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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 23  |  Issue : 1  |  Page : 102-110

Development and validation of a questionnaire assessing knowledge, attitude, and practices about obesity among obese individuals


1 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Home Science, University of Delhi, New Delhi, India
3 NDDTC, All India Institute of Medical Sciences, New Delhi, India
4 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
5 Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication18-Mar-2019

Correspondence Address:
Piyush Ranjan
Department of Medicine, AIIMS, New Delhi - 110 023
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijem.IJEM_487_18

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   Abstract 


Aim: The objective of this study was to develop and validate a knowledge, attitude, and practice (KAP) questionnaire about obesity among obese individuals. Materials and Methods: The questionnaire was developed following a standardized protocol that consisted of literature review, focused group discussions, and expert opinion. A cross-sectional survey on 100 obese individuals was carried out to validate the tool. Exploratory factor analysis was performed, using principal component with varimax rotation, to establish the construct validity of the questionnaire. Internal consistency of the questionnaire was tested using Cronbach's α coefficient. Results: KAP questionnaire with 42 items categorized under three domains knowledge, attitude, and practices was developed. The KAP sections have 14, 15, and 13 items, respectively. Independent Cronbach's α for KAP domains were 0.75, 0.75, and 0.63, respectively, indicating good internal consistency. Conclusion: The developed questionnaire will be helpful in achieving better understanding of the patients' KAP about obesity. It has satisfactory validity and good internal consistency.

Keywords: Attitude, KAP Questionnaire, knowledge, obesity, practices


How to cite this article:
Reethesh S R, Ranjan P, Arora C, Kaloiya G S, Vikram NK, Dwivedi SN, Jyotsna VP, Soneja M. Development and validation of a questionnaire assessing knowledge, attitude, and practices about obesity among obese individuals. Indian J Endocr Metab 2019;23:102-10

How to cite this URL:
Reethesh S R, Ranjan P, Arora C, Kaloiya G S, Vikram NK, Dwivedi SN, Jyotsna VP, Soneja M. Development and validation of a questionnaire assessing knowledge, attitude, and practices about obesity among obese individuals. Indian J Endocr Metab [serial online] 2019 [cited 2019 Aug 19];23:102-10. Available from: http://www.ijem.in/text.asp?2019/23/1/102/254450




   Introduction Top


Obesity is a severe, yet neglected public health crisis across the globe.[1] Despite the increased attention being given to this problem, its prevalence is increasing steeply in both developed and developing countries.[2] As the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed.[3]

Lifestyle modification in the form of dietary intervention and increased physical activity can treat obesity up to a large extent.[4] However, attaining clinically significant weight loss is always challenging for patients as well as physicians.[5] Awareness and motivation are the basic needs to affect a change in behavior. KAP surveys in lifestyle-related diseases have become common in the community settings.[6] It is important for physicians and metabolic experts to understand the KAP of obese individuals so that the factors that support an obesogenic environment can be addressed adequately. However, there is lack of validated KAP instruments focusing on obesity in Indian population.

Therefore, the objective of this study was to develop and validate a tool that will help health practitioners and experts caring for obese patients to understand obesity-related KAP of these individuals. This will enable them in adopting better treatment strategies to tackle obesity in their routine clinical practice.


   Materials and Methods Top


Standardized methodology was followed in the process of development and validation of the questionnaire that included steps such as literature review, focus group discussion (FGD), expert evaluation, pilot study, validation of the questionnaire, etc.[7] The study was approved by the Institutional Ethics Committee of All India Institute of Medical Sciences, New Delhi, India, and all the participants gave written informed consent before their participation.

Development of questionnaire

It consisted of the following steps [Table 1]:
Table 1: Steps involved in questionnaire development

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Item generation

Comprehensive literature review was done to look for concepts necessary for inclusion in the KAP survey. “MeSH” terms such as “obesity,” “knowledge, attitudes, practice,” “surveys and questionnaires” were used in PubMed and other medical search engines to look for studies done over past 5 years. Relevant papers were selected, and questions were identified from previous related questionnaires.

Focus group discussions

Literature review was followed by FGDs for subsequent addition of questions related to each concept. FGDs helped us understand how the target population perceives the subject of interest. Three sessions involving six participants in each were conducted by the primary investigator. Following the collection of unprompted information from the participants, more focused questions were asked to see if the respondents agree with the way the construct was developed. The data were analyzed qualitatively and new items were included in the construct.

A final construct of questions was developed, ensuring that items were nonoverlapping. Survey items were written in simple English language, which could be understood by the participants, referring to a single concept, expressed in first person, and avoiding double negatives. A 5-point Likert scale was used as response options, assuming equal distance between response objects.

Expert evaluation

The developed questionnaire after literature review and FGDs was subjected to expert validation by a team of eight experts (that included faculties from the Departments of Medicine, Gastroenterology and Human Nutrition, Endocrinology and Metabolism, Clinical Psychology, and Biostatistics from our institution) for critical appraisals, inputs, and content validity. On the basis of their feedback, some items were deleted and no new item was added to the questionnaire.

