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City University of New York (CUNY) City University of New York (CUNY)
CUNY Academic Works CUNY Academic Works
Dissertations, Theses, and Capstone Projects CUNY Graduate Center
5-2015
Development and Validation of a Bangladeshi Pediatric Silhouette Development and Validation of a Bangladeshi Pediatric Silhouette
Scale (BPSS) Scale (BPSS)
Ana Mola Graduate Center, City University of New York
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DEVELOPMENT AND VALIDATION OF A
BANGLADESHI PEDIATRIC SILHOUETTE SCALE (BPSS)
by
ANA MOLA
A dissertation submitted to the Graduate Faculty in Nursing in partial fulfillment of the requirements for the degree of Doctor of Philosophy, The City University of New York.
2015
ii
2015
ANA MOLA
All Rights Reserved
iii
This manuscript has been read and accepted for the
Graduate Faculty in Nursing in satisfaction of the
dissertation requirement for the degree of Doctor of Philosophy.
Dr. Martha Whetsell
__________________________________________
Date Chair of Examining Committee
Dr. Donna Nickitas
_____________ __________________________________________
Date Executive Officer
Dr. Donna Nickitas
Dr. H.D. McCarthy
Dr. Lorraine Killion
Dr. James Cox !
Supervisory Committee
THE CITY UNIVERSITY OF NEW YORK
!
!
!
iv
!
Abstract
DEVELOPMENT AND VALIDATION OF A
BANGLADESHI PEDIATRIC SILHOUETTE SCALE (BPSS)
By
Ana Mola
Adviser: Professor Martha V. Whetsell
There is no culturally congruent children’s silhouette scale to understand how
Bangladeshi mothers’ perceive their children’s body sizes and weight categories. The purpose of
this study was to develop and validate an ethnic congruent Bangladeshi Pediatric Silhouette
Scale (BPSS) and a facial feature scale to assess the mothers’ perceptions of their children’s
body sizes, weight categories and facial features. The study methodology was a quantitative,
descriptive design with scale content validation. The sample was comprised of 29 Bangladeshis
mothers ages 25-40 and their four-five year old children living in London, England and New
York City. The Mola Facetool analyses revealed that the gender set preference consensus was
achieved in 13 of 14 facial features which were statistical non-significant. The hair variable
revealed a significant difference with conditions; t (27) = -2.42, p = .02. The BPSS was validated
by the analyses of three gender set sequences of A, B and C silhouette scales from thinnest to
heaviest ordering and weight classifications assignments. The Cronbach alpha coefficients were
significant for the samples. The independent sample t tests and paired t test revealed no
differences between the samples with the ordering and weight classification of sequences A and
B scales, achieving a p > .05. There was a significant difference between the samples in the
scores of identifying correct weight classification of sequence C silhouettes scale, boys with
v
shorts, with the conditions; t (8) = 2.44, p = .04. The BPSS has provided a cultural congruent
adiposity risk tool in the Bangladeshi community.
vi
Dedication
I would like to dedicate this dissertation to my parents, Manuel and Josephine, and my
sister, Liliana. My family has always provided me the love, support, respect and confidence that
I could achieve significant milestones in my life. My father, if he was alive, would have been
very proud that the choice he and my mother made to immigrate to the United States, several
decades ago, afforded the opportunities for their daughters to achieve academic and professional
accomplishments.
vii
Acknowledgements
I would like to extend my sincere gratitude to my dissertation committee as each one was
instrumental in guiding me on this doctorate journey. My warmest thanks to Dr. Donna Nickitas,
for your unwavering support, Dr. James Cox for your valued insights, and Dr. Lorraine Killion,
for your expertise in childhood obesity, the permission to use your children body figures and
your long distance mentorship. A heartfelt thanks to Dr. David McCarthy, who opened the doors
of London to expand my scientific curiosity of the South Asian thin fat phenotype, childhood
obesity and the specialty of pediatric growth and development. My unswerving gratitude is
offered to Dr. Martha V. Whetsell, my dissertation advisor, for the endless hours of reassurances
and inspiration that she provided throughout this doctorate journey. As a nurse scientist and
educator, Dr. Whetsell exemplifies a role model that I aspire to reach every day. I will always
remember and cherish Saturdays with Martha.
I offer my appreciation to all the City University of New York Graduate Center Doctoral
Nursing Faculty for their time and expertise throughout my six years. Thank you Dr. Eleanor
Campbell, Dr. Bridget Cypress, Dr. Barbara DiCicco-Bloom, Dr. Alicia Georges, Dr. Eileen
Gigliotti, Dr. Marianne Jeffreys, Dr. Margaret Lunney, Dr. Violet Malinski, Dr. Kathleen Nokes,
Dr. Carol Roye, and Dr. Vidette Todaro-Franceschi, for your critical insights in my
transformation to become a nurse scientist.
I would like to thank Dr. Mariano Rey and Dr. Keville Frederickson for introducing me
to the international public health initiative of South Asian healthcare disparities and childhood
obesity. Sincere appreciation is extended to Dr. Elsa-Sofia Morote, Dr. Miguel Villegas-Pantoja,
and Shauna Ford, as they removed my fear of numbers and provided me the confidence to
understand inferential statistics. Dr. Villegas-Pantoja gave endless hours to ensure that my
viii
dissertation analyses were true to the numbers. An ocean of gratitude is extended to Ariane
Haas, the talented graphic designer in Paris. Ariane was always available to update facial
features and body silhouettes at any hour of the day.
I would like to acknowledge all those that introduced me to the South Asian Community,
Joyce Moy, Executive Director of the Asian and American Research Institute of the City
University of New York. Joyce introduced me to several Bangladesh community leaders in
order to expand my networking in New York City (NYC). Thanks to Rokeya Akhter, a
Bangladesh community leader to the Queens Borough President's General Assembly in NYC,
and Sanjida Haque, London Metropolitan University doctoral candidate, as you both assisted me
in the recruitment of Bangladeshi mothers.
I would like to acknowledge and express my gratitude to our Cohort Sisters, big hugs to
Meriam, Cathy, Barbara, Monique, Michelle, Kathy, Darcel, Regina and my twin dissertation
sister, Madeleine. These ladies made the dissertation journey very special as the think tank came
together every Friday to explore the novel nursing ideas that one day became our dissertation
topics. A wholehearted appreciation is extended to Suzanne Mullings, a CUNY doctoral nursing
student, as her referrals to colleagues assisted me in the recruitment of Bangladeshi mothers in
NYC.
As social support is integral to the enrichment of the individual, my genuine thanks to
my extended Cuban family and friends who gave of their time, encouragement and support to
assist me in achieving a doctorate degree in nursing. I extend big hugs to Ruth Burtman for
editing my dissertation for grammar, syntax and APA style. A warm thanks to Robert
McGivern, as he not only supported me in this study, but carried my research equipment as we
crisscrossed through London in steamy July.
ix
I would like to highlight two very special people, Madeleine Lloyd and Lina Courtadiou,
as without their constant support, I would have not reached the finish line. Madeleine, my twin
dissertation sister, and personal friend made this journey complete as we encouraged each other
through class assignments, presentations, papers and the editing of our dissertations. Madeleine
made me laugh when I wanted to cry, coached me when I was so frustrated, and reassured me
that my ego was always intact. To Lina, I am forever thankful as you selflessly loved and cared
for me every day, in so many ways, throughout this dissertation endeavor. I cherished this
journey because you walked by my side.
Finally, I would to thank the Bangladeshi mothers who embraced this research as a
meaningful and hopeful scientific inquiry into the future health of their children.
x
TABLE OF CONTENTS
Chapter page
1. INTRODUCTION……………………………………………………………... 1-8
Purpose of the Study………………………………………………………. 8
Conceptual Theoretical Framework………………………………………. 9-10
Research Questions……………………………………………………….. 10
Assumptions………………………………………………………………. 10
Limitations………………………………………………………………… 11
Significance……………………………………………………………….. 11
Conceptual and Operational Definitions…………………………………... 11-12
Summary………………………………………………………………....... 13
2. REVIEW OF LITERATURE…………………………………………………... 14-15
Ethnically Congruent Pediatric Silhouette Scales.………………………… 16-19
Mothers’ Perceptions of their Children’s Body Sizes……………………... 19-23
Implications of the South Asian Thin Fat Phenotype……………………... 23-26
Body Measurements……………………………………………….............. 26-30
Asian Body Measurements Indices Cut-off Points………………………... 30-32
Summary…………………………………………………………………... 32
3. METHODOLOGY……………………………………………………………... 33
Research Design…………………………………………………………... 33
Sample…………………………………………………………………….. 33-34
Setting……………………………………………………………………... 34
xi
Protection of Human Subjects…………………………………………….. 34-35
Data Collection Procedures……………………………………………….. 35-39
Data Analyses……………………………………………………………... 39-41
Summary…………………………………………………………………... 41-42
4. PRESENTATION AND ANALYSIS OF DATA………………………………. 43
Description Statistics of the Sample.……………………………………… 43-46
Testing the Research Questions…………………………………………… 46
Research Question One -Scale Validation………………………… 46-53
Research Question Two- Scale validation………………………… 54-69
Summary…………………………………………………………………... 69-70
5. DISCUSSION…………………………………………………………………... 71
Summary of the Study…………………………………………………….. 71-76
Discussion……………………………………………………………….... 76-78
Implications for Practice………………………………………………….. 78-80
Implications for Future Study…………………………………………….. 80-82
Limitations……………………………………………………………....... 82
Conclusions……………………………………………………………….. 82-83
Appendices……………………………………………………………………….. 84
APPENDIX A: Socio-demographic Survey………………………………………. 85-87
APPENDIX B: Approval CUNY IRB Letters…………………………………….. 88-91
APPENDIX C: Approval LMU IRB Letter……………………………………….. 92
APPENDIX D: Girls and Boys Assignment of Weight Categories and
Point System Silhouette Sequences A, B and C………………………………….... 93-94
xii
APPENDIX E: General Assessment Silhouette Scale Questions…………………. 95
REFERENCES…………………………………………………………………… 96-110
xiii
LIST OF TABLES
Table page
1. Weight Calculations and BMI for 5 Year-old Boys Using Butte's
Estimation of Percentiles…………………………………………………………... 18
2 Weight Calculations and BMI for 5 Year-old Girls Using Butte's
Estimation of Percentiles…………………………………………........................... 19
3. 2003 NYC DOHMH & DOE BMI of Overweight versus Obesity
Results of Children Ages…………………………………………………………. 26
4. WHO Expert Consultations (2004) BMI Cut-Offs of Overweight
and Obesity for Asians (Kg/m2)………………………………………………….. 31
5. Socio-demographic Characteristics of Frequencies and Percentages
of the Samples from London and NYC……………………………………………. 45
6. Socio-demographic Characteristics of Means and Standard
Deviations of the Samples from London and NYC…………………………………. 46
7. Descriptive Statistical Analyses of the Mola Facetool Girls’ Facial Features……. 49
8. Independent t Test Comparing London to NYC Girls’ Facial Features…………. 50
9. Descriptive Statistical Analyses of the Mola Facetool Boys’ Facial Features…… 52
10. Independent t Test Comparing London to NYC Boys’ Facial Features……….... 53
11. Content Validity I: Percentage of Subjects Who Ordered the Silhouettes
Correctly- Sequence A, B, and C (G-F-E-D-C-B-A)……………………………….. 55
12. Content Validity II: Percentage of Subjects Who Correctly Ordered the
Silhouettes from Thinnest to Heaviest: Sequences A, B, and C (G-F-E-D-C-B-A)... 56
