDHQ, the consensus anel of exerts, reviewed and assessed the items, qualitatively, by evaluating the aroriateness and relevance of the items to urban traffic, their necessity, significance, scaling and resonse format. The feedback from the consensus anel, which mostly was regarding the wording and hrasing of items, was used to revise and modify the instrument. Alying indices, Content Validity Index (CVI) and Content Validity Ratio (CVR), the content of the instrument validated, quantitatively. To determine CVR, 0 secialists in the area of health education and behavior, health romotion, community health nursing, environmental health, and eidemiology were asked to reort the necessity of each item on the basis of a -oint Likert-tye scale (It is necessary, It is useful but not necessary, It is not necessary). If the Instrumentation In order to design a new instrument, conducting literature review, qualitative research and/or selecting items from available instruments or a mix of these methods may be used (). The develoment of UTDHQ began with a comrehensive review of the literature (,, -) and the Merseyside Guidelines for HIA () was emloyed as a base for roviding the instrument. As the research toic was new, no similar instrument was found in the literature; therefore, efforts were focused on the studies which have investigated trafficrelated determinants of health and HIAs of traffic and transortation. So, the statements related to urban traffic and determinants of health extracted from the literature and translated into Persian by two Persian native translators and the initial questionnaire was designed. After reviewing the obtained instrument in a consensus anel, it was translated back to English. Finally, the roer items were constructed considering the cultural differences between Iran and communities of the conducted studies. Finally, the initial UTDHQ with sections, dimensions and items (health determinants) was reared. In section, the resondents were asked to indicate, on a -oint Likert scale, how much Sanandaj urban traffic had negative imacts on the health determinants. In section and, they were asked to rate the imacts according to their measurability (qualitative, estimable or calculable) and the risk of occurrence (definite, robable or seculative), resectively. The dimensions of health determinants, encomassed Personal/Family circumstances and lifestyle ( items), Social Environment (9 items), Physical Environment ( MJIRI, Vol... August 0

Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 Psychometric roerties of Urban Traffic-related Determinants of Health Questionnaire value obtained for each item was more than 0. (based on Lawshe table), it was considered as necessary for the instrument (). In order to determine CVI (9), the 0 secialists mentioned above were, also, requested to determine the relevancy, clarity, and simlicity of each item. A -oint Likert-tye scaling was used to analyze these three criteria, searately. The CVI value greater than 0. for each item considered to be aroriate and accetable (0). Therefore, the items with CVI less than 0. deleted from the questionnaire. Exloratory Factor Analysis (EFA) was erformed to determine the construct validity and factor structure of the UTDHQ. Several studies considered -0 samles er item for conducting EFA (). For the resent study, EFA was conducted on the data collected from key informants, alying the rincial comonent factor analysis with varimax rotation. In order to test the reliability of UTDHQ, Cronbach s alha coefficient was used. Cronbach's alha is the most common method used for investigating the internal consistency of instruments (). The test retest reliability coefficient was also calculated. Thus, 0 randomly selected key informants were asked to comlete the questionnaires, on a second occasion, - days later. Intra-class correlation coefficients (ICC) with 9% confidence intervals (CI) were calculated and an ICC equal to or greater than 0.0 was considered accetable. To comare the construct validity, correlations between the dimensions of UTDUQ were tested using Pearson s correlation test. Factor Analysis (EFA) was used to determine the construct validity and factor structure of the UTDHQ. Also, in order to investigate the internal consistency of the instrument, Cronbach's alha method was used. Intra-class correlation coefficients (ICC) were alied to calculate the test retest reliability coefficient. Pearson s correlation coefficient was used to demonstrate the nature of associations between UTDHQ factors. The level of significance was set, a riori, at.0. Results The age of the articiants ranged from to 0 years (mean=.; SD= ). Males (.