Developing and validating questionnaires to assess knowledge, attitude, and

performance toward obesity among Iranian adults and adolescents: TABASSOM study
Parastoo Golshiri(1), Parastoo Yarmohammadi(2), Nizal Sarrafzadegan(3),
Shahnaz Shahrokhi(4), Mehrdad Yazdani(5), Masoud Pourmoghaddas(6)

Abstract
BACKGROUND: The present study describes the methods of developing and validating two
questionnaires that will be used to investigate the knowledge, attitude and practice of adults,
children and adolescents regarding obesity.
METHODS: To design the questionnaires, we used the components of the Health Belief Model.
The questionnaire for adults consisted of 6 sections with 50 questions. The questionnaire for
children and adolescents included 7 sections and 52 questions. The questionnaires were
assessed for face validity, content validity, and clarity of the items. To determine the internal
consistency reliability of the questionnaires, Cronbach's alpha coefficient was measured for 100
questionnaires. Using the correlation coefficient, we determined the equivalent reliability of the
study tools.
RESULTS: The Cronbach's alpha coefficient ranged between 0.60 and 0.80 for the whole
questionnaires. The Cronbach's alpha coefficient of the questionnaires for adults, children and
adolescents were respectively 0.72 and 0.60 for awareness. The corresponding values for
attitude were 0.70 and 0.75. Using Pearson's correlation coefficient, the interobserver
reliability was determined to be significant (r ≥ 0.80; P < 0.001).
CONCLUSION: Our study tools had adequate reliability and validity. They are thus suitable for
assessing the knowledge, attitude, and practices of Iranian adults, and children and adolescents
in toward obesity.

Keywords: Validation Questionnaire, Obesity, Knowledge, Attitude, Behaviors.

ARYA Atherosclerosis Journal 2012, 7(Suppl): S119-S124

Date of submission: 8 Jan 2012, Date of acceptance: 25 Feb 2012

Introduction (42.8% in men and 57% in women) is an important

Lifestyle changes can contribute to the development of contributor to NCD in this country.10
risk factors of non-communicable diseases (NCDs) such In 2001, comprehensive interventions were initiated
as diabetes, hyperlipidemia, hypertension, overweight, as part of the Isfahan Healthy Heart Program (IHHP)
and obesity.1,2 Obesity is an important NCD risk factor. to improve lifestyle, modify CVD risk factors, and
Various studies have implicated weight gain in the reduce NCD-related mortality.11 IHHP interventions
pathophysiology of hypertension, diabetes, were designed to be practical and sustainable and to
cardiovascular disease (CVD) and cancers.3-6 Moreover, offer the possibility of integration.12 In 2010, Isfahan
obesity can lead to increased mortality and disability and Cardiovascular Research Center (ICRC) initiated a new
rising costs of treatment in most communities.7 program titled "TABASSOM" aiming to prevent and
Annually, 300-587 thousand deaths worldwide are reduce the prevalence of overweight/obesity in
attributed to obesity. Obesity is considered as the second Isfahan, Iran. This program had a 2-year design and
important preventable cause of death worldwide.8,9 The consisted of 3 phases. The first phase was the
high prevalence of weight gain and obesity in Iran implementation of a qualitative study to determine the

1- Associate Professor, Department of Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
2- PhD Candidate, Department of Health Education and Health Promotion, School of Health, Isfahan University of Medical Sciences,
Isfahan, Iran.
3- Professor, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, School of Medicine, Isfahan University
of Medical Sciences, Isfahan, Iran.
4- Specialist in Community Medicine, Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, School of Medicine,
Isfahan University of Medical Sciences, Isfahan, Iran.
5- Research Fellow, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, School of Medicine, Isfahan
University of Medical Sciences, Isfahan, Iran.
6- Professor, Department of Cardiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
Correspondence To: Nizal Sarrafzadegan, Email: [email protected]