xiv
13. Content Validity II: Percentage of Subjects Who Correctly Ordered the
Silhouettes Sequence A girls–shorts (G-F-E-D-C-B-A)…………………………… . 57
14. Content Validity II: Percentage of Subjects Who Correctly Ordered the
Silhouettes Sequence B Girls–Bodysuits (G-F-E-D-C-B-A)………………………. 57
15. Content Validity II: Percentage of Subjects Who Correctly Ordered the
Silhouettes Sequence C Boys –Shorts (G-F-E-D-C-B-A)………………………….. 58
16. Cronbach‘s Alpha Coefficient Findings of Ordering the Silhouettes
from the Samples of London and NYC……………………………………………. 59
17. Independent Sample t Test Comparing the Samples from London and NYC
Ordering the Silhouettes of the Three Sequences A, B and C……………………… 60
18. Paired t Test Comparing London Sample (first and second visits) Ordering of
Silhouettes of the Three Sequences A, B and C ……………………………………. 61
19. Content Validity II: Percentage of Subjects from London and NYC Who
Correctly Classified the Weight Categories of the Silhouette Sequences
A, B, and C (U-N-N-N-N-O-O)……………………………………………………… 62
20. Content Validity II: Percentage of Subjects from London and NYC Who
Correctly Classified the Weight Categories of the Silhouette Sequence
A girls –shorts (U-N-N-N-N-O-O)…………………………………………………… 63
21. Content Validity II: Percentage of Subjects from London and NYC Who
Correctly Classified the Weight Categories of the Silhouette Sequence
B Girls – Bodysuits (U-N-N-N-N-O-O)……………………………………………… 64
xv
22. Content Validity II: Percentage of Subjects from London and NYC Who
Correctly Classified the Weight Categories of the Silhouette Sequence
C Boys-Shorts (U-N-N-N-N-O-O)…………………………………………………… 65
23. Cronbach‘s Alpha Findings of Weight Classification of the Silhouettes
from the Samples of London and NYC ……………………………………………… 66
24. Independent Sample t Test Comparing London to NYC Assignment of Weight
Classifications of the Three Silhouettes Sequencing A, B and C…………………….. 67
25. Paired Sample t Test Comparing London Samples
(first and second visits) Assignment of Weight Classification of the Three
Silhouette Sequences A, B and C…………………………………………………….. 68
26. Split Cases from the London and NYC Samples of Perceived Ages
of the Silhouettes……………………………………………………………………… 69
xvi
List of Diagrams
Figures page
1. Conceptual-theoretical-empirical structure for the study……………………. 10
1
Chapter 1- Introduction
Global childhood obesity statistics reveal emerging evidence that there are phenotypes in
children that reflect body composition differences which can lead to health disparities (Misra &
Khurana, 2011). Among South Asian (SA) children, including Bangladeshi, there is a propensity
of a thin fat phenotype of excess adiposity which differs in comparison to other racial and ethnic
groups at given body mass index weight (in kilograms)/height (in meters)2 (BMI) (Bhardwaj &
Misra, 2015; Kurpad, Varadharajan, Aeberli, 2011). This phenotype also termed, metabolically
obese, predispose SA children to a causal link of cardio-metabolic disorders such as
hypertension, dyslipidemia, insulin resistance, and type II diabetes (Misra & Shrivastava, 2013;
Whincup, Nightingale, Owen, Rudnicka, Gibb, McKay, 2010). These cardio- metabolic illnesses
have a chronic trajectory of weight related consequences into adulthood (Bhardwaj & Misra,
2015, Freedman, Katzmarzyk, Dietz, Srinivasan, & Berenson, 2009). A paucity of studies exists
regarding the Bangladeshi mothers’ perceptions of their children’s body sizes. As mothers are
mediators of their children’s preventive health care, the Bangladeshi mothers’ perceptions of
their children’s body sizes can play a critical role in the adaptation of these children to adiposity
risk.
Weight, measured as adiposity or excess body fat can be perceived as an expression of
genetic and environmental adaptation of body size. Mothers’ are very influential in shaping and
modeling an early healthy lifestyle of diet and exercise in their children; hence, the mothers’
perceptions and ability to recognize the problem of increased adiposity in their children is an
important determinant of childhood weight management (De Onis, Blossner & Borghi, 2010).
There is sparse research examining Bangladeshi mothers’ perceptions of the body size of their
children at risk for this thin fat phenotype or excess adiposity. To address this clinical gap, the
2
purpose of this study was to develop and validate an ethnic congruent Bangladeshi Pediatric
Silhouette Scale (BPSS) and a facial feature scale to assess the mothers’ perceptions of their
children’s body sizes, weight categories and facial features. The body figures of the BPSS are a
derivation of Killion (2003) Hispanic and Afro-American Child Body Image Scale (CBIS). The
BPSS will be a facial ethnic congruent instrument to study the Bangladeshi mothers’ perceptions
of their children’s body sizes. The study was conducted in London, England and New York
City, New York (NYC) as each city has an increasing population of Bangladeshi children at risk
for excess adiposity (Hawkins, Cole, Law & the Millennium Cohort Study, 2009; Zilanawala,
Davis-Kean, Nazroo, Sacker, Simonton & Kelly, 2015).
Perception is defined as the construction of an image of one's body size through
observing a figure or silhouette stimuli. Body figures scaled to ethnic congruent silhouettes of
various body sizes have been studied to assess body size perceptions and self-satisfaction of
children and adults with their particular identified body sizes (Barba, Casullo, Russo, Siani, &
ARCA Project Study Group, 2008; Killion, Hughes, Wendt, Pease, & Nicklas, 2006; Mitola,
Papas, Le Fusillo & Black, 2007; Patt, Lane, Finney, Yanek, Becker, 2002). Eckstein, Mikhail,
Ariza, Thompson, Millard & Binns (2006) research findings revealed that using a gender specific
children or child silhouette scale increased the accuracy of parents to select their children’s
weight in order to better adapt the children’s healthy lifestyle. The development and validation
of the BPSS will advance knowledge of Bangladeshi mothers’ perceptions of their children’s
body sizes to facilitate future study in the implications of the thin fat phenotype.
Background
There was an increase in the worldwide prevalence of obesity status in preschool
children from 4.2% in 1990 to 6.7% in 2010 (De Onis, et al., 2010; Haug, Rasmussen, Samdal,
3
Iannotti, Kelly, Borraccino, et al., 2009). Over the past two decades, there has been increasing
childhood overweight and obesity trends in minority groups at early ages in both United
Kingdom (UK) and United States of America (USA). National children’s health surveillance
programs both in UK and USA have focused on interventions to control weight management in
younger children (Hawkins, et al., 2009). An increase in childhood overweight or obesity is of a
particular concern as overweight or obese children are more likely than other children and
adolescents to have risk factors at younger ages (e.g., high blood pressure, insulin resistance, and
type II diabetes mellitus) associated with cardiovascular diseases (Freedman, et al., 2009;
Hawkins, et. al., 2009). In addition, overweight and obese children may become overweight and
obese adults promoting the trajectory of cardiovascular risk (Freedman, et al., 2009; Guo, Wu,
Chumlea, & Roche, 2002).
Among SAs, including Bangladeshi children, an expression of a genetic susceptibility to
higher percentage of body adiposity, specifically central adiposity, and lower skeletal mass are
characteristics of the thin fat or metabolically obese phenotype. This phenotype predisposes
these children to cardio metabolic risk (Bhardwaj & Misra, 2015; Misra, Khurana, Vikram, Goel
& Wasir, 2007). South Asian children, who have BMI in normal weight categories are 14 times
higher than white European children to develop diabetes at younger ages with worse outcomes
than the general population. This diabetic trend in children has been postulated to have a causal
link to this thin fat phenotype (Ehtisham, Crabtree, Clark, Shaw, & Barrett, 2005, Misra &
Khurana, 2011; Misra & Khurana, 2009). Despite these children having increased susceptibility
to a higher body fat percentage, there is no research evidence regarding how mothers perceive
their children’s body size as thin, normal, overweight or obese.
4
Childhood overweight and obesity levels of minority groups remain significant problems
in London, England. In the age category of two-ten year olds, combined weight levels of
overweight and obesity decreased slightly during the periods of 2009-2013. Gender specific data
of boys and girls revealed downward trends of combined weight categories of 29.9% to 26.4%,
and 26.7% to 24.8%. However, these trends remained higher in preschoolers’ of minority
groups, including SAs (Health and Social Care Information Centre, 2013).
In London, specific body compositions of certain children minority groups and rapid
weight gain trajectory in preschoolers were found to be influential factors in Bangladeshi
childhood obesity trends. Children from certain ethnic minority groups, such as Bangladeshi,
were found to be at higher risk of obesity confounded by differences in body composition and
not as strongly linked to obesity as deprivation of social and environmental determinants
(National Obesity Observatory, 2011). Furthermore, Griffiths, Hawkins, Cole, & Dezateux,
Millennium Cohort Study Child Health Group (2010) highlighted that UK pre-school children
were more likely to gain weight rapidly if they had several of the following criteria: a higher than
expected body mass index at age three; if they were of Bangladeshi descent (adjusted odds ratio:
1.88, 95% CI [LL = 1.27, UL = 2.79]) and if their mothers were overweight.
Studies involving ethnic minorities in UK have demonstrated an emerging prevalence of
obesity, higher insulin levels, greater risk of developing HTN, lower level of physical activity,
higher mean total calorie intake, and altered perception to childhood obesity by the parents in SA
populations, with this trend most prevalent in Bangladeshi children (Gatineau & Mathrani, 2011;
Khuntia, Stonea, Bankarta, Sinfielda, Talbot, Farooqi, 2007; Rees, Oliver, Woodman, 2011;
Saxena, Ambler, & Cole, Majeed, 2004). These study findings indicate that the perceptions of
5
Bangladeshi mothers of their pre-school children’s’ body sizes and the mothers’ weight status
would be important to study to establish early childhood obesity prevention programs.
In 2009, England’s National Office of Statistics reported that the British Bangladesh
accounted for 363,000 of the UK population, with a Bangladeshi population of 168,000 living in
greater London. The Bangladeshi population is one of the youngest and fastest growing ethnic
groups in London, with a population aged 25 to 39 compared to London average and they have
the second highest prevalence of obesity by age six. Therefore, an investigation on the
Bangladeshi mothers’ perceptions of their children’s body sizes would be important study using
a cultural tailored BPSS at the early age of preschool.
As in London, the USA reflect similar weight trends in children. Results from the 2011-
2012 United States National Health and Nutritional Examination Survey (NHANES), revealed
the prevalence of obesity in the USA was 34.9% in adults and 16.9% in youth with no significant
change since 2003-2004. In subgroup analyses, the prevalence of obesity among children aged
two to five years decreased from 14% in 2003-2004 to just over eight percent in 2011-2012.
When interpreting these subgroup age analyses for significance, it was reported that the data was
not adjusted for multiple comparisons (Ogden, Carroll, Kit, & Flegal, 2014). In regard to
healthcare economics, the USA welfare costs of hospitalization of overweight and obese
children have tripled over two decades, rising from $35 million in 1979 to 1982 to $127 million
in 1997 to 1999 (Daniels, Jacobson, McCrindle, Eckel, & McHugh, & Sanner, 2009).