%) and health care workers (9.%) constituted the majority of the subjects. The majority (.%) of the articiants were bachelor. Only.% out of all resondents used bicycle as a vehicle to erform their daily works. Alying a series of descritive statistic tests, indeendent samle t-test and one-way ANOVA tests, the characteristics of the resondents as well as the associations between their characteristics and the mean score of the factors were investigated which is shown in Table. Regarding the face validity of UTDHQ, as the Imact Score for all items was more than., no item was deleted; however, the wording and hrasing of some items were modified. Also, the qualitative content validation resulted in some modifications in the items. In quantitative content validation, due to low CVR value (less than 0.), 0 items (such as Housing condition, The range of shoing and Land use ) were deleted. According to CVI assessment, items, with CVI value less than 0., were deleted. The mean items relevancy, clarity, simlicity, and their total mean score were. ± 0., 9. ± 0.,. ± 0., and. ± 0., resectively. At the end of this ste items remained. The mean and standard deviations for the remained items and risk of imact and redicted health imact of the items are shown in Table. Overall, the mean score of items for all articiants was moderate to low Statistical analysis The Statistical Package for the Social Sciences (SPSS) version.0 for Windows was utilized for the urose of data entry, maniulation, and analysis. Measures of central tendency and variability were used to summarize and organize the data. Content validity of the instrument investigated alying Content Validity Index (CVI) and Content Validity Ratio (CVR). Exloratory MJIRI, Vol... August 0

Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 H. Nadrian, et al. Table. Relationshi between the resondents characteristics and the mean score of the factors (n=) variable Frequency (%) Age (year) (n =, M=.±)..0.0.09.0.0.. Under 9(9.) -0 0(.) - 9(9.) -0 0(.) - 0(.) More than (.) Occuation (n = ).0...0.9.0..9 School teacher () University teacher (.) Health worker (9.) Traffic officer (.) Education (n=).0..09.99....9 Diloma 0(.) Suer Diloma (0.) Bachelor (.) Postgraduate (.) Owning an MV* (n=)...99.0.0.0.9.0 Yes 9(.) No (.) History of accident resulted in.....00..00.0 MV damage in the city since 0 yrs ago (n = ) Yes (.) No (.) *MV= Motor Vehicle; Factor = Physical Environment; Factor = Social Environment; Factor =Public Services Delivery and Accessibility; Factor = Family Circumstances; Factor = Public Policy; Factor = Substance Use; Factor = Public Welfare Services; Factor = Air Quality. Only, the demograhic variables which had significant correlation with, at least, one factor were included. excet for the following three items: Air quality, Energy usage, Public transort services. Moreover, the ris k of occurrence for the most of the items was announced robable by most of the resondents. More than 0% of the articiants rated the risk of urban traffic imact as definite for the items such as Risk-taking behaviors, Work trend, Air quality and Public transort services and, also, more than 0% rated the risk as seculative for the items including Education rovided for adults, Non-drinking, Non-smoking and Substance misuse. In order to determine the construct validity of the instrument, Exloratory Factor Analysis (EFA) was conducted using rincial comonent factor analysis with varimax rotation. Kaiser-Meyer-Olkin (KMO) measure (KMO= 0.) and Bartlett s Test of Shericity (Arox. Chi-Square= 0.0, df=, <0.00) showed samling adequacy and suitable correlation matrix for factor analysis, resectively. MJIRI, Vol... August 0 Ten factors extracted with eigenvalues greater than which altogether accounted for.% of the total variance between items. Alying Cattell s scree test, it was indicated that between nine and eleven factors extracted. Then, multile runs of factor analysis were conducted, varying the number of factors. It was found that the ten factor solution yielded a clearer attern of loading. Table shows the rotated factor attern coefficient for variable solution. For each factor, information is rovided regarding the initial eigenvalues (before rotation), variance accounted for after rotation (rotation sum of squares), ercentage of variance exlained (after rotation), intra-class correlation coefficients (ICC) with 9% confidence intervals (CI) and internal consistency reliability as indicated by Cronbach s alha for each factor. As it is indicated in Table, three of the ten factors had low internal consistency reliability (Cronbach s alha less than 0.), which argues omitting of these factors.

