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1.  Body Image Changes Associated with Participation in an Intensive Lifestyle Weight Loss Intervention 
Obesity (Silver Spring, Md.)  2010;19(6):1290-1295.
The primary aim of this study was to test for changes in body image in men and women enrolled in the Look AHEAD trial. Look AHEAD (Action for Health in Diabetes) is a multi-center, randomized controlled trial designed to test whether intentional weight loss reduces cardiovascular morbidity and mortality in overweight individuals with type 2 diabetes. Participants included 157 adults at one site (Pennington Biomedical Research Center) of the Look AHEAD study. At baseline, the mean body mass index (BMI) of the female participants was 36.4, and the mean BMI for males was 33.5. Following baseline assessment, participants were randomly assigned to the Intensive Lifestyle intervention (ILI, n = 81) or Diabetes Support and Education (DSE, n = 76). The Body Morph Assessment version 2.0 (BMA 2.0) was used to assess estimates of perceived current body size, ideal body size, acceptable body size, and body image dissatisfaction at baseline and one year. Over the 1 year, participants in the ILI group had significantly greater reductions in weight (10.1% for men and 8.9% for women) than those in the DSE group (+ 0.8% for men and −0.2%, for women). Perceived current body size was reduced significantly more in both men and women in the ILI group, relative to DSE. There were also significantly greater reductions in body image dissatisfaction in the ILI group, relative to the DSE group for men and women. The results of this study indicate that body image dissatisfaction improved following participation in an intensive behavioral weight loss program.
PMCID: PMC3102126  PMID: 21151020
Body Image; Obesity; Diabetes; Weight loss; Lifestyle Intervention
2.  Psychometric Properties of the Foot and Ankle Outcome Score in a Community-Based Study of Adults with and without Osteoarthritis 
Arthritis care & research  2014;66(3):395-403.
Foot and ankle problems are common in adults, and large observational studies are needed to advance our understanding of the etiology and impact of these conditions. Valid and reliable measures of foot and ankle symptoms and physical function are necessary for this research. This study examined psychometric properties of the Foot and Ankle Outcome Score (FAOS) subscales (pain, other symptoms, activities of daily living [ADL], sport and recreational function [Sport/Recreation], and foot and ankle related quality of life [QOL]) in a large, community-based sample of African American and Caucasian men and women 50+ years old.
Johnston County Osteoarthritis Project participants (N=1670) completed the 42-item FAOS (mean age 69 years, 68% women, 31% African American, mean body mass index [BMI] 31.5 kg/m2). Internal consistency, test-retest reliability, convergent validity, and structural validity of each subscale were examined for the sample and for subgroups according to race, gender, age, BMI, presence of knee or hip osteoarthritis, and presence of knee, hip or low back symptoms.
For the sample and each subgroup, Cronbach’s alphas were 0.95–0.97 (pain), 0.97–0.98 (ADL), 0.94–0.96 (Sport/Recreation), 0.89–0.92(QOL), and 0.72–0.82 (symptoms). Correlation coefficients were 0.24–0.52 for pain and symptoms subscales with foot and ankle symptoms and 0.30–0.55 for ADL and Sport/Recreation subscales with Western Ontario and McMaster Universities Osteoarthritis Index function subscale. Intraclass correlation coefficients for test-retest reliability were 0.63–0.81. Items loaded on a single factor for each subscale except symptoms (2 factors).
The FAOS exhibited sufficient reliability and validity in this large cohort study.
PMCID: PMC4211630  PMID: 24023029
epidemiologic study; foot; ankle; outcome assessment; reliability; validity
3.  Evaluation of decision rules for identifying low bone density in postmenopausal African-American women. 
OBJECTIVE: While African-American women tend to have greater bone mineral density (BMD) than caucasian women, they are still at risk of developing osteoporosis later in life. Clinical decision rules (i.e., algorithms) have been developed to assist clinicians identify women at greatest risk of low BMD. However, such tools have only been validated in caucasian and Asian populations. Accordingly, the objective of this study was to compare the performance of five clinical decision rules in identifying postmenopausal African-American women at greatest risk for low femoral BMD. METHODOLOGY: One hundred-seventy-four (n=174) postmenopausal African-American women completed a valid and reliable oral questionnaire to assess lifestyle characteristics, and completed height and weight measures. BMD at the femoral neck was measured via dual energy x-ray absorptiometry (DXA). We calculated sensitivity, specificity, positive predictive value, and negative predictive value for identifying African-American women with low BMD (T-Score < or = -2.0 SD) using five clinical decision rules: Age, Body Size, No Estrogen (ABONE), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST), Simple Calculated Osteoporosis Risk Estimation (SCORE), and body weight less than 70 kg. RESULTS: Approximately 30% of African-American women had low BMD, half of whom had osteoporosis (BMD T-Score < or = -2.5 SD). Sensitivity for identifying women with a low BMD (T-Score < or = -2.0 SD) ranged from 65.57-83.61%, while specificity ranged from 53.85-78.85%. Positive predictive values ranged from 80.95-87.91%, while negative predictive values ranged from 48.44-58.33%. CONCLUSION: Our data suggest that the clinical decision rules analyzed in this study have some usefulness for identifying postmenopausal African-American women with low BMD. However, there is a need to establish cut-points for these clinical decision rules in a larger, more diverse sample of African-American women.
PMCID: PMC2594895  PMID: 15040510
4.  Psychometric Evaluation of the Persian Version of the ‘Aging Male Scales’ Questionnaire 
Men, much like women, are faced with age-related menopause-like symptoms as they age. In recent years, increasing attention has been drawn to clinical research into elderly men and their health-related quality of life. The Aging Male Scales (AMS) questionnaire is an international tool for assessing the health-related quality of life in elderly men. Hence far this questionnaire has not been subjected to psychometric assessment in Iran. This study aims to evaluate the validity and reliability of the Persian version of the AMS questionnaire specific to the health of elderly men in Iran.