Over the past 30 years the prevalence of obesity in the USA has nearly tripled for
children two to five years of age (Daniels, et al., 2009). Additionally, there appears to be a trend
in overweight and obesity of children from a variety of minority racial and ethnic groups in the
USA. One-third of children were reported as either at risk or obese at 9 months of age (31.9%)
6
and at two years of age (34.3%) with Hispanics, Non-Hispanic Blacks and low socioeconomic
status children at greatest risk (Moss & Yeaton, 2011; Zilanawala, et al., 2015). It appears that
children of minority groups illustrate trends toward obesity and these trends are established by
toddlerhood and pre-school ages. Consequently, there is limited USA epidemiological evidence
examining obesity trajectories and the implications of socio-demographics and weight related
problems in SA pre-school children.
Sparse epidemiological data of SA immigrants in New York City (NYC) reveals SA
exhibiting five times the rate of diabetes compared to US born Non-Hispanic Whites (Lee,
Brancati, & Yeh, 2011). Similar to London, NYC has one of the largest populations of
Bangladeshis living in the USA. The Bangladeshi population in NYC increased by 42 percent,
from 34,237 in 2008 to 48,677 in 2011, fastest among the seven largest Asian groups in the city.
New York City is home to 91 percent of New York State’s Bangladeshi residents. Bangladeshis,
the fifth largest Asian group in the city, comprised 4.3 percent of the Asian population, an
increase from 3.4 percent in 2008. Similar to London, the Bangladeshi population in NYC was
younger overall than the general population. The median age of 30.3 years for Bangladeshis was
lower than the 35.5 years for all races (Asian American Federation Census Information Center,
2013; Gupta, Wu, Young, Perlman, 2011). As the Bangladeshi population increases in NYC,
with these prevailing rates of diabetes, the knowledge of Bangladeshi mothers’ perceptions of
their children’s body sizes can direct healthcare providers in developing culturally adapted early
childhood practices of weight management interventions in this community.
As mothers are recognized as the guardians mainly responsible for their children’s health,
the mother’s perception of their children’s body sizes, as under fat, normal fat or over fat is very
important to study (McCarthy, Cole, Fry, Jebb, & Prentice, 2006). A validated BPSS can direct
7
healthcare providers to understand the Bangladeshi mothers’ perceptions of their children’s body
sizes in relation to healthy weight categories.
Problem Statement
The childhood overweight and obese trend is a global health disparity problem that may
not be only influenced by social determinants but also by thin fat phenotypes of genetic and
environmental origins. Obesity or adiposity risk is more common among certain ethnic groups
in London, including those from Bangladeshi (Zilanawala, et. al., 2015). Correlations between
obesity, deprivation and ethnicity are complex as children from White and Asian Mixed groups
are significantly less likely to be obese than the London average because of varied body
compositions. Paradoxically, the body compositions of these ethnicities may pose them at
adiposity risk within normal weight categories. The London Government Health Collaborative,
National Child Measurement Program is focused on reducing these health care disparities of
childhood obesity that may be reflected in varying ethnic body compositions expressed as thin
fat phenotypes (Ridler, Townsend, Dinsdale, Mulhall, & Rutter, 2009). The BPSS can be used
by clinicians to assess the Bangladeshi mothers’ perceptions of their children’s body sizes. This
knowledge can provide future insights into designing culturally tailored Bangladeshi weight
management programs for both mothers and children in London.
During the past two decades, the overarching goals of the United States Department of
Human Services (USDHS) and the Office of Disease Prevention and Health Promotion
(ODPHP) Healthy People’s (HP) public health initiative have focused on health disparities. In
HP 2000 and 2010, the goals were to reduce and eliminate health disparities among Americans.
In HP 2020, that goal was expanded to achieve health equity, eliminate disparities, and improve
the health of all groups including children with obesity risk (USDHS & ODPHP, 2011).
8
Systematic reviews of childhood obesity interventions in ethnically diverse children found
limited obesity intervention studies focused on ethnic minority preschool children (Bender &
Clark, 2011). Therefore, the validation of the BPSS to assess the mothers’ perceptions of their
children’s body sizes at risk for adiposity answers these public health indicators and initiatives to
reduce or eliminate health disparities in the Bangladesh communities.
The United States Department of Health and Human Services (DHHS) (2010) and the
Institute of Medicine (IOM) (2011) has called for more research to identify effective
interventions for ethnic groups at risk for obesity, including young children below the age of
five, with a focus on children’s rate of weight gain and parents’ weight status. Parental
recognition of their child’s weight, as a problem, is the first step in the prevention or intervention
process. Parental perception of their child’s weight is crucial because successful prevention and
treatment of childhood weight problems are linked to parental awareness of the condition and
involvement in subsequent treatment (Doolen, Alpert, & Miller, 2009, & Wald, Ewing, Cluss,
Goldstrohm, Cipriani, Colborn, et al., 2007). A favorable strategy to help reduce childhood
obesity is to introduce healthy behaviors in culturally diverse preschool children at risk for
excess adiposity while their lifestyle behaviors are still developing (Kimbro, Brooks-Gunn, &
McLanahan, 2007). A validated BPSS, an assessment tool, will contribute to the understanding
of how the Bangladeshi mothers’ perceptions of their children’s body size are pivotal to the
trajectory of adiposity risk within this minority group.
Purpose of Study
The purpose of this study was to develop and validate an ethnic congruent Bangladeshi
Pediatric Silhouette Scale (BPSS) and a facial feature scale to assess the mothers’ perceptions of
their children’s body sizes, weight categories and facial features.
9
Conceptual Theoretical Framework
The study was guided by the Roy Adaptation Model (Roy & Andrews, 1999). This
model describes the individual as an adaptive system who interacts constantly with the changing
environment. To adapt to this changing environment, an individual has certain innate and
acquired mechanisms that are biological, psychological, and social in origin. The individual's
adaptive mechanisms assist the individual to cope with the changing environment. The
mechanistic responses that can impact the person’s process of adapting include perception,
cognition, learning, information processing, emotions, and memory (Roy, 2009).
To adapt, individuals may change themselves, their environment, or both. Environment
is viewed as anything external to the organism or external to any subsystems within a system
(Roy & Andrews, 1999). According to Roy, individuals’ responses to environmental stimuli are
processed through information processing which are directed through two coping mechanisms—
the regulator and the cognator. The regulator, which deals with neural, chemical, and endocrine
systems, will not be considered in this study. The cognator, which deals with perceptual and
information processing, learning, judgment, and emotion, will be represented in the study by
perception of the mother, which is defined according to Roy “the interpretation of a sensory
stimulus and the conscious appreciation of it” (Roy, 2009, p.223).
For the purpose of this study, the focal stimulus of interest is the mothers’ perceptions of
the facial features and the children’s body sizes on a validated BPSS. The contextual stimuli
incorporate the effect of the focal stimulus which contributes directly to adaptation, such as, the
demographics: age, education, marital status, and income of the mother (see Figure 1.1).
10
Figure 1 Conceptual-theoretical-empirical structure for the study
Research Question
To address the paucity of research regarding how Bangladeshi mothers perceive the body
sizes of their children and facial features, the research questions were:
1) What is the validity of the Mola Facetool?
2) What is the validity and reliability of the BPSS that measures mothers’ perceptions of
silhouettes from thin to heaviest and body size weight categories?
Assumptions
1) Mothers will have a misperception of their children’s body sizes.
2) Mothers will have a misperception of Bangladeshi children’s weight categories.
3) Mothers will have a misperception of the facial features on the facetool.
11
Limitations
A limitation of this study is that standard children growth curves are mainly based on
Caucasian populations and other minority groups identified by the National Health Service
(NHS) in England, Center for Disease Control (CDC) in the USA, the World Health
Organizations (WHO) and the International Obesity Task Force (IOTF) (McCarthy, 2014).
Another limitation is that only English speaking Bangladeshi mothers and preschool children
ages four-five years old living in London, and New York City were recruited. The researcher is
not a native Bangladeshi and does not speak Bengali or Sylheti. Recruitment of subjects was
limited to financial grant support.
Significance
The significance of this study is the contribution to nursing science and public health in
designing an instrument to assess the Bangladeshi mothers’ perceptions of their children’s body
sizes. The mothers’ perceptions of identifying under, normal and overweight categories of the
silhouettes within the BPSS will also clarify the mothers’ body size perceptions of their
children’s adiposity risk. The BPSS, as an assessment tool, will enrich the health practices that
promote early preventive mother and child healthy lifestyle interventions which are culturally
relevant to the Bangladeshi community.
Conceptual and Operational Definitions
For the purposes of this research study, the following conceptual and operational
definitions were used:
Adiposity is an accumulation of adipose tissue or body fat or fat depot, loose connective tissue
composed of adipocytes which store energy in the form of lipids, although it also cushions and
insulates the body (Kershaw & Flier, 2004).
12
Anthropometric Measurements is the study of the human body composition measurement in
terms of the dimensions of bone, muscle, and adipose (fat) tissue (Fryar, Gu, & Ogden, 2012).
Body size is the picture we form in our mind of our body in the way our body appears to
ourselves (Schilder, 1950, cited in Shontz, 1969). The pediatric body size silhouettes will be
operationally defined as a derivation of Killion (2003) CBIS.
Cardio Metabolic risk and/or syndrome is a constellation of maladaptive cardiovascular,
renal, metabolic, prothrombotic, and inflammatory abnormalities recognized as a disease entity
that increases the risk of diabetes, heart disease or stroke (Castro, El-Atat, McFarlane, Aneja,
Sowers, 2003) .
Mothers’ perceptions according to Roy are “the interpretation of a sensory stimulus and the
conscious appreciation of it” (Roy, 2009, p.223). The mothers’ perceptions were validated
operationally by Bangladeshi mothers as content experts in selecting Bangladeshi children facial
features to be adapted and derived from Killion (2003) CBIS.
Phenotype is defined as an expression from an organism’s genes as well as the influence of
environmental factors and the interactions between the two (Mahner & Kary, 1997).
South Asian Nationality refers to people with ancestral origins in India, Pakistan, Bhutan,
Nepal, Sri Lanka, and Bangladesh. The collective term “South Asian” was recognized as the
heterogeneity of this group and reporting separate results whenever these are available were
documented (Fischbacher, Hunt, & Alexander, 2004). Bangladesh nationality was defined as
people from Bangladesh.
13
Chapter Summary
In this chapter, the researcher has described the significance of the study to develop and
validate an ethnic congruent BPSS as the mothers’ perceptions of their children’s body sizes are
underexplored. Bangladeshi children express a thin fat phenotype which poses a risk in
developing cardio metabolic illnesses at an early age. This study identified a scarcity in
assessment tools available to measure Bangladeshi mothers’ perceptions of their children’s body
sizes. The statement of problem, conceptual and theoretical framework, and statement of
purpose, research question, assumptions, limitations, significance and definitions of terms were
presented. The next chapter will highlight the review of literature to support the importance of
developing and validating this tool.
