Introduction
Communication is a complex process of sending and receiving messages to exchange information, feelings, needs and priorities, and mutual understanding of the message [1]. Communication in human life is so essential that some experts have considered it the basis of human growth, progress, or injuries. Communication skills are behaviors and actions through which a person communicates with others to create positive responses and avoid adverse reactions. Communication skills with people help establish effective contact and make a positive impact on others [2]. Interpersonal communication skills include speaking (verbal and non-verbal), listening, interpreting the audience’s words, clarifying the audience’s words, asking questions, praising and encouraging, and providing feedback. These skills have long been recognized as crucial to health and medical care [3, 4]. In medicine, communication skills are a set of behaviors that improve communication quality and healthcare effectiveness [5]. 
Communication skills are mainly acquired and can be learned [6, 7, 8]. Teaching communication skills to patients is crucial in improving the quality of services and care. Therefore, this training should be a part of the medical training program [9]. In addition to training, researchers increasingly emphasize evaluating healthcare providers’ communication skills [10]. Today, choosing the appropriate evaluation method is one of the priorities of medical education [11]. Dissatisfaction with the traditional methods of evaluating training and clinical skills has led to a new evaluation method [12]. Balanescu et al. emphasized the importance of a tool to measure communication skills and designed such a tool for Romanian doctors [13].
Boucher et al. emphasized the heterogeneity of measurement tools of doctors’ communication skills and recommended further studies to prepare valid tools [14]. Sinskey et al. highlighted effective communication between health service providers and patients because poor communication leads to conflict between caregivers and patients [15]. In a study conducted at Jahrom University of Medical Sciences entitled “the effect of comfort training course on nurses’ attitude to communication skills”, the necessity of holding a comfort communication skills course in the nursing course was emphasized. The study emphasizes the effect of nurses’ attitudes on communication skills [16]. In another study conducted in Isfahan City, Iran, entitled “teaching communication skills to doctors as a way to increase patient satisfaction: A model for continuous education”, teaching communication skills to general practitioners resulted in greater patient satisfaction [17]. Another study conducted in Bhopal, India, entitled “evaluation of communication skills in medical students”, showed that most students had poor to relatively good communication skills, but none had high communication skills [18]. In another study conducted under the title of “evaluation of the level of communication skills of Qom University of Medical Sciences students in 1996”, the verbal communication skills of female students were found to be better than male students. The study also found it necessary to hold effective workshops to improve students’ communication skills [19]. 
On the other hand, childhood is an unrepeatable, effective, and sensitive period in the process of growth and development, and any shortage in this period will cause irreversible damage to the child [20]. The importance of diagnosing developmental disorders and providing intervention services in infants and toddlers has gained increasing value. Timely and periodic assessment of development in children provides the possibility of diagnosing and treating developmental disorders, preventing the loss of the child’s developmental potential [21, 22]. The diagnostic test of Bayley scales of infant and toddler development, third edition (Bayley-III), is one of the few universally recognized diagnostic tests that, in addition to comprehensiveness in all developmental areas, has high psychometric properties [23]. 
This test is an individual assessment scale that evaluates the developmental performance of children aged 1 to 42 months. Currently, various units are set in the country’s health centers, including a unit of child development for screening and diagnostic and observational tests of development. Every year, the Bayley test training is conducted for selected experts or examiners of health centers. To confirm their qualifications, these examiners prepare videos of several examples of tests performed on children with different age groups, and evaluators watch and assess the submitted videos. One obvious challenge in conducting this test was the lack of proper communication between the examiner and the child and parents during the test. However, there is no scale so far to confirm the competence of examiners’ communication skills. Also, the evaluators have no scale to evaluate the process of the examiners’ work in the desired test tastefully. Thus, designing a suitable scale to measure the examiners’ communication skills is particularly important. This study was conducted to develop a scale to evaluate the communication skills of child experts in the country’s health centers in developmental observational tests.