To validate this instrument, a cross-sectional study was conducted on 521 healthy Iranian men aged 40-65 years old, who attended the blood transfusion center clinic between February 2011 and June 2012. The English version of the AMS questionnaire was translated to Persian and then back-translated. To determine the reliability of the AMS questionnaire, internal consistency was evaluated and test-retest was done. The questionnaire was validated using convergent and structural validity methods. To assess the factor structure of the questionnaire, a correlation matrix of questions and domains was used.
Cronbach's alpha was higher than 0.7 (0.73-0.88) in all domains. A Pearson's correlation coefficient of 0.87 between pretest and posttest indicated a high correlation and an acceptable reliability. The convergent validity of the questionnaire was found acceptable by calculating the correlation between the domains and items-total correlation ranging 0.40-0.85, except for question 14 that had a 0.28 correlation with the whole test. The criterion-related validity of the questionnaire in the psychological domain was confirmed with the “two-item Patient Health Questionnaire” (r = 0.63, P < 0.001).
According to the results, the Persian version of the AMS questionnaire has high validity and reliability and may be used to assess the health-related quality of life of men between 40 and 65 years old.
PMCID: PMC4192781  PMID: 25317302
Aging male scales; andropause; psychometrics; quality of life; reliability; validity
5.  Adapting the Everyday Discrimination Scale to Medical Settings: Reliability and Validity Testing in a Sample of African American Patients 
Ethnicity & disease  2011;21(4):502-509.
Despite evidence that discrimination within the health care system may play an important role in perpetuating health disparities, instruments designed to measure discrimination within the health care setting have not been adequately tested or validated. Consequently, we sought to test the psychometric properties of a modified version of the Everyday Discrimination scale, adapted for medical settings.
Cross-sectional study.
Academic medical center in Chicago.
Seventy-four African American patients.
Outcome measures
We measured factor analysis, internal consistency, test-retest reliability, convergent validity and discriminant validity.
Seventy-four participants completed the baseline interviews and 66 participants (89%) completed the follow-up interviews. Eighty percent were women. The Discrimination in Medical Settings (DMS) Scale had a single factor solution (eigenvalue of 4.36), a Cronbach’s alpha of 0.89 and test-retest reliability of .58 (P<.0001). The DMS was significantly correlated with an overall measure of societal discrimination (EOD) (r=.51, P<.001) as well as two of its three subscales (unfair: r=−.04, P=.76; discrimination: r=.45, P<0.001; worry: r=−.36, P=.002). The DMS was associated with the overall African American Trust in Health Care Scale (r=.27, P=.02) as well as two key subscales (racism: r=.31, P<.001; disrespect: r=.44, P<.001). The DMS scale was inversely associated with the Social Desirability Scale (r=.18, P=.13). The DMS scale was not correlated with the Center for Epidemiologic Studies Depression Scale (r=.03, P=.80).
The Discrimination in Medical Settings Scale has excellent internal consistency, test-retest reliability, convergent validity and discriminant validity among our sample of African American patients. Further testing is warranted among other racial/ethnic groups.
PMCID: PMC3350778  PMID: 22428358
Health Care Discrimination; Health Care Delivery; Health Disparities; Race/ethnicity; Survey Research
6.  Observer ratings of neighborhoods: comparison of two methods 
BMC Public Health  2013;13:1024.
Although neighborhood characteristics have important relationships with health outcomes, direct observation involves imperfect measurement. The African American Health (AAH) study included two observer neighborhood rating systems (5-item Krause and 18-item AAH Neighborhood Assessment Scale [NAS]), initially fielded at two different waves. Good measurement characteristics were previously shown for both, but there was more rater variability than desired. In 2010 both measures were re-fielded together, with enhanced training and field methods implemented to decrease rater variability while maintaining psychometric properties.
AAH included a poor inner city and more heterogeneous suburban areas. Four interviewers rated 483 blocks, with 120 randomly-selected blocks rated by two interviewers. We conducted confirmatory factor analysis of scales and tested the Krause (5-20 points), AAH 18-item NAS (0-28 points), and a previous 7-item and new 5-item versions of the NAS (0-17 points, 0-11 points). Retest reliability for items (kappa) and scales (Intraclass Correlation Coefficient [ICC]) were calculated overall and among pre-specified subgroups. Linear regression assessed interviewer effects on total scale scores and assessed concurrent validity on lung and lower body functions. Mismeasurement effects on self-rated health were also assessed.
Scale scores were better in the suburbs than in the inner city. ICC was poor for the Krause scale (ICC=0.19), but improved if the retests occurred within 10 days (ICC=0.49). The 7- and 5-item NAS scales had better ICCs (0.56 and 0.62, respectively), and were higher (0.71 and 0.73) within 10 days. Rater variability for the Kraus and 5- and 7-item NAS scales was 1-3 points (compared to the supervising rater). Concurrent validity was modest, with residents living in worse neighborhood conditions having worse function. Unadjusted estimates were biased towards the null compared with measurement-error corrected estimates.
Enhanced field protocols and rater training did not improve measurement quality. Specifically, retest reliability and interviewer variability remained problematic. Measurement error partially reduced, but did not eliminate concurrent validity, suggesting there are robust associations between neighborhood characteristics and health outcomes. We conclude that the 5-item AAH NAS has sufficient reliability and validity for further use. Additional research on the measurement properties of environmental rating methods is encouraged.
PMCID: PMC3840667  PMID: 24168373
7.  Spanish cultural adaptation and validation of the shoulder pain and disability index, and the oxford shoulder score after breast cancer surgery 
The Oxford Shoulder Score (OSS) and the Shoulder Pain and Disability Index (SPADI) are patient-based outcome scores with valid psychometric properties which are widely used for shoulder interventions.
The purpose of the study is to adapt both questionnaires cross-culturally to Spanish, and to test their reliability, validity, responsiveness, and feasibility.
Cultural adaptation and psychometric validation study.
Consecutive patients who had undergone breast cancer surgery referred to an outpatient clinic at the University of Alcalá de Henares, Spain. One hundred and twenty women who had undergone breast cancer surgery, with pain and shoulder dysfunction. Cross-cultural adaptation was performed according to the international guidelines. Reliability was analysed by test-retest reliability and internal consistency. Content and convergent construct validity were measured by the Expert Committee’s and Spearman coefficient respectively. Responsiveness, feasibility, floor and ceiling effects were also tested.