14
Chapter 2 Review of the Literature
Introduction
This chapter presents the rational for conducting research on the development and
validation of the BPSS with ethnic congruent Bangladeshi facial features. The validation of the
BPSS will mediate mothers’ perceptions of their children’s body sizes in relation to weight
categories. Paradoxically, the Bangladeshi mothers’ perceptions of their children’s body sizes
are confronted by the children’s health risk of excess adiposity expressed by the thin fat
phenotype. The SA children, including Bangladeshi, express differences in body composition,
observed as excess truncal adiposity, which influences the pathogenesis of insulin resistance at
an earlier age and normal levels of BMI (Ehtisham, et al., 2005; Nightingale, Rudnicka, Owen,
Cook and Whincup, 2011; Whincup, et al., 2010). The BPSS is an assessment tool to evaluate
the Bangladeshi mothers’ perceptions of their children’s body sizes and their perceptions of
weight categories classifications in comparison to their children’s body sizes. This knowledge
will be the base for the development of culturally tailored prevention programs of children
weight management in the Bangladeshi community.
The international interest of studying mothers’ perception of their children’s body size
has been captured by numerous studies which have demonstrated that mothers tend to
underestimate their children’s body size in varying weight categories (Abbott, Lee, Stubbs,
Davies, 2010; Al-Qaoud, Al-Shami, Prakash, 2010; Manios, Moschonis, Karatzi, Androutsos,
Chinapaw, Moreno, et al., 2015). Several behavior change models use awareness as the first
approach through health education and promotion or the utility of a decision making tool to
illustrate a health concern that affects an individual or a community (Dietz, Lee, Wechsler,
Malepati & Sherry, 2007). A public health awareness to identify and measure minority groups’
15
cultural perceptions of body sizes can be assessed through ethnic congruent child figure
silhouettes (Killion, et al., 2006). The Bangladeshi mothers’ perceptions of their children’s body
sizes begin with awareness that their children may be at risk for adiposity which can be assessed
by the BPSS.
The thin fat phenotype of SAs and body fat distribution is distinctive in SA adults and
children. South Asians, have propensity for the thin fat phenotype that has attributes of higher
percentage of body adiposity, specifically central adiposity, and lower skeletal mass for a given
BMI. Among SAs, including Bangladeshi, a higher occurrence of cardio metabolic diseases
have been identified in early ages of adulthood and children at lower BMI and waist
circumferences (WC) ranges in the thin fat or metabolically obese phenotype (Kurpad, et al.,
2011). The relationship of this SA phenotype to cardio metabolic illnesses of hypertension
(HTN), dyslipidemia, insulin resistance and type II diabetes mellitus (DM) has led to an
international expert panel consensus to investigate and debate lowering adult and children body
compositions cut off ranges of overweight and obesity classifications (McCarthy, 2014). The
alignment of BMI and WC cut off points of weight classification to lower weight threshold poses
a perception challenge to Bangladeshi mothers because their perceptions of normal body sizes at
acceptable BMIs can still pose adiposity risk and be underestimated. A validated BPSS, an
assessment tool, would allow researchers to understand how Bangladeshi mothers’ perceive their
children’s body sizes as a risk or not for the thin fat phenotype.
The following review of the literature represents pertinent studies to the rationale for this
research study, namely: ethnically congruent pediatric silhouette scales to measure body sizes;
mothers’ perceptions of their children’s body sizes; and implications of the SA thin fat or
metabolically obese phenotype.
16
Ethnically Congruent Pediatric Silhouette Scales
In the study of weight management, ethnic congruent pediatric silhouette scales are
practical, simple, convenient tools that have been adapted to ethnic groups to assess and measure
perceptions and satisfaction of children’s body sizes by parents and children (Killion, et al.,
2006; Kronenfeld, Reba-Harrelson,Von Holle, Reyes, Bulik, 2010; Li, Hu, Ma, Wu, Ma, 2005;
Patt, Lane, Finney, Yanek, & Becker, 2002; Sherwood, Beech, Klesges, Story, Killen,
McDonald, et al., 2004). Criticism of silhouettes scales include cultural insensitivity as
silhouettes have not always been culturally adapted to reflect body shape and facial compositions
across ethnic groups (Patt, et al,2002).
Silhouette scales have limitations compared to multi-dimensional body image and size
scales; however, the ease of silhouette selections and minimal literacy requirements offers a
needed application for community based assessment (Pulvers, Bachand, Nollen, Guo, &
Ahluwalia, 2013). In a study by Eckstein, et al., (2006) it was demonstrated that children’s body
sketches to identify overweight children was more accurately reported when parents used age-
gender-specific stimuli figures to identify their children’s weight in comparison to verbal
reporting.
Mothers’ perception of their children’s body size will be assessed by figure silhouettes of
four-five year-old children developed by Killion (2003) who is a content expert on psychosocial
aspects of body image and childhood obesity. A derivation of Killion’s (2003) CBIS, which
includes Hispanic and Afro-American children figures of four and five year olds, has served as a
model for the development of an assessment tool, the BPSS. Dr. Killion granted the researcher
permission to use the CBIS in this study (personal communications, April 17th, 2012). This
children silhouette rating scale consist of line drawings of children’s’ bodies designed to be age
17
appropriate in appearance, and congruent with facial features of a five year old Hispanic and
Afro-American child.
Killion (2003) child figure silhouettes were based on input from Head Start parents
through interviews. Multiple iterations of the child figures were culled resulting in ethnically
age-appropriate silhouettes for use with African-American and Hispanic mothers. Killion, (2003)
validated four sets of Hispanic and Afro-American gender and ethnic congruent silhouettes. The
final sets of silhouettes consisted of four laminated cards (based on gender and ethnicity)
depicting seven figures of four and five year-old children. A ‘G’ to ‘A’ code, with G assigned
as thinnest, was assigned to each child figure so mothers could identify the chosen figure during
data collection. Reverse coding was done so that sequencing from thinnest to heaviest was less
pronounced. The metric of BMI, using the USA Center of Disease Prevention (CDC) (2000)
children growth reference standards were assigned to each of the gender specific seven child
silhouettes of Killion’s (2003) CBIS.
As part of Killion’s (2003) validation process in developing these figures, two methods
were used to estimate the BMI for each child figure in the set of seven figures. The bodies of the
Killion’s seven child figures were developed by two separate experts; a pediatric nutritional
scientist and a body composition expert who were commissioned to estimate the BMI for each
child figure. An estimation of BMI percentiles CDC (2000) for each child figure at age five by
these two content experts were validated with a Pearson’s correlation of (r = 0.96; p< 0.001).
The process of validation of this CBIS was reported by Killion, et al. (2006) as follows:
“The first expert, a pediatric nutritional scientist, subjectively assigned BMI values for each child figure using the Center for Disease Control’s (CDC) BMI age and gender-specific data for 4 and 5 year-old children (personal communication with N. Butte). The second expert, a body composition scientist, used a different approach by utilizing a volume of cylinders method (personal communication with K. Ellis). This procedure consisted of measuring the arms,
18
legs, and trunk of each child figure, and forming one cylinder by adding each part together to form the total volume. This procedure is similar to the BOMAD model used in Health Physics to calculate radiation doses (Kramer, Burns, & Noel, 1999). BMI for each child figure was then determined by applying the volume to the CDC age-and gender-specific growth charts for 4 and 5 year-old children. To make certain that the calculations by the two experts were similar, a Pearson’s correlation was conducted showing the two ratings to be highly correlated (r =/0.96; p</0.001). The authors decided to use the mathematical calculations for the estimates of BMI for each child figure because of their relative objectivity (Killion, et al., 2006, p. 98).”
A derivation of Killion’s (2003) CBIS lead to the development of a culturally adapted
BPSS tool with ethnically congruent facial features of Bangladeshi children. In Killion’s (2003)
gender set silhouettes scale, the calculated BMI was converted to weight in pounds (see Table 1),
Boys BMI score = weight/1.06.02 = weight (kilogram) x 2.2lbs = weight and the girls BMI
score = weight/1.04.82 = weight (kilogram) x 2.2bs = weight (see Table 2). These children
growth percentiles and BMIs’ were transposed to the BPSS silhouette sequences of A girls with
shorts, B girls with bodysuits, and C boys with shorts (see Appendix D).
Table 1 Weight Calculations and BMI for 5 Year-old Boys Using Butte's Estimation of Percentiles
Boys-Percentile Boys- weight (kilogram)
Boys-weight (pounds) Boys’ BMI
3rd 15.35 33.80 13.66 5th 15.55 34.20 13.84 25th 16.50 36.30 14.69 50th 17.32 38.10 15.42 75th 18.31 40.30 16.30 95th 20.13 44.30 17.92 97th 20.72 45.60 18.44
19
Table 2 Weight Calculations and BMI for 5 Year-old Girls Using Butte's Estimation of Percentiles
Girls Percentile Girls-Weight (kilograms)
Girls- weight (pounds)
Girls’ BMI
3rd 14.65 32.20 13.34 5th 15.20 34.40 13.84 25th 15.79 34.70 14.38 50th 16.64 36.60 15.15 75th 17.73 39.90 16.14 95th 20.05 44.10 18.26 97th 20.86 46.00 19.00
The BPSS will enrich the understanding of how weight categories of normal weight,
overweight and obesity are perceived by Bangladeshi mothers. The findings of this study will
lead to further research in the design and evaluation of ethnically congruent Bangladeshi healthy
lifestyle interventions to promote awareness for childhood health promotion globally.
Mothers’ Perception of their Children’s Body Sizes
Examining the concept of body size, mothers’ perceptions of their children’s weight is
critical, as successful prevention and treatment of childhood weight problems have been linked
to mothers’ perceptions and involvement in their children’s healthy lifestyle habits (Barba, et al.,
2008; Genovesi, Giussani, Faini, Vigorita, Pieruzzi, Strepparava, et al., 2005). Research in the
field of social sciences has hypothesized that body size and image is a multidimensional concept
(Pruzinsky & Cash, 2004). The mothers’ perceptions of their children’s overweight status have
been studied as a key variable in determining the mothers’ readiness to modify the children’s
environment and lifestyle. If a mother perceives that her child’s weight is a problem, she will be
more likely to employ changes regarding the child’s eating habits, attitudes towards food, and
20
assessment of satiety (Patrick & Nicklas, 2005; Rhee; Delago, Arscott-Mills, Mehta, & Davis,
2005).
Studies have been conducted with various racial and ethnic populations to investigate the
mothers’ perceptions concerning weight status, body sizes, and image of their children in relation
to increasing childhood obesity trends. Several studies have demonstrated caregivers’
misperceptions in estimating their children’s weight status. The mothers’ perceptions of their
children’s body sizes has revealed global findings of an underestimation of their children’s body
sizes (Baughcum, Chamberlin, Deeks, Powers, & Whitaker, 2000; Campbell, Williams,
Hampton, & Wake, 2006; Carnell, Edwards, Croker, Boniface & Wardle, 2005; He & Evans
2007; Jeffery, Voss, Metcaff, Alba, &Wilkin, 2005; Manios, Kondaki, Kourlaba, Vasilopoulou,
& Grammatikaki, et al., 2008; Maynard, Galuska, Blanck, & Serdula, 2003; Muhammad, Omar,
Shah, Muthupalaniappen, & Arshad, 2008).
