Research purpose: The primary objective of this research was to investigate the relationship between organisational commitment, work engagement and meaning of work amongst nursing staff at various hospitals.

Motivation for study: It is important to understand how to optimise the work experience of nursing staff in order to ensure a committed and engaged workforce.

Research design, approach and method: A survey design with a cluster sample (n = 199) was used. The Organisational Commitment Questionnaire, Utrecht Work Engagement Scale, Work-Life Questionnaire and a biographical questionnaire were administered.

Main findings: The majority of the scales showed acceptable reliability. Results indicated that the majority of nursing staff view their work as either a job or a calling. This impacts the organisation in the sense that viewing work as a calling predicts 19% of the variance in organisational commitment and 30% of the variance in work engagement.

Practical/managerial implications: Viewing work as a calling will accompany higher levels of engagement and commitment to the organisation. Nurses who feel that they make a meaningful contribution to the hospital are more inclined to stay in the organisation.

Contribution/value-add: Strategies can be put in place to focus on experiencing work as a calling, rather than a job. Enhancing this experience and creating awareness could lead to higher levels of organisational commitment and work engagement.

Nurses have expressed the importance of being valued by their organisation, and being part of a community of practice that gives them a sense of meaning (Hemsley-Brown, 1997). According to Van den Heuvel, Demerouti, Schreurs, Bakker and Schaufeli (2006), it has become progressively important for employees to find meaning and value in their work. Previous research has also acknowledged the importance of the experience of meaning for optimal human functioning (Van den Heuvel et al., 2006). Lack of meaning in one’s work may lead to disengagement (Van den Heuvel et al., 2006). Therefore, finding meaning in their work may make nurses feel more energised about their work, and thus more engaged (May, Gilson & Harter, 2004). Schacklock and Brunetto (2012) found an interesting view on meaning: according to their study, nursing staff are less committed to a specific hospital but seek an environment where they can experience optimal meaning in their work. The Towers Perrin Talent Report (2003) states that engagement rests on a meaningful work experience. Organisations must thrive on the mental power of their employees by providing work that leads to employee engagement (Townsend & Gebhardt, 2008). If employees are engaged they will become aware of the organisational context and will work with others to improve performance within their roles to benefit the organisation (Devi, 2009).

Since people spend more than a third of their lives at work (Wrzesniewski, McCauley, Rozin & Schwartz, 1997), it is important to look at concepts such as meaning of work and engagement (May et al., 2004). Employees move from one job to another in search of the right company when they don’t experience any personal meaning in their work (Singh, Jain & Bhandarker, 2006).

Organisational commitment can therefore be considered as a fundamental component as it is a result of whether an employee finds meaning in their work (Van den Heuvel et al., 2006). Organisational commitment has been described as the attachment between employees and their organisation (Jacobs & Roodt, 2007). Employees who are engaged are less likely to leave the organisation due to a concern for and desire to meet patients’ needs. Baskin (2007) also found that an employee who is not engaged is more likely to leave the organisation. In a recent global workforce study by the Towers Watson Company (2012), involving 32 000 employees across different industries in the world, the link between engagement and retention is confirmed.

It is reported that the number of qualified and unqualified nurses working as nurses has recently shown a significant decline compared with a decade ago (Hemsley-Brown, 1997). The nursing profession has increasingly become vital internationally, and the local shortage of competent nurses could even be referred to as an: ‘imminent crisis’ (Smyer & Pitt-Catsouphes, 2007). In South Africa, it has been reported that there are 32 000 vacant nursing positions in public hospitals and that most of the employed nurses are over the age of 40 (Pillay, 2009). Brunetto et al. (2013) conclude in their study that the aging population of countries exacerbates the need for nurses, who are already in huge demand. In the current research, it was observed that nurses are working long hours and sacrificing their tea and lunch breaks for the benefit of patients, due to staff shortages. This study will create an understanding of how nurses experience meaning in their jobs and may assist employers to create options for their employees to improve engagement leading to organisational commitment.

The aim of this study was to investigate organisational commitment, engagement and meaning of work amongst nurses in various hospitals. Studies addressing the combination of these topics could not be found in South African research; therefore, this study will add value in the literature, ultimately contributing to an understanding of the relevant issue of the current nursing shortage in this country.