One hundred and twenty women aged 54.2 (±11) years took part in the study. The reliability was excellent; test-retest reliability was 0.974 (p < 0.001) for OSS, and 0.992 (p < 0.001) for SPADI; and Cronbach’s alpha value was 0.947 for OSS, and 0.965 for SPADI. High construct validity was found between the OSS and SPADI questionnaires (r = −0.674). The effect size (ES) and standardized response mean (SRM) was moderate in OSS (ES = 0.50 and SRM = 0.70 (p < 0.001)), and moderate to good in SPADI (ES = 0.59 and SRM = 0.82 (p < 0.001)).
This study has some limitations, such as the group of participants is composed only of women following breast cancer treatment; the measurement took place in a single centre; and all the questionnaires administered were always provided to the participants in the same order.
The OSS and SPADI Spanish versions are applicable, reliable, valid, and responsive to assess shoulder symptoms and quality of life in Spanish women with shoulder pain and disability after breast cancer treatment.
Electronic supplementary material
The online version of this article (doi:10.1186/s12955-015-0256-y) contains supplementary material, which is available to authorized users.
PMCID: PMC4489002  PMID: 26001890
Oxford shoulder score; Shoulder pain and disability index; Validity; Responsiveness; Breast cancer; Spanish
8.  Impact of Alzheimer’s Disease on Caregiver Questionnaire: internal consistency, convergent validity, and test-retest reliability of a new measure for assessing caregiver burden 
There is a lack of validated instruments to measure the level of burden of Alzheimer’s disease (AD) on caregivers. The Impact of Alzheimer’s Disease on Caregiver Questionnaire (IADCQ) is a 12-item instrument with a seven-day recall period that measures AD caregiver’s burden across emotional, physical, social, financial, sleep, and time aspects. Primary objectives of this study were to evaluate psychometric properties of IADCQ administered on the Web and to determine most appropriate scoring algorithm.
A national sample of 200 unpaid AD caregivers participated in this study by completing the Web-based version of IADCQ and Short Form-12 Health Survey Version 2 (SF-12v2™). The SF-12v2 was used to measure convergent validity of IADCQ scores and to provide an understanding of the overall health-related quality of life of sampled AD caregivers.
The IADCQ survey was also completed four weeks later by a randomly selected subgroup of 50 participants to assess test-retest reliability. Confirmatory factor analysis (CFA) was implemented to test the dimensionality of the IADCQ items. Classical item-level and scale-level psychometric analyses were conducted to estimate psychometric characteristics of the instrument. Test-retest reliability was performed to evaluate the instrument’s stability and consistency over time.
Virtually none (2%) of the respondents had either floor or ceiling effects, indicating the IADCQ covers an ideal range of burden. A single-factor model obtained appropriate goodness of fit and provided evidence that a simple sum score of the 12 items of IADCQ can be used to measure AD caregiver’s burden. Scales-level reliability was supported with a coefficient alpha of 0.93 and an intra-class correlation coefficient (for test-retest reliability) of 0.68 (95% CI: 0.50–0.80). Low-moderate negative correlations were observed between the IADCQ and scales of the SF-12v2.
The study findings suggest the IADCQ has appropriate psychometric characteristics as a unidimensional, Web-based measure of AD caregiver burden and is supported by strong model fit statistics from CFA, high degree of item-level reliability, good internal consistency, moderate test-retest reliability, and moderate convergent validity. Additional validation of the IADCQ is warranted to ensure invariance between the paper-based and Web-based administration and to determine an appropriate responder definition.
PMCID: PMC4265347  PMID: 25186634
Alzheimer’s disease; Caregivers; Burden; Psychometrics; Questionnaire
9.  Gender and Ethnic Differences in Body Image and Opposite Sex Figure Preferences of Rural Adolescents 
Body image  2007;4(1):103-108.
This study examined whether rural adolescents would report gender and ethnic differences in body image similar to those that have been observed in urban samples. Data were analyzed for 384 rural adolescents (57% African American, 43% Caucasian, mean age 13 yr) to determine gender and ethnic differences in body dissatisfaction, body size discrepancy, and current and ideal figure ratings. Females wanted to be smaller and reported more body dissatisfaction than did males. Caucasian females reported the most body dissatisfaction. African Americans reported larger current and ideal figure ratings than did Caucasians. African Americans preferred larger opposite sex figures than did Caucasians. Both African American and Caucasian males selected a larger female figure as ideal than was selected by females. Results demonstrated that gender and ethnic differences exist in body image for rural adolescents. This frequently overlooked population may benefit from further study. Implications of findings and limitations of the study are also discussed.
PMCID: PMC2031852  PMID: 18089257
Gender differences; Ethnic differences; Body Image; Rural; Adolescents
10.  Body mass index bias in defining obesity of diverse young adults: the Training Intervention and Genetics of Exercise Response (TIGER) Study 
The British journal of nutrition  2009;102(7):1084-1090.
The BMI cut-score used to define overweight and obesity was derived primarily using data from Caucasian men and women. The present study evaluated the racial/ethnic bias of BMI to estimate the adiposity of young men and women (aged 17–35 years) using dual-energy X-ray absorptiometry (DXA) determination of percentage body fat (DXA-BF%) as the referent standard. The samples were 806 women and 509 men who were tested from one to three times over 9 months providing 1300 observations for women and 820 observations for men. Linear mixed models (LMM) regression showed that with age and BMI controlled, DXA-BF% of African-American (AA) men and women, Asian-Indian men and women, Hispanic women and Asian women significantly differed from non-Hispanic white (NHW) men and women. For the same BMI of NHW women, the DXA-BF% of AA women was 1.76 % lower, but higher for Hispanic (1.65 %), Asian (2.65%) and Asian-Indian (5.98%) women. For the same BMI of NHW men, DXA-BF% of AA men was 4.59 % lower and 4.29 % higher for Asian-Indian men. Using the recommended BMI cut-scores to define overweight and obesity systematically overestimated overweight and obesity prevalence for AA men and women, and underestimated prevalence for Asian-Indian men and women, Asian women and Hispanic women. The present study extends the generalisability of research documenting the racial/ethnic bias of the universal overweight and obesity BMI cut-scores.