Lundahl, Kidwell and Nelson (2014) performed a meta-analysis of parental estimation of
their children’s weight status. A total of 69 articles (representing 78 samples; n = 15,791) were
included in the overweight/obese weight categories with subjects using Likert scales, pictorial
methods to report their estimation of their children’s weight status. Adjusted effect sizes
revealed that 50.7%, 95% CI [LL = 31.1, UL = 70.2], of parents underestimate their
overweight/obese children’s weight. Pooled effect sizes indicated that 14.3% (95% CI [LL =
11.7, UL = 17.4]) of parents underestimated their child’s normal weight status. Comparable
research is needed in the Bangladeshi community to identify if similar misperceptions of
underestimating their children’s body size is prevalent. A validation of the BPSS will assess the
accuracy of the mothers’ perceptions of their children’s body sizes and weight classifications.
21
Hernandez, Cheng & Serwint (2010) investigated the parental report of child body image
with perceived healthy weight body image in preschoolers and described weight-counseling
preferences. The methodology included parents seeking well-child care who were interviewed
and asked to select images that resembled their own child’s current weight; a healthy weight
preschooler; and friend and family report of a healthy weight preschooler. Parents indicating
that their overweight or obese children resembled a healthy weight image were considered to
misclassify their children’s weight. The statistical analysis used was logistic regression to
identify predictors of misclassification. Card-sorting exercises explored weight-counseling
preferences. Study results revealed that of the 150 preschoolers in the sample, 32.7% (n = 49)
were overweight or obese with misclassification occurring in 71.4% of parents (n = 35). Lack of
pediatrician comment on child weight strongly predicted misclassification (odds ratio, 12.3; 95%
CI [LL = 1.74, UL = 87.2). Conclusions of the study identified weight concentrated counseling
from pediatricians’ influences parental identification of early childhood weight risks. The use of
the BPSS by clinicians can be beneficial to identify accurate Bangladeshi maternal perceptions
of their children’s body sizes in order to direct weight management counseling.
Currently, the literature review identified one study by Hodes, Jones, & Davies (1996)
which investigated cross cultural differences of SA mothers’ perceptions of their children’s body
shape. The study was designed as a mixed method research using descriptive statistics of socio-
demographic data including country of origin of parents and household composition. The
mothers’ attitudes to their children’s body shape were assessed by a visual log of children’s body
images adapted with either Eurasian or African appearances in concordance with ethnicity of the
mother. The figure scale used was the Stunkard, Sorenson, and Schulsinger’s silhouettes (1983).
22
The mothers were asked to score the attributes of the child figures in regard to which
ones were attractive, most healthy and underweight. The sample size consisted of 114 mothers,
of which 22 were Asian of normal BMI category and the children were an average age of 3.9
years with more boys than girls recruited. The children’s average body weight was normal and
did not vary significantly regarding BMI categories or according to mother’s ethnic group. The
SA mothers presented to the pediatric clinic with more worries about their children not gaining
weight and growing (p =.01). Furthermore, the study suggested that SA females may be more
tolerant of plumpness than an English comparison group (Furnham & Alibhai, 1983; Wardle &
Marsland, 1990). Consequently, the SA mothers’ perceptions of their children as underweight,
or their tolerance of their children as overweight can contribute to a health disparity between
body composition and actual weight. The thin fat phenotype can place the Bangladeshi child at
an underestimated adiposity level and heighten their weight related problems of cardio metabolic
risk. Bangladeshi mothers’ may not encourage their children to participate in a corrective and
preventive lifestyle of weight management if they underestimate their children’s weight
categories.
A small number of Asian studies regarding the mothers’ perceptions of children’s body
sizes have been conducted, but without the inclusion of the sub aggregates of SAs. One of the
few Asian studies performed (Boutelle, Fulkerson, Neumark-Sztainer, & Story, 2004),
investigated the accuracy of mothers’ perceptions of adolescents’ weight status using the CDC
BMI weight classifications. Boutelle, et al. (2004) utilized a cross-sectional survey of parent
interviews and surveys of 755 mother-child dyads, of which 17% were Asians, mean age 14.6
years, participating in Project EAT (Eating among Teens). The researchers evaluated that the
mothers’ underestimated their adolescents’ weight (35%), especially if the mother was
23
overweight. Mothers were more likely to overestimate their daughter’s versus their son’s weight
status. In a multivariate logistic regression analyses, race/ethnicity and weight status of the
dyads, and adolescents’ gender were significantly associated with the accuracy of mothers’
perception of the adolescent weight status. Higher rates of accuracy were evident for Asian and
White mothers compared with African-American, Hispanic, and other mothers. Compared with
overweight mothers, non-overweight mothers were significantly more likely to be accurate in
their assessment of adolescent weight status.
The findings of this study report that Asians may perceive the correct weight of their
children. However, SAs may perceive the correct body size of their children, but may not
understand the ramifications of the thin fat phenotype, even though their children may appear to
be at a normal BMI category. The first phase of understanding the Bangladeshi mothers’
perceptions of their children’s body sizes was to develop and validate a BPSS to interpret and
analyze these perceptions.
Implications of the South Asian Thin Fat Phenotype
As a causal link to ancestry, SAs are prone to express the thin fat phenotype. This
phenotype is genetically associated to a higher adiposity percentage, specifically to a central
(truncal or abdominal) adiposity, and a greater risk of low skeletal muscle mass at a lower than
normal BMI weight category (Bhardwaj & Misra, 2015). A phenotype is the composite of an
organism’s observable characteristics or traits: such as its morphology, development,
biochemical or physiological properties. Phenotypes result from the expression of an organism’s
genes as well as the influence of environmental factors and the interactions between the two
(Mahner & Kary, 1997). Consequently, the thin fat phenotype of low muscle mass and increased
central adiposity express a body composition studied in SA adults, adolescent and children. This
24
phenotype contributes to their weight risk of insulin resistance, type II DM and Cardiovascular
disease (CVD) at a higher prevalence than European Caucasians. Thus, disproportionate burden
of diabetes in Bangladeshi community is evident as these men and women are six times more
likely to be diagnosed with diabetes than white Europeans (Ajjan, Carter, Somani, Kain, &
Grant, 2007; Chowdhury, Grace, Kopelman, 2003: Krishnaveni, Hill, Veena, Leary, Saperia, &
Chachyamma, 2005; Misra & Khurana, 2011; Misra & Khurana, 2008; Ruderman, Chisholm, Pi-
Sunye & Schneider, 1998).
The thin fat phenotype poses a health risk to the trajectory of type II DM in SAs with an
onset of prevalence at an earlier age of the SA child than white European children. Children of
SA descent are more likely to manifest a higher magnitude of central and subcutaneous
adiposity, insulin resistance, and metabolic perturbations of cardiovascular risk than Caucasian
children, and are diagnosed with diabetes at younger ages, and may have worse health outcomes
than the general population (Misra & Khurana, 2009).
Childhood adiposity studies have elucidated that SA babies have a greater amount of
body fat, central adiposity and low skeletal muscle mass than Caucasians at similar weights. The
researchers (Krishnaveni, et al., 2005 & Yajnik, Fall, Coyaji, Hirve, Rao, Barker, et al., 2003)
investigated and concluded that SA babies had greater amounts of body fat at similar body sizes
and girth measurements as compared to Caucasians. Yajnik, et al., (2003) designed a
community-based observational study in rural India and demonstrated that small Indian babies
have small abdominal viscera and low muscle mass, but preserve body fat during their
intrauterine development. This thin-fat phenotype illustrates the characteristic body composition
of SA neonates, low birth weight, small abdominal viscera and low muscle mass (thin), but
preserved body fat during intrauterine development, as compared to Caucasian neonates (Yajnik,
25
Lubree, Rege, Naik & Deshpande, 2002). This body composition of thin fat may persist
postnatally, and predispose the child to an insulin-resistant state (Yajnik, et al., 2003).
Krishnaveni, et al., (2005), designed a descriptive cross sectional study and found that
Mysore, Indian newborns were small and thin compared with the Southampton, UK neonates.
However, they had preserved truncal body adiposity expressing a thin fat phenotype. Mysore
babies were lighter and smaller in all body measurements than UK neonates. The deficit was
greatest for mid upper arm, head, abdominal circumferences, and least for length, and
subscapular skinfold thickness. Predictors of skinfold thickness were maternal body mass index,
and socio-economic status. At four years, subscapular skinfold thickness was larger than UK,
and Dutch standards, despite all other body measurements remaining smaller. Predictors of four
year skinfold thickness were neonatal skinfold thickness, and maternal insulin concentrations.
This thin fat phenotype may illustrate adaptation to gene susceptibility and/or the adaptation of
the neonate to the ‘maternal environment’. The researchers concluded that this phenotype
persists to the age of four, and may predispose a diabetic risk to the SA adult phenotype.
The thin fat phenotype can underestimate the perception of adiposity risk in the SA
population. Bangladeshi mothers may not perceive their children’s body size at a weight risk for
cardio metabolic complications such as insulin resistance, abnormal lipids, HTN and type II DM
because their children appear thin or normal weight. Examining mothers’ perceptions will
identify the Bangladeshi children’s with this phenotype and early onset of the weight related
health risk of cardio metabolic illness.
In May 2003, the New York City Department of Health and Mental Hygiene (DOHMH),
and the Department of Education (DOE) conducted a height and weight survey reporting the
BMI in children from all grades from kindergarten through fifth grade. Asian children had the
26
lowest level of obesity among all racial/ethnic groups, at 14.4%, and overweight at 30% (see
Table 3) (Thorpe, List, Marx, May, Steven, Helgerson, et al., 2004). If Asian children are only
measured anthropometrically by BMI to interpret their body composition in the school system,
and not by other anthropometric measures, their higher percentage of body fat, lower skeletal
muscle mass, and their thin fat phenotype may not be perceived and identified accurately. As
Asians and SAs are perceived to have lower rates of overweight and obesity, early optimal
preventive screening and counseling of weight management by healthcare providers to these
populations may not occur. This problem may be compounded, if the SA mothers, including
Bangladeshi, do not perceive their children at risk for obesity related complications if their
children appear to be at normal weight. Furthermore, as 15% of Asian, with a sub aggregate of
SA school children was identified as obese, the trajectory of the prevalence of diabetes among
the Asian community can be expected to increase as these obese children become adults
(Wallach & Rey, 2009).
Table 3 2003 NYC DOHMH & DOE BMI of Overweight versus Obesity Results of Children Ages
Percentage Overall Prevalence
Hispanic Afro American
Caucasian Asian*
Overweight 43 52 39.5 37.9 30.2
Obesity 24 31 22.8 15.9 14.4
*Including South Asians
Body Measurements
Body measurement is vital to analyze secular trends in underweight, normal, overweight,
and obese categories to assess weight related health conditions (Fryar, et al., 2012). Body mass
27
index (BMI) and waist circumferences (WC) are commonly used as surrogate anthropometric
measures of adiposity in clinical and epidemiological studies (Fryar, et al., 2012). These indirect
indicators of body have been instrumental in monitoring the overweight and obesity epidemics in
both children and adults (Ogden, Li, Freedman, Borrud, & Flegal, 2011), as well as linking
obesity status with an increased risk for cardiovascular disease (Freedman, et al., 2009), type II
DM (Meisinger, Döring, Thorand, Heier, Löwel, 2006), and mortality (Bajaj, Brennan,
Hoogwerf, Doshi, & Kashyap, 2009).