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Developing and Validating Obesity Questionaire

indicators that could be used in developing the The items in this questionnaire measured the
questionnaires. The questionnaires were then designed influence of family members and friends of the obese
and a descriptive analytical study was carried out on the individuals and the use of information resources for
general population. The second phase consisted of reducing weight. The questionnaires were completed
community-level multidisciplinary interventions and by interviewers in face-to-face interviews. For
specific interventions for overweight or obese people. children/adolescents, the questionnaires were
In the third phase, the same questionnaires, that were completed in face-to-face interviews with mothers.
completed in the first phase, will be completed. Given All subjects had given their written consent prior to
the necessity of using a valid and reliable tool for participating in the study. To keep the information
achieving the study objectives, the researchers initially confidential, questionnaires were anonymous and the
conducted a project to design two questionnaires for research group organized training workshops for the
assessment of knowledge, attitudes, and practices of interviewers to explain the right method of
adults, and children and adolescents (6-14 years). completing the forms and answering the questions.
Therefore, the aim of the present study was to report They were also provided with written instructions.
the design and methodology of evaluating the validity The questionnaire for adults was designed with the
and reliability of the two questionnaires used in following 6 sections:
TABASSOM study. 1. Demographic questions: This part collected
the name of the interviewer, general details of the
Materials and Methods interviewee and demographic variables such as sex,
To design the questionnaires for adults and children age, marital status, number of household members,
and adolescents, we initially searched the literature, education, job, monthly household income, housing
including textbooks, dissertations, scientific status, number of automobiles owned by the family,
publications, and websites thoroughly for similar tools health insurance status, and physical assessments
used in previous studies. Then, we designed the including height, weight, and waist circumference.
preliminary framework of the two questionnaires 2. Questions about the knowledge of the
using the studied resources, experts' opinions, the subjects regarding overweight and obesity: Causes,
Health Belief Model, and the results of the qualitative treatment, and prevention of obesity/weight gain
study performed earlier as part of the first stage of the were included. The questions were designed in a
TABASSOM study for determining the factors "closed" format. The questionnaire for adults
implicated as the causes of obesity according to the contained 11 knowledge-related questions with 3
population beliefs in Isfahan, Iran.13 options of "I don't know", "False", and "True".
The knowledge section of the questionnaire was 3. Attitude questions: These 23 closed questions
designed using scientific textbooks on the causes, were designed in 5 categories of perceived threats (5
complications, treatment, and prevention of obesity in questions), perceived benefits (3 questions), perceived
the two groups of adults and children/adolescents. The barriers (7 questions), and self-efficacy (8 questions).
attitude section was designed based on the Health They were based on a 5-point Likert scale (totally
Belief Model.14 This model offers an appropriate agree, agree, no idea, disagree, and totally disagree).
structure for determining health-related behaviors and Depending on directness or indirectness of the
has been extensively used in behavioral studies. The questions, scores ranged from 1 (totally disagree) to 5
Health Belief Model comprises components of (totally agree).
perceived susceptibility and perceived severity (which 4. Assessment of the attitude about physical
jointly make perceived threat), perceived benefits, appearance: This part consisted of 6 questions (5
perceived barriers, and self-efficacy.14 It is also closed and 1 open questions).
consistent with the results of the primary qualitative 5. Assessment of obese individuals: It included
study for finding the factors influencing obesity in 9 questions.
people. All constructs of the Health belief Model were 6. Assessment of cues to action: This section
used to assess the questionnaire for adults, but self- was designed as 5 closed questions and a final open
efficacy was eliminated for children and adolescents. question regarding the method of providing
The answers regarding attitude were designed based on information about overweight and obesity.
a 5-point Likert scale. The questionnaire for children and adolescents
To evaluate behavior, we assessed the practices of consisted of 7 sections as follows:
people towards obesity and finally assessed cues to 1. Demographic questions: This part was similar
action. Cues to action investigate the factors which to the questionnaire for adults.
encourage individuals to adopt appropriate actions.14 2. Questions about knowledge of parents

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 P. Golshiri, P. Yarmohammadi, N. Sarrafzadegan, SH. Shahrokhi, M. Yazdani, M. Pourmoghaddas