Pretesting

The final draft of the questionnaire was pretested on 15 obese (BMI >25 kg/m 2) participants. It was done to understand if there was any ambiguity in the participant's interpretation of the developed questions. These participants completed the questionnaire and also commented on its clarity, construction, and relevance. Minor changes were made in the questionnaire as per their comments.

Validation of questionnaire

A survey was conducted to validate the questionnaire.

Participants and survey procedure

A total of 100 participants, aged 18–60 years, and body mass index (BMI) >25 kg/m 2 attending Medicine Outpatient Department from January 2017 to March 2017 participated in the study. The questionnaire was administered by the chief investigator.

Statistical analysis

Content validity, face validity, and construct validity of the developed questionnaire were examined. Content validity and face validity were established by expert evaluation and FGDs. Construct validity was established by exploratory factor analysis with varimax rotation to test the hypothesized domain structure and examine its substructure.[8] Items with correlation coefficient >0.7 were omitted. Internal consistency was examined, but test/retest reliability could not be performed because of paucity of time. The homogeneity of the question items in each domain was evaluated using Cronbach's α coefficient.[9] A coefficient of 0.7 or higher is preferred for a questionnaire to be internally consistent.[10]


   Results Top


Development of the KAP questionnaire

Comprehensive literature search with the keywords yielded 255 articles, out of which 136 articles were found to be relevant for our study. Relevant papers were studied and 65 items were generated for the questionnaire. The FGDs with participants led to addition of 13 items. After expert evaluation and removal of overlapping questions, 18 items were deleted, and 18 more items were removed during subsequent steps of questionnaire development and validation.

Validation

A cross-sectional survey on 100 participants was conducted to validate this tool. General characteristics of the participants are included in [Table 2].
Table 2: Baseline characteristics of the participants involved in validation phase

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Content validity and face validity were achieved with expert evaluation and FGD. Construct validity was established by factor analysis. The fully answered questionnaires were subjected to item analysis to determine the construct of the tool. Correlation matrix was developed to look for degree of correlation. Sampling adequacy was established by Kaiser-Meyer-Olkin value (0.579) and the Bartlett test of sphericity (Chi-squared, df = 861; P value <0.001), following which factor analysis was done, using the principal factor and varimax rotation to examine domain structure. Kaiser's criterion was used to enter the 42 items into the analysis. A total of 14 domains were identified after the factor analysis.

For determining the internal consistency of the questionnaire, Cronbach's α coefficient for the whole questionnaire was calculated, which found to be 0.78. Independent Cronbach's α for KAP domains were 0.75, 0.75, and 0.63, respectively. These values indicate good internal consistency.

The final questionnaire is in [Box 1]. The score key of the developed KAP questionnaire is available in [Box 2].




   Discussion Top


The successful management of obesity is highly influenced by patients' education and motivation, which is largely governed by adequate KAP of patients. KAP is an important component of the knowledge–attitude–behavior model, which proposes that accumulated knowledge about a health aspect initiates change in attitude, and results in gradual behavior change.[11] Experts believe that appropriate knowledge about the disease and modification in the attitude and perception is extremely effective in treating lifestyle diseases.[12] We have developed an easy to use and practical tool to understand the KAP of obese people toward obesity.

Researchers in the field of lifestyle diseases have conducted many KAP surveys for major lifestyle diseases such as diabetes,[13] hypertension,[14] metabolic syndrome,[15] etc., These surveys have found that gap lies in the knowledge and attitude of the individuals, which is even more pronounced in their practice. Couple of KAP surveys have been done in the field of obesity also. In a KAP survey from Karachi, it was found that although patients had insight about obesity and intention to lose weight, but their practices toward balanced diet and regular physical exercise were inappropriate.[16] Another KAP study on obesity from Bangladesh that involved type 2 diabetic patients reported that majority of participants were lacking proper knowledge about the disease. Majority of them were unaware about ideal body weight, energy requirement and weight measurement techniques. A substantial proportion of the respondents considered fast food, soft drinks and mayonnaise as healthier foods.[17] Both studies have stressed the necessity of improving patient education programs for empowering persons to transform their knowledge and attitude into practice.

These studies have not provided KAP questionnaires for use by other researchers. It appears that the questions selected for interview from respondents were arbitrary and lacked scientifically approved procedure in its development and validation. The KAP questionnaire developed by us is well validated by following a standard protocol involving required medical and metabolic experts along with bio-statisticians. The questionnaire has 42 items under three domains; KAP consisting of five options designed on a Likert scale. The knowledge part of the questionnaire contains 14 items which emphasizes mainly on participants' knowledge regarding risk factors and complications associated with obesity. The attitude part of the questionnaire consisted of 15 questions designed to assess aspects such as perception of obesity and motivation to lose weight. The practice part of the tool with its 13 questions focused on their dietary habits and physical activity levels in their day-to-day life. It takes around 15 min to administer this questionnaire.