PMCID: PMC2873180  PMID: 19344545
Percentage body fat: BMI; Overweight; Obesity; Diversity
11.  Race and Sex Associations to Weight Concerns among Urban African American and Caucasian Smokers 
Addictive Behaviors  2010;36(1-2):14-17.
This study compared general weight concerns (Drive for Thinness, Body Dissatisfaction, and Cognitive Restraint) and smoking-specific weight concerns among adult African American and Caucasian women and men smokers enrolled in a smoking cessation clinical trial. Participants were 119 African Americans (73 female) and 182 Caucasians (90 female). Results revealed that general weight concerns were higher in Caucasians versus African Americans, and in women compared with men but there were no race by sex interactions. Drive for Thinness and Body Dissatisfaction were higher in women compared with men, and Cognitive Restraint was highest in Caucasian women. Finally, smoking-specific weight concerns were higher in Caucasian women than both Caucasian and African American men, with African American women intermediate. Results indicate that while Caucasian women preparing to quit smoking exhibited the highest levels of concern about weight, smoking-specific weight concerns, and certain sub-components of general weight concerns were also prevalent among African Americans and Caucasians. Future research is needed to elucidate how race and sex differences in weight concerns may impact smoking cessation.
PMCID: PMC3402031  PMID: 20832176
African Americans; Weight Concerns; Smoking
12.  Weight Bias Internalization Scale: Psychometric Properties and Population Norms 
PLoS ONE  2014;9(1):e86303.
Internalizing the pervasive weight bias commonly directed towards individuals with overweight and obesity, co-occurs with increased psychopathology and impaired quality of life. This study sought to establish population norms and psychometric properties of the most widely used self-report questionnaire, the Weight Bias Internalization Scale (WBIS), in a representative community sample.
Design and Methods
In a survey of the German population, N = 1158 individuals with overweight and obesity were assessed with the WBIS and self-report measures for convergent validation.
Item analysis revealed favorable item-total correlation of all but one WBIS item. With this item removed, item homogeneity and internal consistency were excellent. The one-factor structure of the WBIS was confirmed using confirmatory factor analysis. Convergent validity was shown through significant associations with measures of depressive and somatoform symptoms. The WBIS contributed to the explanation of variance in depressive and somatoform symptoms over and above body mass index. Higher WBIS scores were found in women than in men, in individuals with obesity than in individuals with overweight, and in those with lower education or income than those with higher education or income. Sex-specific norms were provided.
The results showed good psychometric properties of the WBIS after removal of one item. Future research is warranted on further indicators of reliability and validity, for example, retest reliability, sensitivity to change, and prognostic validity.
PMCID: PMC3906030  PMID: 24489713
13.  Reliability and validity of the Spanish version of the 10-item Connor-Davidson Resilience Scale (10-item CD-RISC) in young adults 
The 10-item Connor-Davidson Resilience Scale (10-item CD-RISC) is an instrument for measuring resilience that has shown good psychometric properties in its original version in English. The aim of this study was to evaluate the validity and reliability of the Spanish version of the 10-item CD-RISC in young adults and to verify whether it is structured in a single dimension as in the original English version.
Cross-sectional observational study including 681 university students ranging in age from 18 to 30 years. The number of latent factors in the 10 items of the scale was analyzed by exploratory factor analysis. Confirmatory factor analysis was used to verify whether a single factor underlies the 10 items of the scale as in the original version in English. The convergent validity was analyzed by testing whether the mean of the scores of the mental component of SF-12 (MCS) and the quality of sleep as measured with the Pittsburgh Sleep Index (PSQI) were higher in subjects with better levels of resilience. The internal consistency of the 10-item CD-RISC was estimated using the Cronbach α test and test-retest reliability was estimated with the intraclass correlation coefficient.
The Cronbach α coefficient was 0.85 and the test-retest intraclass correlation coefficient was 0.71. The mean MCS score and the level of quality of sleep in both men and women were significantly worse in subjects with lower resilience scores.
The Spanish version of the 10-item CD-RISC showed good psychometric properties in young adults and thus can be used as a reliable and valid instrument for measuring resilience. Our study confirmed that a single factor underlies the resilience construct, as was the case of the original scale in English.
PMCID: PMC3173284  PMID: 21819555
Resilience; 10-item CD-RISC; Young adults; Reliability; Validity; Questionnaire
14.  Development and Validation of a Male Specific Body Checking Questionnaire 
Body checking may be an important behavioral consequence of body image disturbance. Despite the importance of body checking, few measurements of this construct exist, particularly for males. This study describes the development and validation of the Male Body Checking Questionnaire (MBCQ).
Convergent and divergent validity, factor structure, and reliability were tested in three separate samples of men and women.
Factor analyses suggested a reliable four-factor structure with evidence of a higher order global checking factor for men, but not women. The MBCQ demonstrated good concurrent and divergent validity. Short-term test-retest reliability was good with high internal consistency across time.
Interpretation of psychometrics and recommendations for subsequent research are discussed. The MBCQ is likely to be an appropriate tool for investigating body image-based pathology in males.
PMCID: PMC2892168  PMID: 19247988
Male Body Checking Questionnaire; confirmatory factor analysis; psychometrics; body image disturbance; muscle dysmorphia; gender differences; exploratory factor analysis
15.  The Menopause Rating Scale (MRS) scale: A methodological review 
This paper compiles data from different sources to get a first comprehensive picture of psychometric and other methodological characteristics of the Menopause Rating Scale (MRS) scale. The scale was designed and standardized as a self-administered scale to (a) to assess symptoms/complaints of aging women under different conditions, (b) to evaluate the severity of symptoms over time, and (c) to measure changes pre- and postmenopause replacement therapy. The scale became widespread used (available in 10 languages).
A large multinational survey (9 countries in 4 continents) from 2001/ 2002 is the basis for in depth analyses on reliability and validity of the MRS. Additional small convenience samples were used to get first impressions about test-retest reliability. The data were centrally analyzed. Data from a postmarketing HRT study were used to estimate discriminative validity.