Porter, Steers, Mowday and Boulian (1974) explain that there are three types of organisational commitment. Affective commitment can be seen as the first domain, which includes the strength of a person’s identification with and participation in the organisation. Jernigan, Joyce and Kohut (2002) are of the opinion that individuals possessing affective commitment stay within the organisation, not because they have to or feel obligated to do so, but because they want to stay. Continuance commitment is based on the degree to which the person perceives the costs of leaving the organisation as greater than staying, or simply that the person remains committed because it is their only option (Meyer and Allen, 1991). Jernigan et al. (2002) concur that employees with continuance commitment stay with the organisation because they have to.

Lastly, Steers (1977) explains normative commitment as attaching internalised values to the organisation. It can be regarded as a feeling of obligation towards the organisation (Steers, 1977). Meyer and Allen (1991) identify two mechanisms that can contribute to normative commitment. The first one is a strong correlation between the values of the individual and the values of the organisation. The second mechanism is of a more instrumental nature associated with reward systems. Thus, an employee may be rewarded according to certain criteria, and may then in return feel obligated to stay with the company (Jacobsen, 2000). Therefore, individuals who experience normative commitment, according to Jernigan et al. (2002), are committed to the organisation because they feel it is the right thing to do.

Muthuveloo and Che Rose (2005) assert that it is important to recognise an employee’s work perceptions because this could be a direct motivation for the individual and could lead to higher organisational commitment.

These perceptions should be positive in order to improve the motivation of that individual, which could also be an indicator of higher organisational commitment (Muthuveloo & Che Rose, 2005). Dick and Metcalfe (2001) maintain that there are two dimensions that could affect organisational commitment: individual dimensions and managerial dimensions. According to Dick and Metcalfe, individual dimensions include factors such as age, years in the organisation and internal status within the company. The second factor, managerial, can be described as how the individual is treated within the company, which includes factors such as how the individual is supported and developed within the organisation (Dick & Metcalfe, 2001).

Some researchers agree that work engagement not only assists in the decrease of perceived levels of occupational stress (Maslach & Leiter, 1997; Schaufeli & Bakker, 2004), but also brings about organisational and financial success through an increase in employee motivation and organisational commitment (Koyuncu, Burke & Fiksenbaum, 2006; Maslach & Leiter, 1997). Disengaged employees tend to distance themselves from their work roles and to withdraw cognitively from the current work situation (Koyuncu et al., 2006). Therefore, work engagement is an important factor within any organisation, and more specifically within social service occupations such as nursing (Meyers, 2007; Simpson, 2008), especially since these employees interact with various social systems within the organisation and show the lowest level of work engagement (Cooper & Burke, 2008).

Saks and Rothmann (2006) state that employees see engagement as a means of repayment toward the organisation. Leiter and Maslach (1998) also explain that engagement can be seen as a constructive indicator of commitment. Thus, nurses can choose on what level or to what degree they want to be engaged in their work, which, in turn, influences their loyalty and commitment to the organisation (Blizzard, 2002).

Blizzard (2002) declares that engaged employees are loyal and psychologically committed to the organisation. This view was also confirmed by Jordaan and Rothmann (2005). Therefore, a higher level of work engagement benefits the employer in that it has an impact on the competitive advantage of the organisation (Bakker, Schaufeli, Leiter & Taris, 2008).

According to the Towers Perrin Talent Report (2003), work engagement is seen as involving both emotional and rational factors relating to work and the overall work experience. Emotional factors are those leading to a sense of personal satisfaction, and the inspiration and affirmation received from the work and being part of the organisation. This could come from having a strong sense of personal accomplishment in the job they perform. It can therefore be concluded that engagement is related to meaningful work (Maslach & Leiter, 1997).

According to Wrzesniewski et al. (1997), individuals who view their work as a job are engaged in their work only for the material benefits they receive from it. Therefore, these individuals perceive work to be nothing more than a means to a financial end (Bellah et al., 1985; Parry, 2006). In contrast, individuals who view their work as a career are concerned with the progression of continuous advancement within the organisation (Bellah et al., 1985; Parry, 2006; Wrzesniewski et al., 1997), through dedicating considerable amounts of time and energy to work-related activities for future gain (Wrzesniewski et al., 1997). Viewing work as a calling implies the feeling that one was placed on earth to engage in these specific work-related tasks (Parry, 2006). People in this category obtain a sense of fulfilment from those activities (Wrzesniewski et al., 1997). Lok and Crawford (2001) have found that age also plays a role in the meaning employees derive from their work and the level of their commitment.