The utility of BMI and WC in describing overweight and obesity status depends on the
assumption that anthropometric measures are correlated with more direct measures of adiposity
such as fat mass (FM), subcutaneous adipose tissue (SAT), or visceral adipose tissue (VAT), or
with markers of ectopic fat deposition in skeletal muscles (Camhi, Bray, Bouchard, Greenway,
Johnson, Newton, et. al., 2011). Studies have shown that for the same BMI, the amount of body
fat, regardless of fat depot, is significantly influenced by gender (Demerath, Sun, Rogers, Lee,
Reed, Choh, et al., 2007; Després, Couillard, Gagnon, Bergeron, Leon, Rao, et al., 2000) race,
and ethnicity ( Ehtisham, et al., 2005; Deurenberg, Deurenberg-Yap, & Guricci, 2002; Prentice
& Jebb, 2001). These results suggest that simple anthropometric markers may not identify the
same level of adiposity across different demographic groups. Consequentially, varied body
composition measurements are needed in the analysis of body fat percentage relative to body
weight. A direct and indirect measurement of fat mass or body fat percentage such as the Bio-
electrical Impedance Analysis (BIA) is of value to complement the BMI, and WC surface
measurements (Ehtisham, et al., 2005; Deurenberg, et al., 2002; Prentice & Jebb, 2001).
Body measurements such as BMI, WC, and BIA to measure body fat percentage have
been conducted in comparison studies of children and adults from European, White, Black
28
Caribbean, and SA origins. These studies have revealed that SA, including Bangladeshi children
have higher body fat percentage for a given BMI and low skeletal muscle mass compared with
other racial and ethnic groups; hence, earlier identification and intervention for weight
management may be critical for this population (Lear, Humphries, Kohl, & Birmingham, 2007;
Misra & Khurana, 2008; Razak, Anand, Shannon,Vuksan, Davis, Jacobs, et al., 2007).
Ehtisham, et al. (2005) performed a study design of a cross-sectional cohort with 129
healthy white European and SA 14 to 17 year old adolescents. Body measurements were
assessed by anthropometry and dual-energy x-ray absorptiometry (DEXA), and insulin
sensitivity by homeostasis model assessment. The main outcome measures were body fat
percentage and insulin sensitivity. South Asian adolescents had significantly more body fat than
white European adolescents with more central fat. The gender-ethnic differences in insulin
sensitivity were no longer seen when body fat was included as a covariate. The research
revealed the risk of type II DM in SA children is 14 times higher than white European children
with BMI in normal weight categories (Ehtisham, et al., 2005). In conclusion, ethnic differences
in insulin sensitivity are associated with ethnic differences in body fat. South Asian adolescents
are more insulin resistant, with more body fat than white European adolescents, which may
contribute to their increased risk of developing type II DM (Donin, Nightingale, Owen,
Rudnicka, McNamara, Prynne, et al., 2010).
Griffiths, et al. (2010) documented that the health consequences of the Bangladeshi
children’s rapid weight gain and body composition differs from other race and ethnic groups in
England. The UK Millennium Cohort Study examined risk factors and anthropometry for rapid
weight gain of 11,653 preschoolers’ between three and five years of age using BMI z-scores that
were calculated from three to five years. Children in the top quarter of this distribution were
29
classified as gaining weight rapidly. Among the participants, 13% of normal weight, 63% of
overweight and 88% of obese five-year olds had experienced rapid weight gain since three years
of age. The biological and early life risk factors for this growth pattern included greater BMI z-
score at 3 years of age, Bangladeshi or black ethnicity, and maternal smoking.
A large proportion of children who had rapid weight gain in Griffiths, et al. (2010)
studies between three and five years of age were overweight or obese at age three. This growth
pattern was also strongly related to weight status at age five in which 63% of the overweight
children, and 88% of the obese children, had gained weight rapidly. However, the finding that
Bangladeshi children were almost twice as likely as white children to gain weight rapidly at
younger ages, was not previously reported. The study conclusions revealed a rapid weight gain
in young children; thus, signaling the importance of obesity prevention programs for
Bangladeshi children at an early age. Results from other studies suggest that older SA children
are at increased risk of obesity; therefore, a need to focus on SAs, including Bangladeshis, at
younger age groups for risk of adiposity are needed (Saxena, et al., 2004).
The developmental age curve of the BMI is to decrease from approximately two years of
age until five or six years of age and then to increase in growth velocity after this timeframe.
This initial onset of decrease in BMI reflects a corresponding decrease in subcutaneous fat and
percentage of body fat (Malina, Bouchard, & Bar-Or, 2004). This “adiposity rebound” coincides
with the period between four to seven years of age when the BMI reaches its nadir and then
begins to increase through the remainder of childhood into adulthood (Rolland-Cachera,
Deheeger, Bellisle, Sempe, Guilloud-Bataille & Patois, 1984).
This “adiposity rebound” period between four and seven years of age may be a critical
time frame to analyze the pre-school child’s body fat percentage in regard to overall weight. This
30
adiposity rebound is a critical phenomenon to align the mothers’ perceptions of their four-five
year old children’s body sizes to incorporate healthy lifestyles behaviors during this growth burst
which can set a trajectory for weight related issues. Therefore, as anthropometric measurements
of adiposity differ across demographic groups and growth burst occurs between critical ages of
four-seven, specific anthropometric measurements for SA, including Bangladeshi children are
necessary because of their risk for their thin fat phenotype.
Asian Body Measurements Indices Cut-off Points
Emerging evidence suggests that SA adults and children are at risk of developing obesity
related type II DM and HTN at lower levels of BMI and WC compared to the international BMI
conventional classifications of overweight and obese guidelines (Bhardwaj & Misra, 2015; Jafar,
Chaturvedi & Pappas, 2006; Kurpad, et al., 2011). As SAs, including Bangladeshi, have higher
body fat at a given value of BMI than white Caucasians (i.e. <25.0kg/m2), the scientific
community has deliberated on whether BMI cut-offs for diagnosis of overweight and obesity
should be lower for Asian populations (Gupta, & Brister, 2006; Jafar, et al., 2006, Lear, et al.,
2007; Low, Chin, Ma, Heng, & Deurenberg-Yap, 2009).
In 2004, a WHO Expert Consultative Committee, formulated a consensus statement to
lower the BMI thresholds for defining overweight at a BMI = 23 and obesity BMI = 25 in SA
adults. For many Asian countries, the trigger points for public health actions are identified in
(see table 4).
31
Table 4 WHO Expert Consultations (2004) BMI Cut-Offs of Overweight and Obesity for Asians (Kg/m2)
Increasing BMI Risk Increased BMI Risk High BMI Risk
But Acceptable
18.5-23 or higher 23 or higher 27.5 or higher
Ordinarily, the WHO BMI classifications of overweight and obesity are intended for
international use. The WHO expert consultants made no attempt to redefine BMI cut-off points
for each population separately; consequently, they left the decision for guidelines for BMI
classification of risk to the governments of respective Asian countries. The intent of the WHO
experts was to impart public health surveillance references along a continuum of BMI for
countries to study and identify their populations at risk with these BMI classifications (WHO
Expert Consultation, 2004).
Viner, Cole, Fry, Gupta, Kinra, McCarthy, et al. (2010) reviewed children overweight
and obesity BMI thresholds in relation to differences in body composition among various ethnic
groups, including SAs, in the UK. Viner, et al. (2010) reviewed British population studies with
large samples of SAs and concluded that the current International Obesity Task Force (IOTF)
definition for childhood obesity remained as the standard reference for use in the UK. Viner, et
al. (2010) summarized that the IOTF obesity definition did not misclassify children from SA
ethnicities to any substantial level. Waist circumferences cut offs for children and adolescents
are gender specific (McCarthy & Samani-Radia, 2013) and additional adjustment for age is
required because of physiological growth and development. Children WC cut-off values are
presented as percentiles similar to the ≥85th percentile of the body mass index (BMI) considered
for overweight which can be transformed using special growth charts (Wang, Thornton, Bari,
32
Williamson, Gallagher, Heymsfield, et al., 2003). The BPSS will add further analysis of the
application of these SA BMI cut off points as a greater understanding of the Bangladeshi
mothers’ perceptions of their children’s body sizes.
Chapter Summary
This chapter describes the review of the literature where the researcher found the paucity
of research related to the Bangladeshi mothers’ perceptions of their children’s body sizes and
their children’s adiposity risk of the thin fat phenotype. The creation and development of the
BPSS was envisioned as an ethnic congruent body size scale that will be used in Bangladesh
populations to determine the accuracy of the mothers’ perceptions of their children’s body sizes.
The topics to support the development and validation of the BPSS included studies of an
ethnically congruent pediatric silhouette scale to measure body sizes, mothers’ perceptions of
children’s body sizes, and the implications of SA thin fat phenotype and body composition.
Lastly, a review of the Asian BMI and WC Cut-off Points were highlighted to address the risk of
underestimation of adiposity in the SA community using anthropometric measurements. The
next chapter will highlight the methodology of the BPSS instrument development and validation.
33
Chapter 3 Methodology
The purpose of this study was to develop and validate an ethnic congruent Bangladeshi
Pediatric Silhouette Scale (BPSS) and a facial feature scale to assess the mothers’ perceptions of
their children’s body sizes, weight classifications and facial features. This chapter presents the
explanations of the research design, sampling, setting, data collection protocol, instrumentation
development and statistical testing.
Research Design
This study was a quantitative descriptive design with scale content validation that was
initiated in July 2013 after obtaining the institutional review boards permissions in London and
NYC. Then recruitment of subjects was initiated with data collection. This study was composed
of three phases.
Sample
A convenience sample of 17 Bangladeshi mothers and children were recruited through
Bangladeshi community service agencies with the assistance from a community health worker in
London. Other referral sources included Bangladeshi mothers’ groups, personal references and
London primary schools.
The New York City subjects were recruited from four boroughs (Bronx, Manhattan, Queens
and Brooklyn). There were a total of 12 mothers and children recruited in NYC.
The inclusion criteria for the Bangladeshi mothers were the following:
1 self-identification of parents from Bangladeshi descent
2 mothers ability to provide informed consent to be a research subject; ability to speak and
understand English
34
3 mothers between 25 to 40 years of age and being at least 20 years of age at the time of the
delivery of her first child
4 a mother of a biological child between the ages of four and five years
5 not pregnant at time of the study participation
6 primary caregiver of the child study participant
The inclusion criteria for Bangladeshi children were the following:
1. children ages of four and five and ability to speak and understand English.
2. healthy children with no acute or chronic illnesses and not treated with medications
which can alter the children's growth and development; no history of any illness or injury
requiring immobilization of the lower limbs in the previous six months;
3. no children who had been ill two weeks preceding the study or who are undergoing
special physical training that might alter growth and development.
Socio-demographic variables, relevant in the literature when analyzing mothers’
perceptions of their children’s body sizes were included in the socio-demographic survey
(Appendix A).
Settings
The sample population was recruited in London and NYC in community based centers
that did not provide medical care.
Protection of Human Subjects
The study protocol was approved by the research Institutional Review Boards of the City
University of New York (CUNY) (Appendix B), and the London Metropolitan University
(LMU) (Appendix C) for the protection of the human subjects. All identifying information was
removed from the subject’s selection of the child silhouettes and each one was given a unique
35
code. The key for the coded instruments was kept in a locked cabinet and only the principle
investigator (PI) has access to the cabinet. The key for the coded instruments was locked in a
cabinet and only the PI had access to the cabinet. The PI completed the Collaborative
Institutional Training Initiative (CITI) program.