Reliability measures (consistency and test-retest stability) were found to be good across countries, although the sample size for test-retest reliability was small.
Validity: The internal structure of the MRS across countries was astonishingly similar to conclude that the scale really measures the same phenomenon in symptomatic women. The sub-scores and total score correlations were high (0.7–0.9) but lower among the sub-scales (0.5–0.7). This however suggests that the subscales are not fully independent.
Norm values from different populations were presented showing that a direct comparison between Europe and North America is possible, but caution recommended with comparisons of data from Latin America and Indonesia. But this will not affect intra-individual comparisons within clinical trials.
The comparison with the Kupperman Index showed sufficiently good correlations, illustrating an adept criterion-oriented validity. The same is true for the comparison with the generic quality-of-life scale SF-36 where also a sufficiently close association has been shown.
The currently available methodological evidence points towards a high quality of the MRS scale to measure and to compare HRQoL of aging women in different regions and over time, it suggests a high reliability and high validity as far as the process of construct validation could be completed yet.
PMCID: PMC516787  PMID: 15345062
MRS; Health Related Quality of Life; Questionnaires; Reliability; Validity
16.  The Malawi Developmental Assessment Tool (MDAT): The Creation, Validation, and Reliability of a Tool to Assess Child Development in Rural African Settings 
PLoS Medicine  2010;7(5):e1000273.
Melissa Gladstone and colleagues evaluate the reliability and validity of an assessment tool for evaluating child development in rural African settings.
Although 80% of children with disabilities live in developing countries, there are few culturally appropriate developmental assessment tools available for these settings. Often tools from the West provide misleading findings in different cultural settings, where some items are unfamiliar and reference values are different from those of Western populations.
Methods and Findings
Following preliminary and qualitative studies, we produced a draft developmental assessment tool with 162 items in four domains of development. After face and content validity testing and piloting, we expanded the draft tool to 185 items. We then assessed 1,426 normal rural children aged 0–6 y from rural Malawi and derived age-standardized norms for all items. We examined performance of items using logistic regression and reliability using kappa statistics. We then considered all items at a consensus meeting and removed those performing badly and those that were unnecessary or difficult to administer, leaving 136 items in the final Malawi Developmental Assessment Tool (MDAT). We validated the tool by comparing age-matched normal children with those with malnutrition (120) and neurodisabilities (80). Reliability was good for items remaining with 94%–100% of items scoring kappas >0.4 for interobserver immediate, delayed, and intra-observer testing. We demonstrated significant differences in overall mean scores (and individual domain scores) for children with neurodisabilities (35 versus 99 [p<0.001]) when compared to normal children. Using a pass/fail technique similar to the Denver II, 3% of children with neurodisabilities passed in comparison to 82% of normal children, demonstrating good sensitivity (97%) and specificity (82%). Overall mean scores of children with malnutrition (weight for height <80%) were also significantly different from scores of normal controls (62.5 versus 77.4 [p<0.001]); scores in the separate domains, excluding social development, also differed between malnourished children and controls. In terms of pass/fail, 28% of malnourished children versus 94% of controls passed the test overall.
A culturally relevant developmental assessment tool, the MDAT, has been created for use in African settings and shows good reliability, validity, and sensitivity for identification of children with neurodisabilities.
Please see later in the article for the Editors' Summary
Editors' Summary
Babies can do very little when they are first born. But, gradually, over the first few years of life, they learn to walk and run (gross motor skills), they learn to manipulate objects with their hands (fine motor skills), they learn to communicate with words and gestures (language skills), and they learn how to interact with other people (social skills). For each of these skill “domains,” experts have identified “developmental milestones,” skills that are acquired by a specific age if development is proceeding normally. So, for example, by one year, a child should be able crawl, put objects into a container, respond to simple verbal requests, and enjoy imitating people during play. Every child attains the various developmental milestones at a slightly different age but their overall development can be monitored using a series of simple tests (items) covering each of the developmental domains. Clinicians and teachers can use these “developmental assessment tools” to identify children whose development deviates significantly from the norm. It is important to identify these children as young as possible because early intervention can help them reach their full developmental potential.
Why Was This Study Done?
In developing countries, poverty, poor health, and malnutrition are responsible for millions of children failing to reach their developmental potential. But because developmental assessment tools have mainly been designed and validated in western, developed countries, they contain many items that are alien to children in non-western cultures (for example, the use of knives and forks for eating and the use of specific gestures). They cannot, therefore, accurately assess whether a child living in, for example, a rural area of Africa, is developing normally. In this study, the researchers describe the creation and testing of a culturally appropriate developmental assessment tool for use in rural Africa—the Malawi Developmental Assessment Tool (MDAT)—from a 162-item draft tool (MDAT Draft I) that they previously developed from Denver II, an assessment tool widely used in developed countries.
What Did the Researchers Do and Find?
The researchers assessed the “face validity” (do the items look acceptable to untrained judges?) and “content validity” (does the tool examine all the domains it is meant to measure?) of MDAT Draft I and modified it to produce MDAT Draft II. After piloting this version on 80 children in rural Malawi, they modified it further to produce MDAT Draft III, which was used to assess 1,426 normal children aged 0–6 years from rural Malawi and to derive age-standardized norms for each item. After statistically analyzing the performance of each item in MDAT Draft III, all the items were considered at a consensus meeting, and items that were badly performing, unnecessary, and difficult to administer were removed, leaving 136 items (MDAT). The researchers then validated MDAT by using it to assess children with neurodisabilities (disorders of the nervous system that impair normal functioning) and children with delayed development because of malnutrition. The tool was reliable (different testers got similar results for individual children and individual testers got similar results when they retested specific children), sensitive (it correctly identified most children with a neurodisability or delayed development), and specific (it correctly identified most children who were developing normally; that is, it did not give false-positive results).
What Do These Findings Mean?