Another interesting factor is the increase in the numbers of nursing managers becoming separated from their nursing origins (Allen, 2000; Carpenter, 1977). This is due to the restructuring of the health care system, in which nursing managers are moved further away from the clinical setting (Clifford, 1998; Rankin & Campbell, 2006). These changes within organisations may pose a threat to the meaning that individuals experience in their work. As a result of such organisational change individuals may experience disengagement (Burger, Crous & Roodt, 2013). This is problematic as good nursing managers are able to ease the negative impacts of change on nurses within the hospital (Cummings, Hayduk & Estabrooks, 2005). These nursing managers might experience their work as a career rather than a calling. The support provided by nurse managers is essential to a healthy and productive work environment (Kramer et al., 2007). Nurses remain the largest group of professional employees in the health care system.

In previous research it was confirmed that the calling orientation might be attributed to people knowing that they have an impact on others’ lives (Van Zyl, Deacon & Rothman, 2010). Since the nursing profession has a strong impact on the lives of others, nurses might also perceive their work more as a calling as found in the research of both Bellah et al. (1985) and Van Zyl et al. (2010). For this reason, what nurses do, why they do what they do and how well they do it, are significant factors that directly affect the quality of care the patient receives, and hospitals should constantly work towards sustaining such quality (Her Majesty’s Stationery Office, 1979). Burger et al. (2013) are of the opinion that meaning in work should be considered a critical variable in framing change initiatives for organisations to succeed. Therefore, aspects such as organisational commitment, work engagement and meaning of work should be studied. According to Van Zyl et al. (2010), the understanding of the effect of these aspects on employees can lead to a deeper level of understanding of the happiness of employees. Therefore, people who are emotionally, cognitively and physically involved in their work may experience work engagement. Van Zyl et al. (2010) state that organisations need to realise that employees who experience meaning within their work may in the long term be instrumental in organisational success.

In the literature study, the constructs of organisational commitment, work engagement and meaning of work are defined and the relationship between them described. Figure 1 proposes a conceptual model of the relationships between these constructs, which was used in this study.

Based on the above problem statement and literature review, the following hypotheses are formulated:

• Hypothesis 1: A practically significant relationship exists between meaning of work (job, career or calling) and organisational commitment.

• Hypothesis 2: A practically significant relationship exists between meaning of work (job, career or calling) and work engagement.

• Hypothesis 3: Meaning of work as a calling predicts work engagement.

• Hypothesis 4: Meaning of work as a calling predicts commitment.

FIGURE 1: The motivation process.

The study population consisted of 96.5% female participants and 2.5% male participants. Furthermore, the sample comprised Black (34.2%), White (63.8%) and Indian (2.0%) participants (none was mixed-race), of whom 10.6% were managers, 6.1% were senior sisters, 33.5% sisters, 19.3% staff nurses, 7.6% assistant nurses, 19.3% student nurses and 3.6% other types. The majority of the participants were registered nurses. The ages of the participants were 35 years and younger (33.9%), 36–45 years (30.4%), or 46 years and older (35.7%). Most participants had from two to five years’ experience (31.6%), and most indicated a diploma as their level of qualification (42.9%). The majority of nurses were permanently employed (72.4%); 27.6% were employed on a contract basis.

Organisational Commitment Questionnaire (OCQ): According to Meyer and Allen (1991), this measure views organisational commitment from three perspectives: affective, continuance and normative commitment. Affective commitment refers to employees’ degree of emotional attachment to and identification with the organisation. The continuance component refers to the level of commitment that employees associate with the organisation based on the perceived costs of leaving the organisation. Thirdly, the normative component refers to the employee’s feeling that they have a responsibility to remain within the organisation and not leave it for another one. The 18 items are measured on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree), which includes items such as: ‘I would be very happy to spend the rest of my career in this organisation’, ‘I do not feel any obligation to remain with my current employer’ and ‘Right now, staying with my organisation is a matter of necessity as much as desire’. High scores on the affective commitment scale (ACS), normative commitment scale (NCS) and continuance commitment scale (CCS) are an indication of organisational commitment. Research conducted by Meyer and Allen indicates that the reliability figures for the three scales of commitment by means of coefficient alpha values are above the acceptable levels and are as follows: ACS 0.87, CCS 0.75 and NCS 0.79.