Data Collection Procedures
Phase One
Scale Development
Prior to the start of the study, a graphic designer sketched four-five year old Bangladeshi
facial features of Bangladeshi children faces from illustrations of SA’s children books. The
graphic designer applied her illustrations of the SA four--five year old faces to the seven bodies
of the girls and boys child figures wearing tops and shorts derived from Killion’s (2003) CBIS
from thinnest to heaviest (G-A). After the researcher review of initial silhouette drawings of
girls with tops and shorts, the researcher elected to have an addition of a second sequence of the
seven girls’ silhouettes with body suits to make it more of a cultural sensitive instrument. The
graphic designer illustrated each gender set with the following features, girls sequences A scale
(shorts) and B scale (bodysuits) and boys sequence C scale (shorts) with the applied ethnic
specific SA facial features from children books.
The graphic designer then sketched a gender set of seven categories of facial features
resembling SA children. Each of the facial feature categories were drawn on individual pages
including: hair length selections of (average, short, and long); hairline selections (average,
forward, receded); shape of face selections (round, heart shaped, square, oval); eyebrow
selections (average, thin, thick); eyes selections (average, wide-set, deep set, and close set); nose
selections (average, narrow and wide); and lip selections (average, thin, and full). The facial
36
feature scale had 23 questions for each gender to measure the Bangladeshi mothers’ agreement
for each question. Each question had a Likert scale rating of one defined as strongly disagree to
five identified as strongly agree. This tool will be referred as the Mola Facetool for this study.
In the development of the BPSS, a derivation of Killion’s (2003) CBIS was used by
applying the children’s CDC (2000) BMIs assignments to the gender set of the three silhouette
sequences. The Bangladeshi mothers’ assignment of weight categories of underweight, normal
and overweight of the BPSS silhouettes were compared to the assigned CDC (2000) BMIs of
Killion’s seven child figures. As per Dr. Lorraine Killion (personal communication, March 6th,
2015) the applied sequence of weight classifications, underweight (U), normal weight (N) and
overweight (O) to the BMI assignments of each silhouette for the gender set of the three
silhouette sequences was appropriately sequenced as G-F-E-D-C-B-A matched to the sequence
U-N-N-N-N-O-O assignments (Appendix D).
This U-N-N-N-N-O-O assignments for each silhouette for each of the three silhouette
sequences A, B, and C were given varying point scores, one for correct answer if weight
classification matched assigned BMI and zero or minus one if not correct match (Appendix D).
This point score was designed to have a slightly greater risk if mothers assigned incorrect weight
classes to normal BMI to examine the mothers’ perceptions in relation to adiposity risk of the
thin fat phenotype, Asian BMI cut off points or general weight misclassifications (Bhardwaj &
Misra, 2015; Kurpad, et al., 2011).
London- Phase Two-A
Approved research flyers by the LMU and CUNY were distributed to Bangladeshi
community based organizations and London primary schools (preschooler four-five years of age)
with populations of Bangladeshi children. When the subjects were identified by the community
37
health outreach workers or personal references, and the mothers agreed to participate, the
researcher was contacted by email or phone. The researcher then contacted the subjects to
further explain the study criteria. The phase two A of the study in London included 1 hour
interview with 8 dyads of Bangladeshi mothers with their four-five year old children. At the one
interview, the mothers received a $20 for travel and $20 for a child gift for participating. The
$20 payment for each mother and each child was converted to London currency at the market
conversion rate of USA dollars to London pounds (£) rate for the week which equaled £12.50 for
each mother and child. The total payment for the one interview visits for the dyad was £25.
The study protocol was the following:
1. The researcher obtained IRB informed consent from the subjects (mothers) to consent
themselves and their four-five year children.
2. The dyad subjects (mother/child) per study inclusion participated in one encounter
averaging 1 hour. Mothers completed a demographic survey (Appendix A). Decimal age
of the children was calculated from the date of birth to the study interview day.
3. The child silhouettes were identified on seven cards from G to A (thinnest to
heaviest). The bottoms of the cards were folded down so mothers could not see the
letters. A ‘G’ to ‘A’ code was assigned to each child figure so mothers could identify the
chosen figure during data collection. Reverse coding was done so that sequencing from
thinnest to heaviest was less pronounced. The researcher randomly ordered the child
silhouettes in each of the sequences and secured each group of A, B, and C sequences
with a clip and placed them into sealed envelopes. Mothers were asked to open up an
envelope with three sequences of children silhouettes of girls (sequence A), girls
(sequence B) and boys (sequence C). Mothers’ were instructed to “please remove the
38
cards from the envelope and arrange them in a progression with the first card representing
the thinnest child and the last card representing the heaviest child.”
4. The mothers were instructed to assign a weight category of underweight, normal
weight and overweight to each of the figures from left to right.
5. The mothers were given the Mola Facetool and instructed to review the seven facial
features categories of girls and boys. The mothers were instructed to circle the drawing
of each of facial features that most resembled the facial feature of a Bangladeshi girl and
boy. There were 23 questions of each gender facial features that the mothers were asked
to select a Likert score from one strongly disagree to five strongly agree for each of the
facial feature questions.
6. The mothers were asked to complete the two cultural congruent general questions:
a. What is the age of the children figures on the cards from the age selections
three-six and score each age on the Likert scale?
b. Do you prefer the shorts or bodysuits on the girls?
London- Phase Two-B
Phase Two-B of the study in London included nine dyads of Bangladeshi mothers with
their four-five year children. The dyads participated in two interview visits. Each visit was a
one hour interview, three days apart, completing the same research protocol as in Phase One with
the exception of the subject participation payment. Subjects did not receive study payment after
the first interview, as they were informed that they would receive $80.00 on the second
encounter for each mother and child to increase adherence to attend the second interview. The
$80 which was converted to London currency at the market conversion rate of USA dollars to
39
London pounds which equaled £25 for each mother and each child. The total payment for two
interview visits for the dyad was £50.
New York City- Phase Three
The identical study protocol as Phase One in London, England was conducted in NYC.
The IRB Approved CUNY research flyer was distributed to Bangladeshi community based
organizations, personal references and family medical practices. When the subjects were
identified by the community health outreach worker or personal references, the researcher was
contacted via email or phone. Phase three of the study in NYC included a one hour interview
with 12 dyads of Bangladeshi mothers with their four-five year old children.
At the end of the three phases and data analyses the researcher provided the graphic
designer the facial feature selections for the girls and boys. The graphic designer applied these
facial categories to the children silhouettes of the BPSS, sequences A, B and C as a final version.
Data Analyses
The data analyses of the socio demographics, Mola Facetool and the BPSS validation was
comprised of comparing selected variables by the use of descriptive statistics, scale reliability
statistics using the Cronbach alpha coefficient correlations. Further statistical testing of London
and NYC samples included inter and intra-rater observer correlations using the independent
sample t test and paired t test. All data analyses were performed using Statistical Program Social
Sciences (SPSS)® version 22 software.
The socio-demographic variables of the genders of mothers and children, ages of mothers
and children, birthplace of mothers, number of years living in current city, educational
background, mothers’ marital status, mothers’ age of first child, family income, primary
40
caregiver of child were analyzed by descriptive statistics measures of frequencies, means, and
standard deviations (SD).
The 23 question items of each gender set of the Mola Facetool variables included all of
the following facial feature categories (hair, hairline, faces, eyebrows, eyes, nose and lips). The
facial features were analyzed by descriptive statistics measures of means, SD and total
percentage of the subjects from London and NYC that scored a value of one-five on a Likert
scale for each question item. The means of each 23 question items for the gender set were
transformed through added computations of each mean item for a total score of each facial
feature category and then analyzed by the independent sample t test statistic. This analysis of the
independent t test examined the statistical significance of the facial feature categories.
Scale content validation of the BPSS was determined by the following; (1) two forms of
content validity which included agreement about the ordering and weight classification of the
silhouettes by content experts of Bangladeshi mothers in London and NYC; (2) inter and intra-
rater reliability; (3) an assessment of the agreement of the silhouette child figures age and
preference of the girls silhouettes in shorts or bodysuits.
The BPSS content validity was tested by ordering the silhouettes from thinnest to
heaviest. Descriptive statistics measured the percentages of subjects that ordered the silhouette
sequences A, B and C correctly. Content validity analysis was performed on the ordering of the
silhouettes sequences of A, B and C from thinnest to heaviest using scale reliability which
included inter-rater reliability of Cronbach’s alpha coefficient. The scale reliability of the
Cronbach’s alpha coefficient was performed on all three silhouette sequences A, B, and C within
the sample groups of the London and NYC total 29 subjects that had only one interview visit; the
inter-rater reliability group of the 17 London subjects; and the inter-rater reliability group of
41
NYC 12 subjects. An independent sample t test and paired t test was also performed on the
inter-rater reliability group of the London and NYC total sample of 29 subjects that had only one
interview and intra-rater reliability group of the nine London subjects that had two interview
visit.
The BPSS content validity was then tested by inter and intra-rater reliability by the
subjects classifying the weight status (underweight, normal weight and underweight) of the three
silhouette sequences A, B and C using descriptive statistics measures of frequencies and
percentages of subjects that classified the weight status correctly. Additional data analyses was
performed on classifying sequences of A, B, C weight status correctly using the scale reliability
statistics of Cronbach’s alpha coefficient. The scale reliability of the Cronbach’s alpha
coefficient was performed on the three silhouette sequencing A, B, and C on inter-rater reliability
group of the London and NYC total 29 subjects that had only one interview visit; the inter-rater
reliability group of the 17 London subjects; the inter-rater reliability group of NYC 12 subjects
and the intra-rater reliability group of the nine London subjects that had two interview visits. An
independent t test was also performed on inter rater reliability group of the London and NYC
total 29 subjects that had only one interview and the intra- rater reliability group of the nine
London subjects that had two interview visits.
Chapter Summary
This chapter presented a description of the design of the study using methodology for the
instrument development of the Mola Facetool and BPSS. The research design was a quantitative
descriptive design with scale content validation. The sample, setting, methodology and data
analyses were explained. The methodology employed to test the two research questions of the
Mola Facetool and BPSS validation included comparing selected variables through descriptive
42
statistics, scale reliability statistics using the Cronbach alpha coefficient and correlations. The
London and NYC samples were further analyzed by inter and intra-rater observer correlations
using the independent sample t test and paired t test comparison.
43
Chapter 4 Presentation and Analysis of Data
Introduction
This chapter presents the data analyses for the two stated research questions. The
purpose of this study was to develop and validate an ethnic congruent Bangladeshi Pediatric
Silhouette Scale (BPSS) and a facial feature scale to assess the mothers’ perceptions of their
children’s body sizes, weight classifications and facial features.
Descriptive Statistics
Sample
The socio-demographics of the sample cohort of 17 mothers in London, England and 12
mothers in NYC revealed similar but varying trends. Statistical analyses were undertaken using
SPSS® version 22 software. Descriptive characteristics of the sample were calculated and
presented in (see Tables 5 and 6). Descriptive statistics measured socio-demographic data for
the general description of the study population means, standard deviations and ranges are
presented for continuous variables. Percentages were calculated and presented for categorical
variables.