Psychometric roerties of Urban Traffic-related Determinants of Health Questionnaire Table. Items mean (M) and standard deviation (SD) of UTDHQ and risk of imact and redicted health imact of the items M (SD) Family functioning (ie, nurturing children and their socialization) Education rovided for rimary and guidance school students. (.) 9 (.) 9 (0.) (.) (.) 9 (0.) (.). () 0 (9.) 0 (.) 0 (.) (.) 9 () 90 (.9). () (.). (). (). (.) (.).9 (.).9 (.). (.). (.). () (.9) (.) (.) (0.) 9 (0.) 90 (.9) (.) 0 (.) 0 (9.) (.9) 0 (.) (.9) 0 (.) 9 (0.) 9 () 9 (.) 0 (.) 0 (.) (.) (.) 0 (.) (.) (.) (0) (.) (.) 0 (.) (.) (.) (.) (.9) 9 () 9 (0.) (.) () 9 (.) (.9) (.) (.) (.) (.9) (.) (0.9) (9.) 0 () 9 (.) (9.) (.) 09 (.9) 0 (.) (.) (.) (.) 0 (.) (.) 0 (.) (.) (.) (.) 0 (.) 9 (9.) 0 (.) 9 (0.) 0 (.) (.) 9 (). () (.) (9.) (.) 09 (.9) 0 (.) 9 (.). (). () (.) 0 (.) () (.) 0 (.) 9 () (.) (.9) 0 (.) (0.) (.) 0 (.). (). (.).9 (.) (.) 0 (.) (.) 0 (.) (.) (.9) 9 (9.) 9 (9.) (.9) (.) (.9) (.) 0 (.) (9.) (.) (.) (.) (.). (.) 0 (.) (.) 9 (9.) (.) 0 (.) 9 (9.). (.) (.) 0 (.) 0 (.) (.) (.) 0 (.) (). (.). (.). (.). (). (). (.) 0 (.9) 0 (.) 9 (0.) 9 (0.) (.) 9 (0.) (.) 90 (9.9) (.) 00 () () (.) (9.) (.) (.) 0 (.) (.) 0 (.) (.) 9 (0.) (.) (.) (.) 9 (9.9) (.) (.) 9 (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) (.) 0 (.) 9 (0.) (.) 99 (0.). () () 9 (.) 99 (0.) 0 (.) 9 (.) 9 (). (.). (). () (.). (). (). (). (). (). () (.) () () 0 (.) () 0 (.) 9 (.) (.) 9 (.) (.) 9 () 0 (.) (.) () 09 (.9) (.) (.) 0 (.) (.) (.9) 0 (.) 9 (0.) 9 (0.) 9 (9.) 9 (9.) 9 (9.) 9 (.) 9 (9.) (.) 9 (0) (.) (.) (.) (.) (0) (.) (0.) (.) (9) 9 (.) 0 (.) 9 (.) 0 (0.) 0 (.) (.) 0 (.) (.) 00 () 0 (.) () (.) 0 (.) (.) (0.) 0 (.) (.) (.) (0.) (.) (.). () (.) (.) 9 (0.) (.) () () (9.) (.) (.9) 9 (9.) 0 (.) (.) (.) 0 (.) 9 (.) 0 (.) () 90 (.9) (.) 9 (9.) (9) 0 (.) 9 (.) () (.) (.) 9 (9.) 9 (.) (.) 0 (.) Education rovided for high school and the university students Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 Risk of imact - is it: D, P or S?* How much Sanandaj urban traffic has had negative imact on the following health determinants? Education rovided for adults (ie, Literacy Movement) Occuation and emloyment status of the residents Income status of the residents Risk-taking behavior (ie, while driving) Diet status (ie, the contents of household food basket) Non-smoking Non-drinking Substance misuse Doing exercise by eole Work trend (ie, the work trend of eole who forced to commute in the city, several times daily because of their work situation) The society culture (observing resect and courtesy to citizens) Joining in eer grous (ie, gathering elderly grous in arks) Social justice (ie, equitable distribution of services delivered by different organizations) Family relations Neighborhood relations Community articiation (ie, articiation as health volunteers) Cultural articiation (ie, attending art and literacy exhibitions) Siritual articiation (ie, attending charity institutions or congregational rayers) Air quality of the city Water quality of the city Noise condition within the city Smell condition within the city Urban landscae and the face of local environment Selecting the lace of living in the city Recreations erformed by residents (ie, going to a movie or ark) Public safety (ie, arents feeling of safety from sending their children to school) civic lanning (ie, making the streets one-way, mandatorily) Selecting the lace of shoing The quality of shoing (ie, feeling comfort while shoing) Energy usage (ie, the amount of oil use) Access of residents to destination Access of disables to destination Access of elderly residents to destination The costs of access to destination The status of rimary health care delivery Urban services to take care of children (ie, the existence of edestrian lane on the streets near to schools) Urban services to kee the environment clean and beautiful D (%) P (%). () (0.) (.) Recreational services (ie, constructing arks or laces for laying and/or launching a ublic walking congress). (.) (.9) 0 (.9) Social security services (ie, the services delivered by security forces). (.9) (.) 9 (0.) Public transort services (ie, the rocess of services delivered by taxies). () (0.) (.) Economic develoment trend (ie, the trend of constructing factories). () (.) (.) Social develoment trend (ie, the trend of romoting driving behaviors). (.) (9.) 