Original article| Volume 93, ISSUE 10, P1814-1821, October 2012

Development of a Measure of Skin Care Belief Scales for Persons With Spinal Cord Injury

Published:April 12, 2012DOI:


      King RB, Champion VL, Chen D, Gittler MS, Heinemann AW, Bode RK, Semik P. Development of a measure of Skin Care Belief Scales for persons with spinal cord injury.


      To develop and validate a measure of skin care beliefs and to describe the skin care behaviors of persons with spinal cord injury (SCI).


      A mixed-methods design was used to develop the Skin Care Beliefs Scales (SCBS). The health belief model framed the hypotheses. Phase 1 included item development, content validity testing, and pilot testing. Phase 2 included testing the scale structure (principal components analysis), internal consistency reliability, test-retest reliability, and relationships between the belief scales and care behaviors.


      Two acute rehabilitation hospitals and Internet websites.


      Patients with SCI (N=462; qualitative/pilot n=56; psychometric study n=406) participated.


      Not applicable.

      Main Outcome Measures

      The pilot and phase 2 studies, respectively, used 146-item and 114-item versions of the SCBS. A skin care activity log was used to record skin care behaviors.


      Content validity indicated that the items were relevant and clear. The analysis resulted in 11 independent scales reflecting 3 general beliefs (susceptibility, severity, self-efficacy) and barrier and benefit behavior-specific scales for skin checks, wheelchair pressure reliefs, and turning and sitting times. With the exception of skin check barriers (α=.65), Cronbach alphas of the scale ranged from .74 to .94. Test-retest intraclass correlations were fair to excellent (range, .42–.75). Construct validity was supported. Hierarchical linear regression indicated that turning benefits, barriers, susceptibility, and self-efficacy were significant predictors of turning time. Benefits or barriers were correlated significantly with skin check and pressure relief adherence (ρ range, −.17 to −.33). Self-efficacy was correlated with wheelchair pressure relief (ρ=.18). Skin care behavior adherence varied widely (eg, 0%–100%).


      The scales showed acceptable reliability and validity. Further testing with larger samples is desirable.

      Key Words

      List of Abbreviations:

      SCI (spinal cord injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cardenas D.D.
        • Hoffman J.M.
        • Kirshblum S.
        • McKinley W.
        Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis.
        Arch Phys Med Rehabil. 2004; 87: 1757-1763
        • Fuhrer M.J.
        • Garber S.L.
        • Rintala D.H.
        • Clearman R.
        • Hart K.A.
        Pressure ulcers in community-resident persons with spinal cord injury: prevalence and risk factors.
        Arch Phys Med Rehabil. 1993; 74: 1172-1177
        • Garber S.L.
        • Rintala D.H.
        • Hart K.A.
        • Fuhrer M.J.
        Pressure ulcer risk in spinal cord injury: predictors of ulcer status over 3 years.
        Arch Phys Med Rehabil. 2000; 81: 465-471
        • Haisma J.A.
        • van der Woude L.H.
        • Stam H.J.
        • et al.
        Complications following spinal cord injury: occurrence and risk factors in a longitudinal study during and after inpatient rehabilitation.
        J Rehabil Med. 2007; 39: 393-398
        • Garber L.S.
        • Rintala D.H.
        • Rossi D.C.
        • Hart K.A.
        • Fuhrer M.J.
        Reported pressure ulcer prevention and management techniques by persons with spinal cord injury.
        Arch Phys Med Rehabil. 1996; 77: 744-749
        • King R.B.
        • Porter S.L.
        • Balfanz Vertiz K.
        Preventive skin care beliefs of people with spinal cord injury.
        Rehabil Nurs. 2008; : 154-162
      1. King RB, Porter SL, Champion V, Vertiz K. Development of a measure of preventive skin care beliefs. In: Proceedings of the Midwest Nursing Research Society Annual Conference; April 4-7, 2003; Grand Rapids, MI.