The Utrecht Work Engagement Scale (UWES): The scale developed by Schaufeli et al. (2002) was utilised as a measure of work engagement amongst nurses at hospitals. This 17-item questionnaire is measured on a seven-point frequency scale, ranging from 0 (never) to 6 (always); the measure has three sub-scales: vigour, dedication and absorption. Example items are, ‘I feel strong and vigorous in my job’, ‘I always persevere at work, even when things do not go well’ and ‘In my job, I can continue working for very long periods at a time’. Regarding internal consistency, Cronbach’s alpha coefficients have been determined at between 0.68 and 0.91 (Schaufeli et al., 2002). In a study amongst South African workers, Olivier and Rothmann (2007) obtained an alpha coefficient of 0.72, implying that the instrument is reliable in the South African context.

The Work-Life Questionnaire (WLQ): This questionnaire was developed by Wrzesniewski et al. (1997) and aims to measure an individual’s orientation to work (meaning of work). These orientations are classified into three main categories: work as a job, work as a career and work as a calling. The questionnaire is divided into two parts. The first part contains three paragraphs signifying the three work orientations and is a self-report measure. Participants have to read all three paragraphs and then rate their level of association with each paragraph as: ‘very much me’, ‘somewhat’, ‘a little’, or ‘not at all like me’. The second part consists of 18 true or false items about specific aspects of relation to work that are relevant to the three work orientations in the first part of the questionnaire. A typical item is: ‘My primary reason for working is financial’.

In previous research, that included nurses in the sample, Wrzesniewski et al. (1997) found the reliability of this instrument to be adequate. Van Zyl et al. (2010) reported Cronbach’s alpha coefficients ranging between 0.87 and 0.80 for the WLQ in a South African study. The results of this questionnaire provide an indication of where the respondent falls on the job-career-calling continuum.

Multiple regression analyses were carried out to determine the percentage variance in the dependent variables that was predicted by the independent variables.

A principal component analysis was conducted on the 24 items of the OCQ. The Kaiser-Meyer-Olkin measure of sampling adequacy revealed a value of 0.79, which indicates that the items were factorable (Field, 2006). Bartlett’s test of sphericity was shown to be highly significant at 276.00. The scale produced communalities that were all higher than the suggested 0.30. A principal component analysis showed that eight factors could be extracted, all of which were higher than 1. They represented 64.13% of the total variance explained. Further analysis was done using the Total Commitment Scale.

A principal component analysis was conducted on the 17 items of the UWES. The Kaiser-Meyer-Olkin measure of sampling adequacy showed a value of 0.92, which indicates that the items were well above the suggested 0.60 (Field, 2006). Bartlett’s test of sphericity was found to be highly significant at 136.00. The scale produced communalities that were all higher than the suggested 0.30.

The principal component analysis showed that two factors (with eigenvalues of 9.13 and 1.07) could be extracted that were larger than 1 and this was confirmed by the scree plot which also showed two factors. These components explain in total 60% of the variance of the instrument. A one-factor structure was used in further analysis because the original three-factor structure was not found.

At first, a direct oblimin rotation was used. However, because the inter-item correlation did not show sufficient correlation, the varimax rotated factor analysis was used on the WLQ and three factors were specified. All items loaded onto factor 1 (calling) factor 2 (career) or factor 3 (job). Two items did not load on any factors and were deleted. The Kaiser-Meyer-Olkin measure of sampling adequacy showed a value of 0.79, which indicates that the items were factorable. Bartlett’s test of sphericity was shown to be highly significant (c² (210) = 885.05; p < 0.05). Communalities for the scale were produced, all showing higher than the suggested 0.30. The principal axis factoring showed that three factors (with eigenvalues of 5.22, 2.30 and 1.66 respectively) could be extracted. They represented 63.75% of the total variance explained.