99 (.9) The imlementation trend of the local and national rograms and rojects (ie, the imlementation of a underass/overass roject) *D= Definite, P= Probable, S= Seculative Q= Qualitative, E= Estimable, C= Calculable After determining simle structure and the best solution considering visual insection and the hyerlane count (), resectively, the authors decided to eliminate items one at a time and rerun the factor analysis. The items omitted were as follows: The society culture, Water Quality, Diet status, Work trend, doing exercise by eole, Public S (%) Predicted health Imacts How measurable imact is is it: Q, E or C? Q (%) E (%) C (%) safety. Finally, the otimal reduced solution consisted of 0 items and factors, which is shown in Table. In order to interret factors, the factor attern coefficient values were considered. Based on the cut-offs recommended by Gorsuch () and Tabachnick and Fidell () and also, similar with the study con MJIRI, Vol... August 0

H. Nadrian, et al. Table. Rotated factor attern coefficients for variable solution ( variables) of UTDHQ Factor attern coefficient * Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 How much Sanandaj urban traffic has had negative imact on the following health determinants? 9 0 Smell condition within the city.. Noise condition within the city. Recreations erformed by residents.0 Urban landscae and the face of local environment..99 Selecting the lace of shoing.09.9 Selecting the lace of living in the city.0. The quality of shoing..9.9 civic lanning.0.0.0. Access of elderly residents to destination..0 Access of disables to destination.. Access of residents to destination.0. The costs of access to destination..0 The status of rimary health care delivery.. Energy usage..0.. Cultural articiation. Family relations. Community articiation.0. Siritual articiation..9 Neighborhood relations.0. Social justice.0.0.0 Occuation and emloyment status of the residents.. Education rovided for rimary and guidance school students. Income status of the residents.. Education rovided for high school and the university students.09.9 Education rovided for adults.. Family functioning... Risk-taking behavior.0. Non-drinking.90. Non-smoking. Substance misuse. Economic develoment trend. Social develoment trend.0..0 The imlementation trend of the local and national rojects.9. Public transort services.0.. Recreational services.. Social security services.. Urban services to take care of children.0. Urban services to kee the environment clean and beautiful.9. Work trend.0. -.0 Air quality of the city.9.0.. Doing exercise by eole..00. Public safety.0... The society culture.0. Joining in eer grous.9. Water quality of the city...0. Diet status. -..0..9 Initial Eigenvalues 9..9......0.. Rotation sums of squares..9...0..9...0 Percent of variance exlained 9..0....0.9... Cronbach α...0..0...9 Factor = Physical Environment; Factor = Public Services Delivery and Accessibility; Factor = Social Environment; Factor = Family Circumstances; Factor = Substance Use; Factor = Public Policy; Factor = Public Welfare Services; Factor = others; Factor 9 = Culture/Peers; Factor 0 = Diet/Water; * In order to hel in decreasing comlexity of the table, the loadings above. were indicated in bold tye and the loadings less than. are omitted 9 0 9 0 9 0 9 0 ducted by Mousavi et la., () the cut-off of 0.0 was considered to include one item in interretation of a factor (Tables and ). The factors were named as follows: Physical Environment, Social Environment, Public Services Delivery and Accessibility, Family Circumstances, Public Policy, Substance Use, Public Welfare Services, Air Quality. This solution accounted for.% of the total variance. Alying Pearson s correlation coefficient, it was found that the factor correlations were in the low (at the lowest 0.0 between the factors, Substance use and Public welfare services ) to modest (at the highest 0. between the factors Physical environment and Public services delivery and accessibility ) range (Table ). MJIRI, Vol... August 0 Discussion There was found several quite clear factors, which altogether can define the urban traffic related determinants of health. The first four factors were, articularly, so strong that together exlained more than % of the total variance. Factor refers to Physical Environment, Factor refers to Social Environments, Factor refers to Public Services Delivery and Accessibility and Factor refers to Family Circumstances. Desite the moderate and strong relationshis found between Factors and and Factors and, resectively, each of the factors is comletely distinct. Two of the other factors were regarded with lifestyle within ersonal (Factor ) and family circumstances (Factor ). Moreover, these two Factors had a relatively strong relation