        • Merbitz C.T.
        • King R.B.
        • Bleiberg J.
        • Grip J.C.
        Wheelchair push-ups: measuring pressure relief frequency.
        Arch Phys Med Rehabil. 1985; 66: 433-438
        • Consortium for Spinal Cord Injury
        Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health care professionals.
        PVA, Washington (DC)2000
        • Rosenstock I.M.
        Why people use health services.
        Milbank Mem Fund Q. 1966; 44: 94-127
        • Janz N.
        • Becker M.H.
        The health belief model: a decade later.
        Health Educ Q. 1984; 11: 1-47
        • Glasgow R.E.
        • Stryker L.A.
        • Hampson S.E.
        • Ruggiero L.
        Personal-model beliefs and social-environmental barriers related to diabetes self-management.
        Diabetes Care. 1997; 20: 556-561
        • Aljasem L.I.
        • Peyrot M.
        • Wissow L.
        • Rubin R.R.
        The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes.
        Diabetes Educ. 2001; 27: 393-404
        • Robinson-Whelen S.
        • Bodenheimer C.
        Health practices of veterans with unilateral lower-limb loss: identifying correlates.
        J Rehabil Res Dev. 2004; 41: 453-460
        • Rosenstock I.M.
        • Strecher V.J.
        • Becker M.H.
        Social learning theory and the health belief model.
        Health Educ Q. 1988; 15: 175-183
        • Dai Y.T.
        • Catanzaro M.
        Health beliefs and compliance with a skin care regimen.
        Rehabil Nurs. 1987; 12: 13-16
        • Basta S.M.
        Pressure sore prevention self-efficacy and outcome expectations: a study of people with spinal cord injury.
        Rehabil Nurs Res. 1994; 3: 11-17
        • Champion V.L.
        Instrument refinement for breast cancer screening behaviors.
        Nurs Res. 1993; 42: 139-143
        • Strecher V.J.
        • Champion V.L.
        • Rosenstock I.M.
        The health belief model and health behavior.
        in: Gochman D.S. Handbook of health behavior research I: personal and social determinants. Plenum Pr, New York1997: 71-91
        • Maynard F.M.
        • Bracken M.B.
        • Creasey G.
        • et al.
        International standards for neurological and functional classification of spinal cord injury.
        Spinal Cord. 1997; 35: 266-274
        • Tabachnik B.G.
        • Fidell L.S.
        Using multivariate statistics.
        Allyn and Bacon, Boston2001
        • Norman G.
        Likert scales, levels of measurement and the “law” of statistics.
        Adv Health Sci Educ. 2010; 15: 625-632
        • McLaughlin G.H.
        SMOG grading: a new readability formula.
        J Reading. 1969; 12: 639-646
        • Lynn M.R.
        Determination and quantification of content validity.
        Nurs Res. 1986; 35: 382-385
        • McDowell I.
        Measuring health: a guide to rating scales and questionnaires.
        Oxford Univ Pr, New York2006
        • Garber S.L.
        • Rintala D.H.
        • Holmes S.A.
        • Rodriguez G.P.
        • Friedman J.
        A structured educational model to improve pressure ulcer prevention knowledge in veterans with spinal cord dysfunction.
        J Rehabil Res Dev. 2002; 39: 575-588
        • Nunnally J.C.
        • Bernstein I.H.
        Psychometric theory.
        3rd ed. McGraw-Hill, New York1994
        • Wallace L.S.
        Osteoporosis prevention in college women: application of the expanded health belief model.
        Am J Health Behav. 2002; 26: 163-172
        • Townsend A.
        • Hunt K.
        • Wyke S.
        Managing multiple morbidity in mid-life: a qualitative study of attitudes to drug use.
        BMJ. 2003; 327: 837-841
        • DiMatteo R.M.
        • Haskard K.B.
        • Williams S.L.
        Health beliefs, disease severity, and patient adherence: a meta-analysis.
        Med Care. 2007; 45: 521-528
      2. King RB, Chen D, Gittler M, et al. A randomized trial to prevent pressure ulcers after SCI. Final grant report: Centers for Disease Control Cooperative Agreement; 2002. Report no. U59/CCU514156-01.

        • Fisher S.V.
        • Patterson P.
        Long-term pressure recordings under the ischial tuberosities of tetraplegics.
        Paraplegia. 1983; 21: 99-106
        • Rodriguez G.P.
        • Garber S.L.
        Prospective study of pressure ulcer risk.
        Paraplegia. 1994; 32: 50-58
        • Knapp T.R.
        • Brown J.K.
        Ten measurement commandments that often should be broken.
        Res Nurse Health. 1995; 18: 465-469
        • Gonder-Frederick L.A.
        • Julian D.M.
        • Cox D.J.
        • Clarke W.L.
        • Carter W.R.
        Self-measurement of blood glucose, accuracy of self-reported data and adherence to recommended regimen.
        Diabetes Care. 1988; 11: 579-585
        • Ross M.M.
        • Rideout E.
        • Carson M.M.
        The use of the diary as a data collection technique.
        West J Nurse Res. 1994; 16: 414-425
        • Chmelik F.
        • Doughty A.
        Objective measurements of compliance in asthma treatment.
        Ann Allergy. 1994; 73: 527-532
        • Venmans L.M.
        • Gorter K.J.
        • Hak E.
        • Rutten G.E.
        Short-term effects of an educational program on health-seeking behavior for infections in patients with Type 2 diabetes: a randomized controlled intervention trial in primary care.
        Diabetes Care. 2008; 31: 402-407
        • Sethares K.A.
        • Elliott K.
        The effect of a tailored message intervention on heart failure readmission rates, quality of life, and benefit and barrier beliefs in persons with heart failure.
        Heart Lung. 2004; 33: 249-260