Inspection of Table 1 shows that acceptable Cronbach’s alpha coefficients were obtained for most of the scales. All of the alpha coefficients were higher than the guideline of a > 0.70 (Nunnally, 1978), except for the MOW-Job and MOW-Career subscales of the WLQ. Furthermore, the scores on all scales were normally distributed, as indicated by their skewness and kurtosis. It therefore appears that the measuring instruments had acceptable levels of internal consistency, although engagement has a slight skewness of -1.01 and the work-life calling construct a kurtosis of -1.03. The mean scores of the meaning of work orientations, calling and job, varied by only 0.51, indicating, therefore, that the majority of nurses view their work as either a job (18.81) or a calling (18.30).

Next, Pearson product-moment correlations were done as reported in Table 2.

Table 2 shows the following statistically and practically significant correlations: the MOW-Calling and MOW-Job correlated negatively statistically and practically significantly (r = 0.50; p < 0.01; large effect). This indicates that people experience meaning of work as either a job or a calling on a continuous scale, which was confirmed in previous research by Wrzesniewski et al. (1997). Furthermore, Organisational Commitment and MOW-Job had a positive statistically and practically significant correlation (r = 0.38; p < 0.01; medium effect). It should be noted that the fact that the scale on the WLQ was reversed means that people viewing their work as a job are less committed or that less committed people tend to view their work as a job. MOW-Calling and Organisational Commitment had a statistically negative correlation, with a practically significant negative correlation with a medium effect (r = -0.47; p < 0.01); again, it should be remembered that the WLQ items were reversed. Therefore, the stronger an individual’s view of their work as a calling, the more committed they will be to the organisation. Based on the above analysis, Hypothesis 1, ‘A practically significant relationship exists between meaning of work (job, career or calling) and organisational commitment’, can be accepted.

Work engagement and MOW-Job had a statistically and practically significant positive correlation (r = 0.54; p < 0.01; large effect). The more people view their work as a job the less engaged they will be, because the scale on the WLQ was reversed. MOW-Calling and work engagement had a statistically and practically significant negative correlation (r = -0.57; p < 0.01; large effect); therefore, the stronger a person’s view of their work as a calling, the more engaged they will be in their work. Based on the above analysis, Hypothesis 2, ‘A practically significant relationship exists between meaning of work (job, career or calling) and work engagement’, can be accepted.

Lastly, work engagement and organisational commitment had a statistically and practically significant positive correlation (r = 0.42; p < 0.01; medium effect). Those who are engaged in their work will be more committed to the organisation, or if they are more committed they will be more engaged.

Next, a multiple regression analysis was conducted to test whether meaning of work predicts organisational commitment and work engagement. Step 1 was used to control for the influence that meaning of work (calling) has on the dependent variable work engagement and step 2, career, was included to control for the influence on work engagement as the dependent variable. Step 3, job, was included as the independent variable.

Table 3 indicates that 30% of the variance in work engagement is predicted by the meaning of work variable calling (F = 58.81; p < 0.00). When career was added it made no significant contribution to the variance explained. Adding job (F = 28.53; p < 0.00) in step 3 increased the R², explaining 39% of the variance in work engagement. The meaning of work variable job, therefore, predicted 9% of the variance in work engagement and calling predicted 30%. Based on the above analysis, Hypothesis 3, ‘Meaning of work as a calling predicts work engagement’, can be accepted.

Next, a series of multiple regression analyses were performed to test whether meaning of work (calling, career or job) predicts organisational commitment. Firstly, the previous results have already shown that being engaged in one’s work is predicted by whether one views one’s work as a calling or a job. Secondly, to test whether organisational commitment is predicted by meaning of work, a multiple regression analysis was carried out with organisational commitment as the dependent variable and meaning of work (calling, career or job) as the independent variable. Step 1 was used to control for the influence that meaning of work (calling) has on the dependent variable organisational commitment and step 2, to control for the influence of meaning of work (career) on organisational commitment as the dependent variable. Step 3 included meaning of work (job) to control for the influence on organisational commitment.

Table 4 shows that meaning of work (calling) predicts 19% of the variance in organisational commitment (F = 32.50; p < 0.00). When career was added it also made no significant contribution to the variance explained. It also showed that when job was added in step 3 it increased the R², explaining 23% of the variance in organisational commitment (F = 13.66; p < 0.00). The meaning of work variable, job, therefore predicted 4% of the variance in organisational commitment and calling predicted 19%. It can be concluded that calling predicts organisational commitment. Therefore, based on the above analysis, Hypothesis 4, ‘Meaning of work as a calling predicts commitment’, can be accepted.

