Assessing Managers’ Attitudes Toward Health Promoting Hospitals at a Teaching Hospital in Tehran, Iran

1Medicine, Quran and Hadith Research Center & Department of Community Medicine, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran 2Health Management Research Center & Department of Community Medicine, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran 3Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran 4Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran


Background
Health promotion is defined in WHO's Ottawa Charter for Health Promotion as a broader concept and as a process empowering people to increase control and improve their health. 1 Ottawa Charter defines five preferred areas of health promotion activities: building healthy community policy, creating supportive environments for health, strengthening community action for health, developing personal skills, and reorienting health services. 2 Ottawa Charter promoted the idea that "health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love" by considering health as a positive concept. This environmental approach to health promotion which is associated with the settings of everyday life has led to initiatives such as health-promoting cities, health-promoting schools, and health promoting hospitals (HPH), etc. so that the health of people can be promoted in places where they spend most of their time. 3 This environmental approach is adopted based on social experience and organizational development. 4 The idea of creating HPH was first presented at the WHO Global Health Promotion Conference in 1986 by the World Health Organization and has been steadily expanding and progressing throughout the world to this day. 1 Purpose of HPH is to transform a hospital from a mere diagnostic and therapeutic site to a disease prevention and health promotion place for patients, staff, clients, and all members of society. 5,6 Although many people regard hospitals as a health promotion setting, there are still differences in attitudes toward the actual impact of these hospitals on public health in practice, and the idea of health promotion is slowly developing in hospitals. 7 Policymaking, planning, implementing, and monitoring of health promotion activities are the requirements of moving toward a healthpromoting hospital, 8,9 and hospital managers' attitudes toward health promotion policies and programs are particularly important in achieving the mentioned goals.
The main reason for the slow implementation of health promotion programs in hospitals was limited to the understanding of the concept of health promotion hospital at management level 10 and lack of commitment to coordination and performing planning activity. 11

Objectives
This study was conducted to design a valid questionnaire and determine the managers' attitudes of a teaching hospital in Tehran toward the implementation of healthpromoting policies in the hospital.

Methods
This research was a cross-sectional study. The study population included all managers working in organizational positions associated with health promotion in a 700-bed teaching hospital in Tehran, Iran in 2018. The sample of this study consisted of 75 senior and middle managers working in organizational positions such as administrative, financial, and medical management whose field of work is directly or indirectly associated with health promotion processes, and sampling was conducted through a census. The inclusion criteria were the following: managers who have been employed over five years in hospital and in senior and middle management positions for more than two years. The exclusion criteria were dissatisfaction with participation in the study.
In the first step, a research instrument was designed by overviewing the available documentation (articles and books) and expert opinion (who were skilled in concepts, planning, and implementing of HPH programs). The questionnaire included 24 items in two domains of health promotion policies and activities based on five-point Likert scale and its validity and reliability were evaluated in this study. The validity of instrument was assessed using face and content validity approaches. The face validity of the questionnaire was assessed through qualitative and quantitative methods. Face validity was qualitatively evaluated by a five-member panel consisting of technical experts and health promotion professors, three of the panel members are social medicine experts (two of them are HPH experts and one of them is an HPH researcher) and two of the panel members hold PhDs in epidemiology and health education and are experts in designing a questionnaire to measure difficulty level, degree of irrelevancy, ambiguity in phrases, or incomprehensibility in meanings and their corrective comments were applied to the questionnaire. The impact score of each item was calculated in order to evaluate the face validity quantitatively. First, the 5-point Likert scale was considered for each item of the questionnaire: strongly agree (scored 5), agree (scored 4), neither agree nor disagree (scored 3), disagree (scored 2), and strongly disagree (scored 1). The total score was considered 100 and therefore attitude scores were interpreted as follows: below 20 completely negative, 20 to 39 negative, 40 to 59 neither negative nor positive, 60 to 79 positive, and 80 to 100 completely positive. Then, the designed instrument was distributed among 11 technical experts and professors of health promotion who were asked to examine items based on the mentioned criterion. Then the importance of each instrument item was calculated using the impact score formula:

Impact Score = Frequency (%) × Importance
And, the results were compared with the standard score. The items whose scores were higher than the standard score were included in the questionnaire. Next, the content validity of the instrument was analyzed using content validity ratio (CVR) and content validity index (CVI) ( Table 1). CVR was used to ensure that the most important and correct content (item essentiality) is selected. And CVI was used to ensure that the instrument items are best designed to measure the content. Eleven respondent experts also participated in this phase. Experts were asked to group items as "essential", "essential but not useful", or "not essential" in order to calculate CVR. Their responses were calculated based on CVR formula and the results were compared with Lawshe's Table. Numbers higher than 0.59 were approved.
CVI survey was performed based on the Waltz and Basel content validity index. 12 The questionnaire was distributed among the experts who were asked to rank 24 items based on the four-part Likert scale as compatible with three criteria of relevancy, simplicity, and clarity. (For example, unrelated items, partially related items, related items, and fully related items were scored 1, 2, 3, and 4, respectively). CVI score was calculated by dividing the sum of the compatible scores for each item (i.e. items scored 3 and 4 which are the highest scores) by the total number of experts. Items higher than 0.79 were approved according to CVI score.
After evaluating the validity of questionnaire, Cronbach's alpha method was used to assess its reliability. The reliability obtained was high with a Cronbach's alpha of 0.84.
Questionnaires were distributed among the population of this study after standardization. The method of data collection was self-completed and questionnaires were collected within 48 hours after distribution considering confidentiality principles by the trained researcher.
Collected data was analyzed using SPSS 20 software. The scoring basis of questionnaires on the Likert scale was changed to 100. Frequency distribution, mean, and standard deviation were used successively to perform descriptive tests for qualitative and quantitative variables. Moreover, Mann-Whitney, t test, and Kruskal-Wallis tests were used for inferential statistics. The significance level was set at 5% in this study.

Evaluating the Validity and Reliability of the Instrument of This Study
The findings of Table 2 show that since the scores of all items of the questionnaire were higher than the criterion score (i.e. 1.5), experts approved the quantitative face validity of all items.
The results of CVR show that "Health promotion is considered as a form of service", "Hospital ensures a safe and healthy work environment", "Organization has a planned approach to continuously work with other levels of health services and other institutions and departments", and "Health promotion services empower patient to deal with disease and cooperate with healthcare staff " that are items of the questionnaire with a score smaller than 0.59 based on Lawshe's Table, and thus experts did not recognize them as essential items to be included in the final version of the questionnaire.
Moreover, the results of CVI indicate that all items of the questionnaire except for "In general, health promotion is always the central core of medicine, especially in hospital" obtained a score higher than 0.79 and were considered as appropriate items by experts. Furthermore, the score of the mentioned item was 0.75, and it thus needs to be revised. The reliability of the questionnaire based on Cronbach's alpha was 0.77, 0.83, and 0.88 for policies, activities, and questionnaires, respectively.
The total score of managers' attitude toward health promotion policies was estimated to be 84.5 ± 10.6 out of 100 and the total score of their attitude toward health promotion activities of the hospital was estimated to be 85.3 ± 8.65 out of 100. The highest scores of components associated with health promotion policies were 94.9 ± 9.34 and 93.8 ± 10.36 out of 100 belonging to "Awareness of hospital staff of health promotion policies" and "Enjoyment of a written health promotion policy" items, respectively. The lowest scores of components associated with health promotion policies were 75.4 ± 20.68 and 77 ± 19.36 out of 100 belonging to "Hospital supports actions done to inform patients, their companions, and staff about factors associated with disease and their health" and "Resources needed for implementation of health promotion programs The quality of health promotion programs is monitored and evaluated in the hospital. are allocated by hospital" items, respectively. The highest scores of components associated with health promotion activities were 94.1 ± 9.74 and 93.1 ± 10.65 out of 100 belonging to "Increasing patients' trust by providing health promotion services" and "Impact of health promotion of hospital staff on patient satisfaction" items, respectively. The lowest scores of components associated with health

Item Frequency Importance Impact Score
The hospital should have a written health promotion policy. 9.5 1 9.5 In general, health promotion is always the central core of medicine, especially in the hospital. 13.4 0.8 10.7 Hospital recognizes its health promotion responsibilities. 9.4 0.91 8.5 The hospital should ensure that its staff is committed to conducting health promotion activities. 7.9 1 7.9 Health promotion is considered as a form of service. 9.25 0.82 7.57 Hospital staff should be aware of health promotion policies. 11.3 1 11.3 Hospital allocates the resources needed to implement health promotion programs. 6.4 1 6.4 Hospital evaluates patients' health promotion needs in the hospital. 9.5 1 9.5 Patients' needs for health promotion are assessed for the first time they enter the hospital. 9.25 0.91 8.4 The hospital supports actions done to inform patients, their companions, and staff about factors associated with disease and their health. 11.3 1 11.3 Patients should receive clear, understandable, and appropriate information about their real condition, treatment, care, and factors affecting their health in the hospital. 11.71 0.73 7.79 The hospital ensures a safe and healthy work environment. 10.9 0.82 8.9 Hospital guarantees training and development of its staff health promotion skills. 9.5 1 9.5 The organization has a planned approach to continuously work with other levels of health services and other institutions and departments. 9 0.73 6.55 The quality of health promotion programs is monitored and evaluated in the hospital. 9.5 1 9.5 Health promotion of hospital staff influences patient satisfaction. promotion activities were 65.6 ± 21.2 and 72.2 ± 19.4 out of 100 belonging to "Assessment of patients' needs for health promotion for the first time they enter the hospital" and "Performing health promotion activities in the hospital during outpatient care and after patient's discharge" items, respectively ( Table 4). Managers of this study recognized therapeutic-centered perspective, lack of resources, lack of health promotion professionals, lack of human resources as main obstacles to providing health promotion services. The frequency of these obstacles equaled 36, 28, 19, and 17% for therapeuticcentered perspective, lack of resources, lack of health promotion professionals, and lack of human resources, respectively. The mean scores of health promotion policies of the hospital were significantly different for male and female managers (P = 0.02). Scores that male managers gave to health promotion policies of the hospital were significantly higher than the scores that female managers gave to health promotion policies of the hospital.
Mean scores of hospital health promotion activities were not significantly different between male and female managers (P = 0.904).
There was no statistically significant difference between mean scores given to health promotion policies and activities of the hospital by managers with different education levels, work and managerial experience, and organizational status.