These findings show that MDAT is a culturally relevant assessment tool that reliably identifies children with neurodisabilities and delayed development in rural Malawi. Importantly, they also provide a detailed illustration of how to create and validate a culturally relevant assessment tool. Although MDAT is likely to be applicable in other similar settings, further research is needed to test its generalizability and to test whether it will work in children with more subtle developmental problems. MDAT, the researchers note, should be useful as a clinical tool for the early identification of neurodisabilities and as an outcome measure in clinical trials of interventions designed to improve child development. However, they stress, because developing countries have limited resources available for screening and for helping children whose development is delayed or disrupted, for now tools like MDAT are more likely to be used for research studies than for routine developmental assessments in Malawi and other African countries.
Additional Information
Please access these Web sites via the online version of this summary at
The World Health Organization has information on disability, prevention, and management in children and adults worldwide
UNICEF has a site on early childhood and in particular, provides information on programming experiences for early child intervention programs worldwide
Disability World is a website for international views and perspectives on disability worldwide. It provides information and links about the worldwide state of disability in children and adults in developing countries
Source, the International Information Support Centre has a good website of information about disability, inclusion, and development in children with links to many other sources of information
Wikipedia has a page on child development (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The US Centers for Disease Control and Prevention provides information on developmental screening and on developmental milestones
The American Academy of Pediatrics also provides information on developmental stages and on developmental milestones
The UK National Health Service Choices site has an interactive guide to child development
MedlinePlus has links to further resources on infant and toddler development (in English and Spanish)
PMCID: PMC2876049  PMID: 20520849
17.  Development and validation of parenting measures for body image and eating patterns in childhood 
Evidence-based parenting interventions are important in assisting parents to help their children develop healthy body image and eating patterns. To adequately assess the impact of parenting interventions, valid parent measures are required. The aim of this study was to develop and assess the validity and reliability of two new parent measures, the Parenting Intentions for Body image and Eating patterns in Childhood (Parenting Intentions BEC) and the Knowledge Test for Body image and Eating patterns in Childhood (Knowledge Test BEC).
Participants were 27 professionals working in research or clinical treatment of body dissatisfaction or eating disorders, and 75 parents of children aged 2–6 years, who completed the measures via an online questionnaire. Seven scenarios were developed for the Parenting Intentions BEC to describe common experiences about the body and food that parents might need to respond to in front of their child. Parents ranked four behavioural intentions, derived from the current literature on parenting risk factors for body dissatisfaction and unhealthy eating patterns in children. Two subscales were created, one representing positive behavioural intentions, the other negative behavioural intentions. After piloting a larger pool of items, 13 statements were used to construct the Knowledge Test BEC. These were designed to be factual statements about the influence of parent language, media, family meals, healthy eating, and self-esteem on child eating and body image. The validity of both measures was tested by comparing parent and professional scores, and reliability was assessed by comparing parent scores over two testing occasions.
Compared with parents, professionals reported significantly higher scores on the Positive Intentions subscale and significantly lower on the Negative Intentions subscale of the Parenting Intentions BEC; confirming the discriminant validity of six out of the seven scenarios. Test-retest reliability was also confirmed as parent scores on the two Parenting Intentions subscales did not differ over time. Eleven out of the 13 Knowledge Test items demonstrated sufficient discriminant validity and test-retest reliability.
Overall, results indicated that the six-scenario Parenting Intentions BEC and the 11-item Knowledge Test BEC are valid and reliable measures for parents of young children.
Electronic supplementary material
The online version of this article (doi:10.1186/s40337-015-0043-5) contains supplementary material, which is available to authorized users.
PMCID: PMC4359773  PMID: 25774298
Parent; Children; Body image; Eating patterns; Validity; Knowledge
18.  Cross-cultural validation and analysis of responsiveness of the QUALIOST®: QUAlity of Life questionnaire In OSTeoporosis 
The QUALIOST® was designed for use with the SF-36 to measure established osteoporosis-specific quality of life (QoL). The reliability (internal consistency and test-retest) and validity of the questionnaire were established in a stand-alone psychometric validation study. The objective of this paper is to provide additional information on the instrument's responsiveness using clinical trial data, along with the reliability and validity of translated versions.
The Spinal Osteoporosis Therapeutic Intervention (SOTI) was an international clinical trial comparing strontium ranelate to placebo on the occurrence of new vertebral fracture in patients with postmenopausal osteoporosis. QoL was a secondary endpoint, assessed using the SF-36 and QUALIOST® at baseline and every six months, with the main analysis at 3-year follow-up. Questionnaire acceptability, analysis of the hypothesised structure, internal consistency reliability and responsiveness to clinical change over time were assessed at the 3-year follow up.
1592 patients from 11 countries completed at least one QoL questionnaire. The psychometric properties of the questionnaires were assessed on cross-sectional (N = 1486) and longitudinal (N = 1288) data. Item discriminant validity of the QUALIOST® was excellent, as was item convergent validity, with 100% of item-scale correlations being above the 0.40 level. Internal consistency reliability was also extremely good, with high Cronbach's alpha scores above the 0.70 benchmark. Responsiveness results were consistent for all QUALIOST® scores, indicating that greater decreases in QoL corresponded to greater numbers of fractures experienced. QUALIOST® scores also differed according to the type of fracture suffered. This was demonstrated by increased effect sizes for more severe vertebral fractures (clinical vertebral and painful vertebral). In comparing responsiveness, the QUALIOST® scores were generally more consistent than those of the SF-36. Most notably, the QUALIOST® was more responsive with regard to painful vertebral fractures than the SF-36.
The QUALIOST® is a reliable and valid tool for measuring QoL in postmenopausal osteoporotic women. Being available in several validated language versions, it is ready to be used in a variety of settings, including international clinical trials.
PMCID: PMC1325267  PMID: 16283929
19.  The Role of Lifestyle and Psycho-Social Factors in Predicting Changes in Body Composition in Black South African Women 
PLoS ONE  2015;10(7):e0132914.
This study aimed to determine whether lifestyle and psycho-social factors determine changes in body composition over 10 years in a population of black African females with a high prevalence of obesity.