The Pearson correlations in this study indicated that the calling orientation towards work correlated negatively with the job orientation. Therefore, nurses who view their work as a calling are not influenced much by financial gain; they are in the profession as they feel that they were born to do it.

Calling also correlated positively with work engagement and organisational commitment, demonstrating that the more that nurses view their work to be a calling, the more likely they are to be engaged in their work and the more committed they are to the organisation. Wu (2010) also found that engaged nurses experienced meaning in their work.

Lastly, organisational commitment and work engagement had a positive correlation (as the one increases, so will the other). This indicates that the more committed nurses are to the organisation, the more engaged they will be in their work or, similarly, the more engaged they are, the more committed they will be. Career and calling orientations had a slightly positive correlation with each other, indicating that nurses who view their work as a calling might want to achieve a higher level of employment within the organisation.

The second set of regression analyses indicated that the meaning of work variable, calling, predicts both work engagement and organisational commitment; this is a positive relationship. Therefore, nurses viewing their work as a calling will be more engaged in their work and more committed to the organisation than nurses viewing their work as a job.

In conclusion, based on the results of this study, it is evident that many nurses view their work as a calling, whilst some view their work as a job. Nurses who view their work as a calling are more committed to the organisation and more engaged in their work.

• The knowledge gained from this study’s results and the theoretical knowledge gained from literature could be incorporated into the effective nursing criteria in the screening and selection of appropriate participants for the future. Muthuveloo and Che Rose (2005) state that it is important to recognise an employee’s work perceptions, which can be a direct motivation for the individual, which would in return lead to higher organisational commitment.

• Regular staff feedback sessions or focus groups should be implemented, in which nurses have the opportunity to share their insights with regard to how processes may be improved, to share inspiring stories about patients they may have encountered and treated, and so on. By doing so the hospital establishes a sense of organisational support and enhances nurses’ self-fulfilment they receive from hearing and sharing.

• Hospitals should consider implementing community projects, where nurses willingly provide their services pro bono in order to help out patients who do not have the financial capacity to afford such services. By doing so nurses give something back to the community and in turn realise the difference they make in people’s lives; this will also enhance the feeling of finding meaning in their work.

• Most of the nurses in the hospitals are 46 years and older; therefore, hospitals should realise the risks and opportunities of an aging workforce and implement recruitment strategies accordingly. It is important that older workers be retained to optimise transfer of learning to younger, inexperienced workers.

• Considering the nurse shortage in South Africa, crafting job options that are consistent with the preferences of employees of different age groups is an important employer strategy. It is important to ensure smooth flow of talent management to ensure vacancies are filled quickly, thus avoiding unnecessary demands on current staff.

• Hospitals should implement bursary programmes to provide support to staff members, in order to further their careers. The information obtained in this study showed that career correlated positively with calling; therefore, viewing your work as either a calling or a career enhances organisation commitment and work engagement.

• Outreach programmes to universities may be looked at, in which current nurses give motivations and explanations regarding their occupation to motivate young people to follow in their footsteps. This will raise awareness about the occupation and in turn bring more people into the profession. Talent can be identified and bursaries offered; bursary holders who have agreed and been selected could then work for the hospital for a set period after studies have finished.

• A cross-sectional research design was used and the respondents were only assessed once; this limits the determination of cause-and-effect relationships. Participants were also only assessed at a single time in their lives.

• A cluster sample was used as the sampling method of permanent and non-permanent nurses in hospitals. However, only 199 questionnaires were returned. Although a larger sample would have been more beneficial, the sample size of 199 is reasonable and large enough to generalise findings to the larger population.

• The measures that were administered were in English; this could be a limitation due to a potential language barrier for participants whose first language was not English. Translation into other languages could have resulted in better feedback.

• The use of self-report measures could be a limitation as it tests the participants’ perceptions about the constructs and might not measure the constructs themselves.

• The test battery itself was lengthy and this may have caused participants to give a convenient answer instead of the needed consideration.

• Longitudinal studies need to be utilised in order to determine the causal factors and relationships between organisational commitment, work engagement and meaning of work.

• The sample size of 199 should be expanded to a larger sample size to enhance external validity and the involvement of both government and private hospitals could be obtained to see differences in environment.

• To enhance cultural appropriateness, equivalence studies can be conducted and the questionnaire could be translated into other applicable languages.

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