Psychometric roerties of Urban Traffic-related Determinants of Health Questionnaire Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 Table. Rotated factor attern coefficients for reduced solution (0 variables) of UTDHQ How much Sanandaj urban traffic has had negative imact on the following health determinants? Smell condition within the city Noise condition within the city Recreations erformed by residents Urban landscae and the face of local environment Selecting the lace of shoing The quality of shoing Selecting the lace of living in the city Civic lanning Community articiation Siritual articiation Cultural articiation Family relations Neighborhood relations Joining in eer grous Social justice Access of elderly residents to destination Access of disables to destination Access of residents to destination The costs of access to destination The status of rimary health care delivery Energy usage Income status of the residents Occuation and emloyment status of the residents Education rovided for rimary and guidance school students Risk-taking behavior Education rovided for high school and the university students Family functioning Education rovided for adults Economic develoment trend Public transort services Social develoment trend The imlementation trend of the local and national rojects Non-drinking Substance misuse Non-smoking Recreational services Social security services Urban services to take care of children Urban services to kee the environment clean and beautiful Air quality of the city Initial Eigenvalues Rotation sums of squares Percent of variance exlained Cronbach α ICC (9% CI).9..9..0..0..0..0..0.9...9.9.0.....0....9...0..0.0...9...0...0.9..9....0.....0.0..0.0.0.....0.. Factor attern coefficient*.9.9....... -.9.0. -.0.9..........9...0.0...9...0. 0. 9..9............0....... (.-.) (.-.) (.-.) (.-.) (.-.) (.-.) (.-.) Factor = Physical Environment; Factor = Social Environment; Factor =Public Services Delivery and Accessibility; Factor = Family Circumstances; Factor = Public Policy; Factor = Substance Use; Factor = Public Welfare Services; Factor = Air Quality; ICC: Intra-class Correlation Coefficient; CI: Confidence Interval; * In order to hel in decreasing comlexity of the table, the loadings above. were indicated in bold tye and the loadings less than. are omitted shi with Factor (Social Environment) suggesting that the lifestyle of eole in a wide variety of social contexts and networks and in different ways may be associated with urban traffic. The UTDHQ and its derived factors showed accetable internal consistency. The Cronbach s alha for the questionnaire and its factors ranged from 0.0-0., which are in the range of high to very high based on the reference table resented by DeVellis () as well as Sim and Wright (). Similar to the resent study, Taymoori (), Mahmoodi et al., (9), Parshal (0) and Montazeri et al., () used internal consistency to confirm the reliability of their instruments. Moreover, the face and content validity ensured the simlicity and clarity of the instrument and, also, CVI showed an accetable relevancy. In the resent study, when investigating construct validity, there was found that the ten factor solution yielded a clearer attern of loading, but three of the ten factors had low internal consistency reliability. Therefore, as Munro () recommended, the items loaded on these three factors eliminated and the factor analysis reran. Based on the decision made in an additional exert anel, the item Air Quality chose not MJIRI, Vol... August 0

Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 H. Nadrian, et al. Table. UTDHQ factors Correlation Matrix Variables 0.0** 0.** 0.** 0.0* 0.** 0.0 0.** 0.** 0.9** 0.** -0.0 0.** -0.0 0.** 0.0-0.00 0.0-0.0 0.0-0.0-0.0 0.0** 0.* 0.** -0.0 0.** -0.0-0.0 * <.0, ** <.0 Factor = Physical Environment; Factor = Social Environment; Factor =Public Services Delivery and Accessibility; Factor = Family Circumstances; Factor = Public Policy; Factor = Substance Use; Factor = Public Welfare Services; Factor = Air Quality to be omitted because of its high imortance and relevancy and so, the otimal reduced solution found in the factor analysis consisted of 0 items and factors. This result strongly confirms the concetual analysis of urban traffic related determinants of health. For examle, the first five Factors, namely, Physical Environment, Social Environment, Public Services Delivery and Accessibility, Family Circumstances and Public Policy all resent the main concetual comonents of health determinants related to urban traffic, as discussed in the literature (). Moreover, these factors exlained about % of the total variance, which is another confirmation on their imortance as the main comonents of urban traffic-related determinants of health. The results of the resent study showed that there was a small difference between the total variance exlained in ten (.%) and eight (.%) factors solutions. In addition, by declining two factors, the total variance decreased only about.%. In the other hand, the total variance exlained by each factor increased in almost all factors, after decreasing the ten factor solution to eight. Also, a clearer attern of item loading found in the eight factors solution. All of these findings arove the decision on considering the eight factors solution as the best solution. As recommended by Gorsuch (), correlations between the factors were showed in the resent study. The resentation of correlations between factors in this study may hel researchers in comaring the results of their future studies with those found in the MJIRI, Vol... August 0 resent study. The correlation between a factor and its associated factor scores may be interreted like alha which indicates the stability of each factor (). This is for the first time that such an effort has been made in Sanandaj and it is resumed that conducting this study gave birth to HIA in Iran. An extensive literature review showed that excet for some review studies on HIA (-) and two HIA on air ollution in Tehran () and Shiraz (), no other HIA studies has documented. Although the best ractice is to carry out HIA, rosectively, in accordance with the same international studies, in some cases this is not ossible due to delays with emloying associates, lack of knowledge on HIA and delays in acquiring fund (). For examle, in Sanandaj, before commencing this HIA on urban traffic, a large art of measures were comleted. Therefore, UTDHQ designed to use in retrosective HIAs on urban traffic. Similar with the resent study, the steering grou of a HIA conducted in Ballyfermot () on traffic and transort, necessitated the need for a secial survey on urban traffic related determinants of health in order to obtain such comlementary information from general ractice. Considering the novelty of HIA in Iran and some other countries esecially the develoing ones, conducting such studies may have several imlications for ractice; increasing knowledge and awareness about HIA and its usage around the countries, roviding evidence for alicability of HIA in different settings, increasing its olitical accetability to hel in obtaining healthy 9

Psychometric roerties of Urban Traffic-related Determinants of Health Questionnaire Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 ublic olicy, serving in designation of curriculums for HIA educational courses ().. A health imact assessment of traffic and transort in Ballyfermot, December 00. 00.. Levy J.I. BJJ, & von Stackelberg K. The Public Health Costs of Traffic Congestion:. Environmental Health. 00;9():.. Isradisaikul C. Urban Traffic Control. 009.. Acheson D. Indeendent inquiry into inequalities in health reort. 99.. Health imact assessment: main concets and suggested aroach, Gothenburg consensusaer.. 999. 9. Quigley R dbl, Furu P, Bond A, Cave B, and Bos R. Health Imact Assessment, International Association for Imact Assessment,International Best Practice Princiles. 00. 0. Introducing health imact assessment (HIA): Informing the decision-making rocess. 00.. Eslami M, Heidrania, A.A, et al. Designing and determining validity and reliability of the questionnaire for the effect of HBM on users of two methods of birth control with ills and condoms. Oromieh Journal. 0;():-90.. Kearns N PL. Evaluation of the HIA of Traffic and Transort in Ballyfermot. 00.. Scott-Samuel A. AK, Birley M. Assessing health imacts on a oulation. 00.. Jackson RJ. The imact of the built environment on health: an emerging field. Am J Public Health. 00;9:-.. Frank-Stromborg M. Instruments for clinical health-care research (rd ed.). 