Materials and Methods
The purpose of this study was to design a scale to determine the validity and reliability of the communication skills of health center experts working in the country’s child developmental units. The sampling method was purposeful. First, to reach a consensus and use the opinions of specialists and experts, the Ministry of Health provided a list of experts of these units working in health centers in medical sciences universities of the country. Ten experts were selected from Shahid Beheshti, Tehran, Tabriz, Shiraz, Ahvaz, Zanjan, Qazvin, Zahedan, Arak, and Kermanshah universities of medical sciences. The experts were assured of maintaining trustworthiness and honesty in data collection. After reviewing the texts and related scientific articles derived from the models of communication skills, both internal and external, a pool of communication items was extracted.
 Hence, the initial draft was compiled with 37 items. Then, using the Delphi method and presenting the initial draft, the experts were asked to express their opinions and suggestions regarding compiling communication items. Their comments were collected and coded. According to the structure of the Bayley test and its instructions, the group of experts and research team members concluded that the compiled items should be classified into three sections: Communication with children, communication with parents, and the general section. Next, to determine the content and face validity of the items, the consensus opinion of 16 experts in the field of communication evaluation, such as a child psychiatrist, a psychologist with experience in children’s tests, a speech and language pathologist, and an occupational therapy specialist, was used. To complete the questionnaire, they were asked to express their opinions regarding the script of the items, their ability to understand and the presence of ambiguity in words and phrases while studying each item. According to the consensus of the respondents, necessary changes were made to understand the items better. To determine the items’ content validity, we used the items’ content validity ratio (CVR) provided by Lawshe and the content validity index (CVI) provided by Waltz and Bausell. First, the objectives of the scale design were explained to the experts, and the operational definitions related to the content of the items were stated. They were asked to rate each item based on the 3-point Likert scale: It is necessary; it is useful but not necessary; it is not necessary. After gathering the opinions of experts, the CVR index was calculated using the Equation 1:


, where N=the total number of experts and ne=the number of experts who have chosen the necessary option. 
Based on the calculation of the CVR, considering the number of experts (16 people), the criterion of 0.49 was set, and the items that were less than this value were removed. To calculate the CVI, the experts were asked to determine the degree of clarity, simplicity, and relevance of each item with a 4-point scale for each item: 
- Clarity (“it is completely clear”, “clear but needs revision”, “needs serious revision”, “is ambiguous”);
- Simplicity (“it is quite simple”, “it is simple but needs to be revised”, “it needs serious revision”, “it is ambiguous”); and
- Relevancy (“completely relevant”, “relevant but in need of revision”, “in need of serious revision”, “not relevant”). 
The number of experts who chose the first and second options in each range was divided by the total number of experts (16 people). If the result in each item was less than 0.7, the item was rejected; if it was between 0.7 and 0.79, it was revised. If it was more significant than 0.79, it was acceptable. Based on the expert group’s suggestions and CVI’s results, a series of items were revised, and changes were made to the structure of sentences and verbs. Due to the suggestion of the majority of the expert group, the text of sentences and items were summarized. After finalizing the items and determining their validity, a 5-point Likert scale (weak, average, good, very good, and excellent) was compiled and agreed upon for each item.
To determine the reliability of the designed scale, the videos of the Bayley test examiners in the center’s unit were used while performing the test with children. First, 6 full videos of the performance of the Bayley test were prepared by examiners with different ability levels from 6 age groups of children (3-4 months, 5-6 months, 12 months, 20 months, 31-32 months, and 42 months) was sent to 8 evaluators to assess with the designed communication scales and the evaluators were asked two weeks later to rate the film again with the designed scale without referring to the first evaluation. The scores of the evaluators were checked and subjected to statistical analysis the first and second times. The intracluster correlation coefficient (ICC) was determined to calculate the scoring reliability between evaluators. 
According to studies, ICC values less than 0.5 indicate a weak correlation coefficient, values between 0.5 and 0.75 indicate an average correlation coefficient and values between 0.75 and 0.90 indicate a good correlation coefficient. Finally, values above 0.9 are excellent [24]. The Cronbach α method was used to confirm the internal consistency of the items. Internal consistency indicates the homogeneity between the changes in the subscales scores among the individuals of the same sample at a time. The Cronbach α coefficient is the most common index used in such studies to evaluate the internal consistency. This coefficient is variable between 0 and 1, and the closer it is to 1, indicates that the studied scale has a higher internal consistency. The Cronbach α coefficient is often considered more than 0.70. The Cohen kappa coefficient was used to determine the agreement between each rater and the reference rater. The size of the kappa coefficient in statistical analysis is -1 to +1. The closer this number is to 1, the more proportional agreement is present [25].

Results 
This study extracted a pool of items to design a scale to assess the communication skills of examiners of observational child development tests. In this regard, we used experts’ consensus and reviewed relevant scientific texts and articles. After collecting and coding the items, the initial draft was prepared in three sections: Communication with children, communication with parents, and general items. Communication items with children were 17, communication items with parents were 6, and general items were 14. Based on the criteria of the table for calculating the CVR considering the number of experts, the criterion was determined to be 0.49. As a result, the CVR value was less than 0.49 in 4 items in the communication with children section and 3 in the general section, so they were removed. The rest of the items had an acceptable validity, and the review was done in terms of correcting the verbs and sentences. The lowest value of CVI was related to one item in the simplicity section of communication with the children (0.75). In the general section, the lowest value in clarity was in one item with a value of 0.75; in the relevance section, there were 3 items with a value of 0.75. The rest of the items had acceptable validity. To adjust the scoring of the scale items, experts’ opinions were summarized, and the items were rated on a Likert scale (weak, average, good, very good, and excellent). The scale was finalized with 30 items (Appendix 1). 