Materials and Methods
Data were collected from 430 women at baseline and 10-year follow-up. Dual energy x-ray absorptiometry-derived body fat mass and fat free soft tissue mass, and simple anthropometric measures were taken at both time points. Data on physical activity (PA), diet, smoking, and alcohol intake were collected at baseline. Body size dissatisfaction and body size discrepancy were determined at baseline using the feel minus ideal (FID) index and the perceived minus actual weight status discrepancy score (PAD), respectively.
All body composition measurements increased over 10 years (p<0.0005). Two distinct groups of overweight/obese females were identified using PAD and FID: one that was content with their body size and one that wished to be leaner. Vigorous PA at baseline was inversely associated with absolute changes in all measures of adiposity. In subjects who underestimated their body size at baseline (74.0% of the study population) changes in total and peripheral levels of body fat were less than in subjects who correctly identified their body size. In the group that underestimated body size, more women wanted to be leaner than in the group who knew their body size (60.1% vs 47.5%, p<0.05).
Underestimation of body size is common and is associated with a lower gain in total body adiposity and a prevalent desire to lose weight.
PMCID: PMC4501844  PMID: 26171972
20.  Examining the reliability and validity of a modified version of the International Physical Activity Questionnaire, long form (IPAQ-LF) in Nigeria: a cross-sectional study 
BMJ Open  2014;4(12):e005820.
To investigate the reliability and an aspect of validity of a modified version of the long International Physical Activity Questionnaire (Hausa IPAQ-LF) in Nigeria.
Cross-sectional study, examining the reliability and construct validity of the Hausa IPAQ-LF compared with anthropometric and biological variables.
Metropolitan Maiduguri, the capital city of Borno State in Nigeria.
180 Nigerian adults (50% women) with a mean age of 35.6 (SD=10.3) years, recruited from neighbourhoods with diverse socioeconomic status and walkability.
Outcome measures
Domains (domestic physical activity (PA), occupational PA, leisure-time PA, active transportation and sitting time) and intensities of PA (vigorous, moderate and walking) were measured with the Hausa IPAQ-LF on two different occasions, 8 days apart. Outcomes for construct validity were measured body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP).
The Hausa IPAQ-LF demonstrated good test–retest reliability (intraclass correlation coefficient, ICC>75) for total PA (ICC=0.79, 95% CI 0.65 to 0.82), occupational PA (ICC=0.77, 95% CI 0.68 to 0.82), active transportation (ICC=0.82, 95% CI 0.75 to 0.87) and vigorous intensity activities (ICC=0.82, 95% CI 0.76 to 0.87). Reliability was substantially higher for total PA (ICC=0.80), occupational PA (ICC=0.78), leisure-time PA (ICC=0.75) and active transportation (ICC=0.80) in men than in women, but domestic PA (ICC=0.38) and sitting time (ICC=0.71) demonstrated more substantial reliability coefficients in women than in men. For the construct validity, domestic PA was significantly related mainly with SBP (r=−0.27) and DBP (r=−0.17), and leisure-time PA and total PA were significantly related only with SBP (r=−0.16) and BMI (r=−0.29), respectively. Similarly, moderate-intensity PA was mainly related with SBP (r=−0.16, p<0.05) and DBP (r=−0.21, p<0.01), but vigorous-intensity PA was only related with BMI (r=−0.11, p<0.05).
The modified Hausa IPAQ-LF demonstrated sufficient evidence of test–retest reliability and may be valid for assessing context specific PA behaviours of adults in Nigeria.
PMCID: PMC4256540  PMID: 25448626
21.  Developing a tool to measure satisfaction among health professionals in sub-Saharan Africa 
In sub-Saharan Africa, lack of motivation and job dissatisfaction have been cited as causes of poor healthcare quality and outcomes. Measurement of health workers’ satisfaction adapted to sub-Saharan African working conditions and cultures is a challenge. The objective of this study was to develop a valid and reliable instrument to measure satisfaction among health professionals in the sub-Saharan African context.
A survey was conducted in Senegal and Mali in 2011 among 962 care providers (doctors, midwives, nurses and technicians) practicing in 46 hospitals (capital, regional and district). The participation rate was very high: 97% (937/962). After exploratory factor analysis (EFA), construct validity was assessed through confirmatory factor analysis (CFA). The discriminant validity of our subscales was evaluated by comparing the average variance extracted (AVE) for each of the constructs with the squared interconstruct correlation (SIC), and finally for criterion validity, each subscale was tested with two hypotheses. Two dimensions of reliability were assessed: internal consistency with Cronbach’s alpha subscales and stability over time using a test-retest process.
Eight dimensions of satisfaction encompassing 24 items were identified and validated using a process that combined psychometric analyses and expert opinions: continuing education, salary and benefits, management style, tasks, work environment, workload, moral satisfaction and job stability. All eight dimensions demonstrated significant discriminant validity. The final model showed good performance, with a root mean square error of approximation (RMSEA) of 0.0508 (90% CI: 0.0448 to 0.0569) and a comparative fit index (CFI) of 0.9415. The concurrent criterion validity of the eight dimensions was good. Reliability was assessed based on internal consistency, which was good for all dimensions but one (moral satisfaction < 0.70). Test-retest showed satisfactory temporal stability (intra class coefficient range: 0.60 to 0.91).
Job satisfaction is a complex construct; this study provides a multidimensional instrument whose content, construct and criterion validities were verified to ensure its suitability for the sub-Saharan African context. When using these subscales in further studies, the variability of the reliability of the subscales should be taken in to account for calculating the sample sizes. The instrument will be useful in evaluative studies which will help guide interventions aimed at improving both the quality of care and its effectiveness.
PMCID: PMC3704923  PMID: 23826720
Job satisfaction; Sub-Saharan Africa; Health workers; Measurement
22.  Predicting waist circumference from body mass index 
Being overweight or obese increases risk for cardiometabolic disorders. Although both body mass index (BMI) and waist circumference (WC) measure the level of overweight and obesity, WC may be more important because of its closer relationship to total body fat. Because WC is typically not assessed in clinical practice, this study sought to develop and verify a model to predict WC from BMI and demographic data, and to use the predicted WC to assess cardiometabolic risk.