00.. Frumkin H FL, Jackson R. Urban Srawl and Public Health: Designing,Planning, and Building for HealthyCommunities. 00.. Lacasse Y, Godbout C, & Series F. Healthrelated quality of life in obstructive slee anoea. Euroean Resiratory Journal. 00;9():9-0.. Lawshe CH. A qualitative aroach to content. Personnel Psychology. 9;():-. 9. Waltz CF, Strickland, O.L, & Lenz E.R. Measurement in nursing and health research (rd ed.). New York 00. 0. Polit DF, Beck, C.T, & Owen S. V. Is the CVI an accetable indicator of content validity? Araisal and recommendations. Research in Nursing & Health. 00; 0():9-.. Munro B, H. Statistical methods for health care research. (th ed). 00.. Polit D, Beck C, & Hungler, B. Essentials of Nursing Research: Methods, Araisal, and Utilization. 00.. Gorsuch RLL. Factor analysis. 9.. Tabachnick BG, & Fidell L.S. Using multivariate statistics (th ed). 00.. Mousavi S.J, Askary Ashtiani A.R, Mohamad Hadian R, Rostamian A, and Montazeri A. Translation and validation study of the Persian version of the Arthritis Imact Measurement Scales (AIMS) in atients with osteoarthritis of the knee. Musculoskeletal Disorders. [Original Article]. Conclusion Based on the results of the resent study, UTDHQ demonstrated an aroriate validity, reliability, functionality and simlicity. Therefore, this instrument is a ractical and useful tool for researchers, health romoters, community agencies and organizations interested in HIA in order to rovide the finest available information to decision makers and stakeholders on the health influences of their decisions and measures. Certainly, further studies are needed to comare different dimensions of the instrument in different communities and also, to comare the dimensions with other ublic health indicators derived from qualitative and quantitative studies. Limitations A limitation of the study may be the difficulty in comaring the develoed UTDHQ with the other similar instruments, due to the lack of comarable instruments in Iran and/or other countries or instruments which would be secific to urban traffic related determinants of health. Acknowledgments In this article, we used some information from the study roosal number which had been aroved by the Deuty of Research of Tehran University of Medical Sciences. The authors would like to thank all the study articiants. References. Dannenberg A L. BR, Cole BL., Heaton SK, Feldman JD, Rutt CD. Use of Health Imact Assessment in the U.S. Case Studies, 999-00. Am J Prev Med. 00;():-.. Office. DT. A latform for change: outline of an integrated transortation strategy for the Greater Dublin Area 000 to 0. Dublin Dublin Transortation Office. 000.. A latform for change: outline of an integrated transortation strategy for the Greater Dublin Area 000 to 0. Dublin Dublin Transortation Office, Office DT; 000. 0 MJIRI, Vol... August 0

Downloaded from mjiri.iums.ac.ir at : IRST on Monday November th 0 H. Nadrian, et al. 009;0(9).. DeVellis RF. Scale Develoment: Theory and Alications. 99.. Sim J WC. Research in Health Care. 000.. Taymoori P, Moeini B, Lubans D, & Bharami M. Develoment and sychometric testing of the Adolescent Healthy Lifestyle Questionnaire. Journal of Education and Health Promotion. 0;(). 9. Mahmoodi Z KM, Sajjadi H, Dejman M & Vameghi M. Develoment of Mother's Lifestyle Scale during Pregnancy with an Aroach to Social Determinants of Health. Global Journal of Health Science. 0;():0-9. 0. Parshal MB. Psychometric charachteristics of disnea descritor rating in Emergency Deartment atients with exacerbated Chronic Obstructive Pulmonary Disease. Research in Nursung and Health. 00;.. Montazeri A, Harirchi A.M, Shariati M, MJIRI, Vol... August 0 Garmaroudi G, Ebadi M, & Fateh A. The -item General Health Questionnaire (GHQ-): translation and validation study of the Iranian version.. Health and Quality of Life Outcomes. 00;().. Jaafarzadeh N. AMB. A Review on Health Imact Assessment (HIA), Its frame of structure and tyes. 009.. Shojaei P. FAS. Health Imact Assessment of Transort Plan. 0.. Naddafi K. HMS, Yunesian M., Momeniha F., Nabizadeh R., Faridi S. and Gholamour A.. Health imact assessment of air ollution in megacity of Tehran, Iran. Iranian Journal of Environmental Health Sciences & Engineering. 0; 9 ().. Gharehchahi E. MAH, Amini H, Nabizadeh R, Akhlaghi A.A, Shamsiour M, and Yunesian M. Health imact assessment of air ollution in Shiraz, Iran: a two-art study. Journal of Environmental Health Sciences & Engineering. 0;.