To determine the reliability of the designed scale, the videos of the examiners performing the Bayley test in different age groups were scored by evaluators twice in two weeks; the scores given were statistically analyzed, and the internal correlation coefficient was calculated. The correlation coefficient values in 6 age groups of children in the total scale were estimated to be 0.83 (Table 1).


ICC between raters in the sections of communication with children, parents, and general was above 0.75, and an appropriate confidence interval was obtained (Table 2). 


To check the internal consistency of the items, Cronbach α was calculated in six age groups (Table 3). 


The agreement between 7 raters and the reference rater was calculated. Among the 5 raters, the Kappa coefficient was calculated above 0.7 and acceptable; for two raters, it was calculated below 0.4 (Table 4).



Discussion
 The examiner’s communication skills with children and parents are essential to achieve the desired results in evaluating children’s observational developmental tests. An experienced examiner should know and use effective ways of communicating with children and parents. To check an examiner’s performance in performing developmental tests, we should have a reliable and valid tool to evaluate effective communication. Considering the lack of tools to assess communication skills, especially in child experts, and to confirm the qualifications of working examiners at the request of the country’s health system, the research team decided to prepare a scale to measure communication skills for examiners of the developmental tests of children. The designed scale had good validity and reliability. The Cronbach α calculated for the internal consistency of the items was 0.81 in 6 age groups in the communication with the children section, 0.82 in the communication with parents, and 0.76 in the general section, which suggested a high and significant correlation. The results of the ICC among the raters were 0.84, which confirmed the favorable level of agreement between the raters in reviewing the test videos by the examiners and had good reliability results with a suitable confidence interval. The highest correlation coefficient related to communication with parents was 0.88, and the lowest was 0.77 in communication with children, indicating that communication with parents is easier than communication with children among these examinees.
Accordingly, to communicate effectively with children, more training is needed at different levels of medical education, including health center experts. Also, using the Kappa coefficient, a comparison was made between the raters and the reference rater, indicating the raters’ high agreement and desirability of the mentioned scale. In Iran, communication skills with clients are not taught in post-graduate education. The international literature review shows little evidence of scales suitable for measuring communication skills in children. Most studies were based on measuring the communication skills of medical sciences with clients. Recent studies emphasize the importance of communication skills and the need for a suitable scale to measure these skills. In a study to design a tool for evaluating the communication skills of rehabilitation students based on Carkhuff’s model, the average total content validity was 87.5%, the average total face validity was 87.25%, and the Cronbach α coefficient was reported as 0.93. The results of this study were similar to those reported in this research in the preparation of the tool [5]. Studies conducted in Shahid Beheshti University of Medical Sciences, Faculty of Rehabilitation and Hamedan and Hamedan and Qazvin Universities of Medical Sciences to evaluate students’ communication skills emphasized the necessity of training these skills, consistent with the results of the present research [26-28].

Conclusion 
This study was conducted for the first time to design and determine the validity and reliability of a comprehensive and reliable scale to measure the communication skills of health center experts in performing observational tests of children’s development. So far, no evaluation of the communication skills of this group of experts with a scale has been conducted. The results of this study indicate that examiners need training in communication with parents and children to evaluate observational developmental tests. Therefore, it is suggested that training workshops on communication skills be held periodically for examiners and other health system experts. The results of this research can be the beginning of more complete studies in the healthcare communication skills field. 

Study limitations 
The impossibility of holding face-to-face focus group meetings due to the COVID-19 pandemic was one of the limitations of this research.

Ethical Considerations
Compliance with ethical guidelines
The participants were informed about the study objectives and methods and signed a written consent form. They were assured of the confidentiality of their information and were free to leave the study at any time. Ethical approval was obtained from the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1400.273).

Funding
The Iran Ministry of Health and Medical Education (Children’s Health Department) supported this study financially and operationally.

Authors' contributions
Conceptualization, data analysis, writing: All authors; Data collection and supervision: Farin Soleimani, Leila Yazdi, and Nahideh Hassani Khiabani.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors want to express their gratitude to the Population Youth and Family Health Center, Ministry of Health and Medical Education, Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Health Deputies of Shahid Beheshti and Tabriz Medical Universities for providing the necessary facilities to carry out the project. Also, The authors would like to thank Mahboobe Mafinejad for her cooperation in designing the project.


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