toward obesity and overweight: This part included validity of tests is Cronbach's alpha coefficient, which
causes, complications, and prevention of overweight is an estimate of the test's consistency coefficient.15
and obesity in 14 questions. To determine the internal consistency of components,
3. Items about parents' attitude: According to we performed an initial assessment of 100 adults and
the Health Belief Model, 16 closed questions were 100 parents of children and adolescents who were
designed based on a 5-point Likert scale. The selected in the city of Isfahan using cluster sampling
questions measured perceived threats (4 questions), method. The questionnaires were completed by
perceived benefits (3 questions), and perceived interviews and scores corresponding to the questions
barriers (9 questions). Because parents answered these were separately entered in SPSS15. These individuals
questions, self-efficacy component was not used. were not included as main participants. In addition, a
4. Questions about parents' attitude toward split-half model was used to study the internal
their children's physical appearance: This part reliability of the tools.
included 3 closed questions. Determining Equivalent Reliability
5. Statements about dietary behaviors toward There were 6 interviewers who performed the
obesity and overweight: In this section, 10 questions interviews in this study. To determine equivalent
evaluated the child or adolescent's behaviors and 7 validity (including assessing the correlation between
items evaluated parents' dietary behavior. scores achieved by two measurements from parallel
6. Five questions were designed for obese and forms)15 of these 6 interviewers, 5 subjects were
overweight children or adolescents who have tried to selected for every 2 interviewers. The first 3
lose weight. interviewers were asked to conduct interviews with 5
7. Three questions asked about cues to action. individuals. After 6 days, the next 3 interviewers
The validity and reliability of the questionnaires interviewed the same subjects again. This way, each
were determined as follows: subject had two questionnaires filled (30
Assessing item clarity questionnaires in total). Pearson's correlation
The questionnaires were given to 10 people (including coefficient was measured to determine the
overweight and obese people) to answer. Based on interobserver reliability which is indicative of the
the feedback received from them, the necessary equivalent reliability of study tools.
changes were made to improve clarity of items. Those
people were not part of the statistical population. Results
Assessing face validity The results of the preliminary study, which was
To assess face validity, the questionnaires were given conducted to determine the internal reliability of
to a number of lecturers of the Department of Health
Education, Statistics and Epidemiology of the School
questionnaires showed the mean age of the adults
of Health and the Department of Social Medicine of (100 individuals) to be 32.14 ± 14.79 years
the School of Medicine (Isfahan University of (range: 25-63 years). Males and singles
Medical Sciences) and the managers of this project at constituted 51% and 48% of the studied
Isfahan Cardiovascular Research Center. They were population, respectively. The majority of
asked to comment on the soundness of the households (32%) had 4 members. The highest
questionnaires based on the research objectives. All educational degree was high school diploma in
comments were addressed, and the face validity of the both women (63.3%) and men (53%).
questionnaires was confirmed. Evaluating children and adolescents
Assessing Content Validity (100 individuals) revealed their mean age to be
In order to enjoy greater content validity, test contents 9.82 ± 2.40 years (range: 6-14 years). Half (50%)
must be designed to be reflective of the targets for of these subjects were female and the largest
which they are made.15 The same group of experts
household size was 4 members (57%). Most
assessed both the face validity of the tools and their
fathers (38%) and mothers (44%) had high school
contents. Hence we ensured proportionality of each
item with the component considered for assessing it. diplomas. The majority of fathers (45%) were self-
Based on the views and suggestions of the experts, employed and 94% of mothers were housewives.
changes were made to the tools and content validity of The results of the validating stage of the study
the questionnaires was finally confirmed. showed that compatibility of the content with
Assessing Internal Reliability reliable scientific textbooks was approved by all
One of the methods widely used for assessing internal members of the expert panel whose comments
were used to apply necessary changes in the

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Developing and Validating Obesity Questionaire