Discussion
This study showed that managers of a hospital had a very high score of attitude toward establishing health promotion policies (scored 84.5 out of 100) and implementation of health promotion activities in the hospital (scored 85.3 out of 100).
Since hospitals have wide access to healthcare professionals, they have a high capacity to formulate and implement HPH services. Other studies have pointed to similar results consistent with the results of the present study. Khowaja et al conducted a study on hospital staff and participants of their study had a positive attitude toward HPH and regarded it beneficial for patients, society, and hospital staff. 13 "Awareness of hospital staff of health promotion policies"; the item of this study has the highest score in policy domain. Other studies have reported varying levels of awareness of health promotion. Afshari et al researched hospital specialists and concluded that most participants had limited awareness of health promotion policies and activities. 14 Richard et al performed an investigation on nurses and claimed that health promotion is often defined as larger-scale health education. A significant number of participants were unable to define health promotion clearly. 15 Khowaja et al stated in their study that only those who had a health-related education defined health promotion more comprehensively and had understood the preventive role of hospitals well. 16 Hospital managers of this study believed that hospitals have written health promotion policies. It seems that other studies reported that overall health promotion policies have been preferred to practical activities in this domain. Whitehead et al carried out a review and found that although health promotion has been addressed in theoretical texts and overall policies, it is not frequently observed in executive activities and published studies are mostly on the theoretical dimension of health promotion. In fact, there are fewer activities performed about its application in health centers. 17 Results of this study show that managers have considered an increase in trust and satisfaction of patients as the result of providing health promotion services in hospitals as the best advantage of HPH executive activities. Casey et al in their study claimed that providing health promotion services in hospitals was an important factor in improving the quality of life of patients. 18 Moreover, the lowest executive scores of this study belonged to "Assessment of patients' health promotion needs" and "Performing health promotion activities in the hospital during outpatient care and after patient's discharge". Studies show when chronic patients are informed about disease status and factors affecting it, they can control the condition better and they are more What Is Already Known? Health promoting hospitals have been founded to transform the hospital from a therapeutic site to a health promotion place. Although health promotion has been addressed in theoretical texts and overall policies of hospitals, it is not frequently observed in executive activities and the idea of health promotion is slowly developing in hospitals.

What This Study Adds?
Hospital managers have a positive attitude toward health promotion policies and activities but there are still obstacles to the implementation of health promotion activities, the most important of which is a therapeuticcentered perspective.

Research Highlights
satisfied with received services. 19. 20 Lee et al conducted a review study and stated that hospitals need regular organizational support to fulfill their role in promoting the health of society. However, many of the identified obstacles are not solely due to insufficient organizational support because poor coordination and integration of health promotion services into hospital services can be an important factor in failing to implement action plans for patients. 21 Studies have shown that insufficient knowledge and understanding of health care professionals about the concept of HPH is an obstacle to effective implementation of related programs in hospitals. 22

Conclusion
The hospital managers' attitudes score was high toward health promotion policies and activities, but there are still problems and obstacles to health promotion activities, the most important of which is a therapeutic-centered perspective. Establishing infrastructure, coordinating, and integrating health promotion services into hospital services can help the implementation of HPH action plans in hospitals. It is suggested to emphasize on positive perspectives and attitudes of the majority of managers in future studies in order to address obstacles and problems of implementing HPH and applying it in the patient's visiting process.

Authors' Contributions
Study design: MSI, AN; Data collection: YN; Data analysis: YN; Manuscript writing: ED; Critical revisions for important intellectual content: ED.

Conflict of Interest Disclosures
There was no conflict of interest in this research.

Ethical Approval
Participants participated in the study with informed consent and their anonymity and confidentiality were respected.