Data were obtained from the Third National Health and Nutrition Examination Survey (NHANES) and the Atherosclerosis Risk in Communities Study (ARIC). We developed linear regression models for men and women using NHANES data, fitting waist circumference as a function of BMI. For validation, those regressions were applied to ARIC data, assigning a predicted WC to each individual. We used the predicted WC to assess abdominal obesity and cardiometabolic risk.
The model correctly classified 88.4% of NHANES subjects with respect to abdominal obesity. Median differences between actual and predicted WC were − 0.07 cm for men and 0.11 cm for women. In ARIC, the model closely estimated the observed WC (median difference: − 0.34 cm for men, +3.94 cm for women), correctly classifying 86.1% of ARIC subjects with respect to abdominal obesity and 91.5% to 99.5% as to cardiometabolic risk.
The model is generalizable to Caucasian and African-American adult populations because it was constructed from data on a large, population-based sample of men and women in the United States, and then validated in a population with a larger representation of African-Americans.
The model accurately estimates WC and identifies cardiometabolic risk. It should be useful for health care practitioners and public health officials who wish to identify individuals and populations at risk for cardiometabolic disease when WC data are unavailable.
PMCID: PMC3441760  PMID: 22862851
23.  Cross-validation of generalised body composition equations with diverse young men and women: the Training Intervention and Genetics of Exercise Response (TIGER) Study 
The British journal of nutrition  2008;101(6):871-878.
Generalised skinfold equations developed in the 1970s are commonly used to estimate laboratory-measured percentage fat (BF%). The equations were developed on predominately white individuals using Siri's two-component percentage fat equation (BF%-GEN). We cross-validated the Jackson–Pollock (JP) generalised equations with samples of young white, Hispanic and African–American men and women using dual-energy X-ray absorptiometry (DXA) as the BF% referent criterion (BF%-DXA). The cross-sectional sample included 1129 women and men (aged 17–35 years). The correlations between BF%-GEN and BF%-DXA were 0.85 for women and 0.93 for men. Analysis of measurement error showed that BF%-GEN underestimated BF%-DXA of men and women by 1.3 and 3.0%. General linear models (GLM) confirmed that BF%-GEN systematically underestimated BF%-DXA of Hispanic men and women, and overestimated BF%-DXA of African–American men. GLM were used to estimate BF%-DXA from the JP sum of skinfolds and to account for race/ethnic group bias. The fit statistics (R and standard error of the estimate; see) of the men's calibration model were: white, R 0.92, see 3.0%; Hispanic, R 0.91, see 3.0 %; African–American, R 0.95, see 2.6 %. The women's statistics were: white and African–American, R 0.86, see 3.8%; Hispanic, R 0.83, see 3.4 %. These results showed that BF%-GEN and BF%-DXA were highly correlated, but the error analyses documented that the generalised equations lacked accuracy when applied to these racially and ethnically diverse men and women. The inaccuracy was linked to the body composition and race/ethnic differences between these Training Intervention and Genetics of Exercise Response (TIGER) study subjects and the men and women used to develop the generalised equations in the 1970s and using BF%-DXA as the referent criterion.
PMCID: PMC2873181  PMID: 18702849
Body composition; Skinfolds; Dual-energy X-ray absorptiometry; Generalised equations
24.  Ethnic variation in validity of classification of overweight and obesity using self-reported weight and height in American women and men: the Third National Health and Nutrition Examination Survey 
Nutrition Journal  2005;4:27.
Few data have been published on the validity of classification of overweight and obesity based on self-reported weight in representative samples of Hispanic as compared to other American populations despite the wide use of such data.
To test the null hypothesis that ethnicity is unrelated to bias of mean body mass index (BMI) and to sensitivity of overweight or obesity (BMI >= 25 kg/m2) derived from self-reported (SR) versus measured weight and height using measured BMI as the gold standard.
Cross-sectional survey of a large national sample, the Third National Health and Nutrition Examination Survey (NHANES III) conducted in 1988–1994.
American men and women aged 20 years and over (n = 15,025).
SR height, weight, cigarette smoking, health status, and socio-demographic variables from home interview and measured weight and height.
In women and Mexican American (MA) men SR BMI underestimated true prevalence rates of overweight or obesity. For other men, no consistent difference was seen. Sensitivity of SR was similar in non-Hispanic European Americans (EA) and non-Hispanic African Americans (AA) but much lower in MA. Prevalence of obesity (BMI >= 30 kg/m2) is consistently underestimated by self-report, the gap being greater for MA than for other women, but similar for MA and other men. The mean difference between self-reported and measured BMI was greater in MA (men -0.37, women -0.76 kg/m2) than in non-Hispanic EA (men -0.22, women -0.62 kg/m2). In a regression model with the difference between self-reported and measured BMI as the dependent variable, MA ethnicity was a significant (p < 0.01) predictor of the difference in men and in women. The effect of MA ethnicity could not be explained by socio-demographic variables, smoking or health status.
Under-estimation of the prevalence of overweight or obesity based on height and weight self-reported at interview varied significantly among ethnic groups independent of other variables.
PMCID: PMC1262765  PMID: 16209706
Overweight; Obesity; Hispanics; Mexican Americans; Body weight; Blacks
25.  Do men hold African-American and Caucasian women to different standards of beauty?✩ 
Eating behaviors  2006;8(3):319-333.
Racial differences in men’s preferences for African-American and Caucasian women’s body size and shape were examined. As expected, there was a trend for African-American men to choose ideal figures with a lower waist-to-hip ratio (WHR), which is associated with a more curvaceous figure. Contrary to expectations, however, African-American men did not choose heavier female figures as ideal. In fact, both groups chose underweight and normal weight figures as ideal. The results from this study suggest that while preferences for WHR may continue to be associated with cultural factors, African-American and Caucasian men may have become more similar than different in their preferences for female weight. Also, the results suggest that within the African-American sample, there were two subsamples with regard to WHR preferences, with one subgroup endorsing the same ideal WHR as their Caucasian counterparts. The results are discussed in terms of possible changes to cultural values that may be reflected in a change in what is considered attractive.
PMCID: PMC3033406  PMID: 17606230
African-Americans; Caucasians; Waist-to-hip ratio

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