tools. Cronbach's alpha coefficient of the whole Discussion

questionnaire ranged between 0.60 and 0.80 One of the most important steps in developing a new
(Tables 1 and 2). It is worth noting that tool is to assess its reliability and validity. In this
Cronbach's alpha was not measured for study, the validity of the tools was demonstrated by
behavioral assessment questions since they content validity through the help of a group of experts.
merely addressed people's actions towards In general, evaluating the validity of the tools showed
obesity/overweight through a qualitative design. that all four subscales and the whole questionnaire had
Cronbach's alpha coefficient was determined an acceptable internal correlation coefficient. These
findings were consistent with the results of the Story
for some questions with quantitative design in
study which assessed weight reduction and attitudes
the questionnaire for children and adolescents. In toward body size, diet, and physical activity among
the main project, dietary behaviors and physical primary school children.16 In this study, Cronbach’s
activity were separately evaluated, which is out of alpha coefficient was calculated as 0.50 to 0.80. In fact,
the scope of this report. Using the split-half alpha was 0.46 for children's intention to consume
method, the correlation coefficients for both food products with low fat and sugar, 0.64 for
questionnaires were calculated to be greater than children’s sense of self-efficacy to consume food
0.60. Pearson's correlation coefficient was products with low fat and sugar content, 0.61 for their
employed to determine the interobserver self-efficacy to do physical activity, and 0.77 for having
reliability. It was reported as significant (r ≥ 0.8; attempted to reduce weight.
P < 0.001) for knowledge (r = 0.90), perceived Although a large sample size was used in the Story
threat (r = 0.85) perceived benefits (r = 0.93), et al. study, it is still recommended to perform further
studies on other populations to better determine the
perceived barriers (r = 0.80), and self-efficacy
validity of the questionnaire.16 However, their
(r = 0.87). These figures indicate that the used questionnaire was designed based on the cognitive
scales had sufficient equivalent reliability, the social model, and the subjects were children with a
interviewers had no significant effects on the mean age of 8.6 years. Swift et al. studied the
results of calculation, and application of the tools knowledge of adolescents over 13 years of age
by different individuals for similar subjects would regarding the health risks of obesity. They found a
yield in similar results. Cronbach's alpha coefficient of over 0.70 which is
similar to our study.17 The Swift et al study designed
Table 1. Cronbach's alpha coefficient of knowledge, responses as "True", "False", and "I don't know". We
attitude, and behaviors in the two questionnaires for adults therefore believe that the design of the questionnaire
and children/adolescents can be used to assess the knowledge of adolescents
Adults'
Children and and their parents. Similar to our study, Swift et al.
Adolescents' claimed that their questionnaire could reliably show
Questionnaire
Questionnaire the relationship between awareness about obesity
Knowledge 72 60 health risks and weight control behaviors.17 In
Attitude 70 75 addition, since the questionnaire in the study by Swift
Behaviors* - 61
et al.17 can be used in both cognitive social and health
belief models, some of their questions were used in
* The reason for not being assessed is given in the text.
the present study. Lin and Lee studied the
Table 2. Cronbach's alpha coefficient of the two relationship between knowledge and attitude
questionnaires based on various components of the regarding diet among 1937 elderly people. They
attitude reported a Cronbach's alpha coefficient of 0.87 for
Children and the relationship between knowledge toward nutrition
Adults'
Questionnaire
Adolescents' and diseases. The alpha was 0.69 and 0.86 for general
Questionnaire nutrition attitudes and dietary behaviors, respectively.
Perceived Threat 70 70 They used a 3-point Likert style in 48 knowledge-
Perceived Benefits 80 80 related questions whose options included "True",
Perceived Barriers 60 64
"False", and "I don't know". Attitude questions were
divided into 3 sections of diet, health care, and
Self-Efficacy* 66 - healthy food which were designed as a 3-level option
* The reason for not being assessed is given in the text. scale.18 Likewise, Lin et al. performed a study on two

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 P. Golshiri, P. Yarmohammadi, N. Sarrafzadegan, SH. Shahrokhi, M. Yazdani, M. Pourmoghaddas

groups of children (1-3 years old and 4-6 years old) and Berenson GS. Relationship of childhood obesity to
found Cronbach's alpha of 0.72 and 0.76 for coronary heart disease risk factors in adulthood: the
knowledge, 0.65 and 0.68 for attitude, and 0.62 and Bogalusa Heart Study. Pediatrics 2001; 108(3):
0.65 for dietary behavior, respectively.19 712-8.
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James WP, Torp-Pedersen C. Impact of obesity as a
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Acknowledgement population of Iranian adolescents and adults in
This study was supported by a research grant from comparison to a Western population: the Isfahan
the National Elite Foundation. Healthy Heart Programme. Public Health Nutr 2010;
The authors would like to extend their 13(3): 314-23.
appreciation to all the lecturers and experts of the 11. Sarraf-Zadegan N, Sadri G, Malek AH, Baghaei M,
Mohammadi FN, Shahrokhi S, et al. Isfahan Healthy
Schools of Medicine and Health at Isfahan University
Heart Programme: a comprehensive integrated
of Medical Sciences and Isfahan Cardiovascular community-based programme for cardiovascular
Research Center, who shared their opinions in disease prevention and control. Design, methods and
validating our questionnaires. We also thank Dr initial experience. Acta Cardiol 2003; 58(4): 309-20.
Bahram Soleimani for his valuable guidance in 12. Sarrafzadegan N, Baghaei AM, Sadri GH, Kelishadi
statistical analyses. R, Malekafzali H, BM, et al. Isfahan Healthy Heart
Program: Evaluation of comprehensive, community-
Conflict of Interests based interventions for non-communicable disease.
Prevention and Control J 2006; 2(2): 73-84.
Authors have no conflict of interests.
13. Abolhassani SH, Doosti Irani M, Sarrafzadegan N.
Barriers and facilitators of weight management in
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