The strength of this tool is that it contains questions from all aspects that affect obesity such as diet (intake of sweets, refined foods, fried foods), eating patterns (meal frequency, meal skipping), physical activity (exercise duration, exercise frequency), lifestyle habits, motivation to lose weight, etc., Each question has five response items (a to e). The best possible response gets a score of 5 and the wrong response gets a score of 1. By analyzing the score of individual items, the physician or metabolic experts can identify the areas which need to be addressed while counseling the patient to make the treatment more effective.

This questionnaire can also be used by researchers to assess KAP at community level. The findings from subsequent studies can be helpful in developing strategies to modify the risk factors, and hence controlling this overgrowing epidemic. Besides, at individual level, this questionnaire will help practitioners to counsel their patients in a better way, making sure that the gaps in patients' KAP are addressed appropriately.

However, in studies of this kind, the items generated and the questions are affected by the responses of the participants. Since the study was done in North Indian setup, the questionnaire is affected by the habits of the local population. So, there may be concerns regarding its applicability in other population groups that have an entirely different lifestyle. Besides, despite our effort to maintain balance between understandability, simplicity, and response bias, some questions are still oversimplified and somewhat leading in nature.


   Conclusion Top


This study presents a new analysis of knowledge and attitudinal data on physical activity and dietary intake in obese individuals and investigates the factors that may be mediators of behavior change in these people. This KAP tool will be helpful in designing clinical and education interventions in Indian scenario in the field of obesity. It has satisfactory validity and internal consistency.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization (WHO). Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. (1-253). World Health Organ Tech Rep Ser 2000;894:i-xii.  Back to cited text no. 1
    
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Arroyo-Johnson C, Mincey KD. Obesity epidemiology worldwide. Gastroenterol Clin 2016;45:571-9.  Back to cited text no. 2
    
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Dietz WH, Baur LA, Hall K, Puhl RM, Taveras EM, Uauy R, et al. Management of obesity: Improvement of health-care training and systems for prevention and care. Lancet 2015;385:2521-33.  Back to cited text no. 3
    
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Lifestyle modification in the management of obesity: Achievements and challenges | SpringerLink [Internet]. Available from: https://link.springer.com/article/10.1007/s40519-013-0049-4. [Last cited on 2018 Feb 08].  Back to cited text no. 4
    
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7.
Arora C, Sinha B, Malhotra A, Ranjan P. Development and validation of health education tools and evaluation questionnaires for improving patient care in lifestyle related diseases. J Clin Diagn Res 2017;11:JE06.  Back to cited text no. 7
    
8.
Kim H, Ku B, Kim JY, Park Y-J, Park Y-B. Confirmatory and exploratory factor analysis for validating the phlegm pattern questionnaire for healthy subjects [Internet]. Evidence-Based Complement Alternat Med 2016. Available from: https://www.hindawi.com/journals/ecam/2016/2696019/. [Last cited on 2018 Feb 09].  Back to cited text no. 8
    
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Tavakol M, Dennick R. Making sense of Cronbach's alpha. Int J Med Educ 2011;2:53-5.  Back to cited text no. 9
    
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Deniz MS, Alsaffar AA. Assessing the validity and reliability of a questionnaire on dietary fibre-related knowledge in a Turkish student population. J Health Popul Nutr 2013;31:497-503.  Back to cited text no. 10
    
11.
Gumucio S, Merica M, Luhmann N, Fauvel G, Zompi S, Ronsse A, et al. Data collection quantitative methods, the KAP survey model (knowledge, attitude and practices). IGC communigraphie: Saint Etienne, France; 2011. p. 4-7.  Back to cited text no. 11
    
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Arora C, Sinha B. Ranjan P, Malhotra A. Non alcoholic fatty liver disease: Problems in perception and solution. J Clin Diagn Res 2018;12:OE01.  Back to cited text no. 12
    
13.
Raj CP, Angadi MM. Hospital-based KAP study on diabetes in Bijapur, Karnataka. Indian J Med Spec 2010;1:80-3.  Back to cited text no. 13
    
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Mahajan H, Kazi Y, Sharma B, Velhal GD. Assessment of KAP, risk factors and associated co-morbidities in hypertensive patients. IOSR J Dental Med Sci (IOSRJDMS) 2012;1:06-14.  Back to cited text no. 14
    
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Joshi A, Mehta S, Grover A, Talati K, Malhotra B, Puricelli Perin DM. Knowledge, attitude, and practices of individuals to prevent and manage metabolic syndrome in an Indian setting. Diabetes Technol Ther 2013;15:644-53.  Back to cited text no. 15
    
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Qidwai W, Azam I. Knowledge, attitude and practice regarding obesity among patients, at Aga Khan University Hospital, Karachi. J Ayub Med Coll Abbottabad 2004;16:32-4.  Back to cited text no. 16
    
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Saleh F, Mumu SJ, Ara F, Ali L, Hossain S, Ahmed KR. Knowledge, attitude and practice of type 2 diabetic patients regarding obesity: Study in a tertiary care hospital in Bangladesh. J Public Health Afr 2012;3:e8.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2]


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