All the mothers were married and the primary care givers of their children. Seventy-nine
percent of the samples were born in Bangladesh, 21% were born in London and no subjects were
born in NYC. The subjects in both countries were of similar ages (M = 32.97, SD = 4.75). The
mean of age of mothers in London was similar (M = 32.35, SD =4.75) compared to NYC
(M = 33.83, SD = 4.17). The London sample migration status revealed a higher mean of years of
migration (M = 22.59, SD = 12.47) in comparison to NYC sample (M = 7.38, SD = 3.14). The
NYC sample had greater years of education (M = 14.38, SD = 2.15) versus London cohort
(M = 13.59, SD = 3.14). The education years were calculated with a base of 12 years equivalent
44
to 4 years of high school education. The mean age of the London Bangladeshi mothers having
their first child was younger (M = 21.62, SD = 2.69) compared to NYC (M = 25.50, SD = 4.98).
The children’s mean birth order (n = 28, missing one) was approximately two from both cities.
The children socio-demographic characteristics revealed the London subjects had a mean age of
5.14 years (SD = 0.58) in comparison the NYC children mean age of 4.78 years (SD = 0.66).
The mothers reported that their children, ages four-five were healthy with no acute or chronic
illnesses and not treated with medications for any illnesses. They also reported that their four-
five year old child had not suffered injuries requiring immobilization of the lower limbs in the
previous six months and had not been ill two weeks preceding the study or undergoing special
physical training that might alter growth and development.
45
Table 5 Socio- demographic Characteristics of Frequencies and Percentages of the Samples from London and NYC Demographic characteristics-Mothers N
London
NYC
Total
ƒ % ƒ % ƒ %
Gender Females
29 17
12
29 100
Birthplace Born in the Bangladesh Born in London Born in the NYC
29 11 6 0
12 0 0
23 6 0
79 21 0
Marital Status Single Married Divorced/Separated Widowed
29 0 17 0 0
0 12 0 0
0 29 0 0
0
100 0 0
Does your family income cover your daily expenses (food, shelter, clothes, education and healthcare)
Yes No
29
12 5
12
24 5
82 17
Who is the primary caregiver of the child being measured? Mother
29 17
(mothers)
12
(mothers)
29
(mothers)
Children Demographics 29 17 12 29 100 Gender Male Female
29
6 11
8 4
14 15
48 52
46
Table 6 Socio-demographic Characteristics of Means and Standard Deviations of the Samples from London and NYC Demographic characteristics-Mothers N
London
NYC
Total
SD SD SD
Age 29 32.35 4.75 3.83
4.17
32.97 4.50
Number of Years Living in current city and mean total for living outside of Bangladesh
29 22.59 2.47 7.38 3.41 16.29 12.31
Educational background
29 13.59 3.14 14.58 2.15 14.00 2.77
How old were you when you had your first child?
29 21.62 2.69 25.52 4.98 23.48 4.35
Number birth order of child Included in the study
29 2.19 .981 1.62 .492 1.96 .838
Children Demographics 29
Age/years
29
5.14
. 0.58
4.78
0.66
4.98
0.60
Testing the Research Questions
Research Question 1
Scale validation
Descriptive statistics and parametric tests of the independent sample t test were used to
investigate the following research question: What is the validity of the Mola Facetool?
X X X
47
The scale validity of the Mola Facetool was measured using descriptive statistics, content
validity with inferential statistics to describe and analyze the data of the subjects’ selections of
gender set facial features of a Bangladeshi children four-five year old. Twenty-nine Bangladeshi
mothers of four-five year olds were the experts identified who evaluated the content validity of
the new scale. Content validity of the Mola Facetool was comprised of seven categories of
variables (hair, hairline, faces, eyebrows, eyes, nose and lips) with 23 questions items for the
facial categories for each gender set. The means of each 23 question items for each gender were
transformed through added computations of each mean item for a total score of each facial
feature category. The total sample of 29 were then analyzed by the independent sample t test
statistic to evaluate inter-rater reliability, the consistency among the ratings by the subjects (Polit
& Beck, 2012). This analysis examined the statistical significance and difference of each facial
feature category.
Mola Facetool girls’ features
There were seven facial features categories; hair (three questions), hairline (three
questions), face (four questions), eyebrows (three questions), eyes (four questions), nose (three
questions) and lips (three questions) for a total of 23 questions. The data was analyzed using
descriptive statistics and the independent sample t test to analyze the facial feature preferences
and differences between London and NYC subjects with one visit (see Table 4.3). The
independent sample t test, can answer research questions analyzing if groups differ on an
outcome measure and are a normally distributed sample (Munro, 2005).
The descriptive analyses revealed that the facial features of hair (average) (M = 3.51, SD
= 1.27) and percentage of 48.30% of selection preference was trending close to the hair variable
(long) at mean (M = 3.51, SD =1.35) with a selection preference of both countries at 44.80%.
48
The descriptive statistics of the hairline (average) revealed the highest mean (M = 3.72, SD =
1.22) and a percentage of 58.60%, from both countries. The analysis of the face variable (oval)
revealed the highest mean (M = 4.06, SD = 0.96) and a percentage of 58.60%, from both
countries. The analysis of the eyebrows (average), revealed the highest mean (M = 3.89, SD =
1.26) and a percentage of 65.50% from both countries. The analysis of the eyes (average)
revealed the highest mean (M = 4.00, SD = 1.28) and a percentage of 65.50% from both
countries. The analysis of the nose (average), revealed the highest mean (M = 3.89, SD = 1.23)
and a percentage of 69.00% from both countries. The analysis of the lips (average) revealed the
highest mean (M = 3.89, SD = 1.14) and a percentage of 44.80%, from both countries (see Table
7).
The descriptive statistics of the facial features question items demonstrated that the
selections hairline (average), face (oval), eyebrows (average), eyes (average), nose (average),
and lips (average) revealed the highest means and percent selections from both countries for each
facial category.
49
Table 7 Descriptive Statistical Analyses of the Mola Facetool Girls’ Facial Features
Facial Feature Items
Question (Q)
Likert Scale 1-5 Total Percent of
London & NYC
SD
Hair Q-1 (Average) 3.51 !1.27 48.30%
Q-2 (Short) 2.31! 1.16 6.90%
Q-3 (Long) 3.51! 1.35 44.80%
Hairline Q-1 (Average) 3.72! 1.22 58.60%
Q-2 (Forward) 3.17! 1.25 24.10%
Q-3 (Receded) 2.51! 1.37 17.20%
Face Q-1 (Round) 3.51! 1.18 34.50%
Q-2 (Heart Shaped) 2.65! 1.07 6.90%
Q-3 (Square) 1.93! 0.99 0.00%
Q-4 (Oval) 4.06! 0.96 58.60%
Eyebrows Q-1 (Average) 3.89! 1.26 65.50%
Q-2 (Thin) 2.58! 1.37 17.20%
Q-3 (Thick) 2.68! 1.19 17.20%
Eyes Q-1 (Average) 4.00 1.28 65.50%
Q-2 (Wide Set) 3.10 1.26 24.10%
Q-3 (Deep Set) 2.13 0.99 3.40%
Q-4 (Close Set) 2.20 1.14 6.90%
Nose Q-1 (Average) 3.89! 1.23 69.00%
Q-2 (Narrow) 3.44! 1.18 31.00%
Q-3 (Wide) 1.86! 0.87 0.00%
Lip Q-1 (Average) 3.89! 1.14 44.80%
Q-2 (Thin) 3.24! 1.18 37.90%
Q-3 (Full) 2.68! 1.25 17.20%
The independent sample t test answered the research question one by analyzing if the
London and NYC samples with one interview visit differed consensus on the girls’ seven facial
X
50
categories. The means of each 23 question items for each gender were transformed through
added computations of each mean item for a total score of each facial feature category and then
analyzed by the independent sample t test statistic. This analysis examined the significance of
each of the facial feature categories. The researcher determined that the six of the seven girls’
facial features did not demonstrate statistical significance; hence, there was a preference
consensus in the six girls’ facial features of both countries (see Table 8). The hair variable
revealed a significant difference between London (M = 8.82) and NYC (M = 10.08) conditions
t (27) = -2.42, p = .02.
Table 8 Independent t Test Comparing London to NYC Girls’ Facial Features
Variable N df t p Hair London NYC
17 12
8.82 10.08
27 -2.42 .022
Hairline London NYC
17 12
9.23 9.66
27 -.757 .456
Face London NYC
17 12
12.35 11.92
27 .593 .558
Eyebrow London NYC
17 12
8.76 9.75
27 -1.58 .124
Eyes London NYC
17 12
11.47 11.42
27 .071 .944
Nose London NYC
17 12
9.17 9.25
27
-.117
.908
Lips London NYC
17 12
9.58 10.17
27 -1.03
.312
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Mola Facetool boys’ facial features
There are seven facial features categories; hair (three questions), hairline (three
questions), face (four questions), eyebrows (three questions), eyes (four questions), nose (three
questions) and lips (three questions) for a total of 23 questions. The data was analyzed using
descriptive statistics, and the independent t test to analyze the facial feature preferences and
differences between London and NYC subjects with one visit.
The descriptive analyses revealed that the facial features of hair (short) was the highest
mean (M = 3.97, SD = 1.21) with a percentage of 55.20% of selection preference of both
countries. The descriptive statistics of the hairline (average) revealed the highest mean
(M = 3.62, SD = 1.39) and a percentage of 55.20% from both countries. The analyses of the face
variable (oval) revealed the highest mean (M = 3.69, SD = 1.31) and a percentage of 44.80%
from both countries. The analyses of the eyebrows (average), revealed the highest mean
(M = 4.31, SD = 1.03) and a percentage of 79.30% from both countries. The analyses of the eyes
(average), revealed the highest mean (M = 4.41, SD = 0.78) and a percentage of 86.20% from
both countries. The analyses of the nose (average), revealed the highest mean (M = 3.97, SD =
1.18) and a percentage of 65.50% from both countries. The analyses of the lips (average)
revealed the highest mean (M = 3.97, SD = 1.18) and a percentage of 65.50% from both
countries (see Table 9).
The descriptive statistics of the facial features question items demonstrated that the
selections of hair (short), hairline (average), face (oval), eyebrows (average), eyes (average),
nose (average), and lips (average) revealed the highest means and percent selections from both
countries for each facial category.
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Table 9 Descriptive Statistical Analyses of the Mola Facetool Boys’ Facial Features
Facial Feature Items
Question (Q)
Likert Scale 1-5 Total Percent of
London & NYC
SD
Hair Q-1 (Average) 3.17 ! 1.22 34.50%
Q-2 (Short) 3.97 ! 1.21 55.20%
Q-3 (Long) 2.34 ! 1.26 10.30%
Hairline Q-1 (Average) 3.62 ! 1.39 55.20%
Q-2 (Forward) 2.83 ! 1.25 20.70%
Q-3 (Receded) 2.76 ! 1.45 24.10%
Face Q-1 (Round) 3.55 ! 1.29 34.50%
Q-2 (Heart Shaped) 2.69 ! 1.31 17.20%
Q-3 (Square) 1.97 ! 0.94 3.40%
Q-4 (Oval) 3.69 ! 1.31 44.80%
Eyebrows Q-1 (Average) 4.31 ! 1.03 79.30%
Q-2 (Thin) 2.28 ! 0.96 3.40%
Q-3 (Thick) 2.76 ! 1.27 17.20%
Eyes Q-1 (Average) 4.41 ! 0.78 86.20%
Q-2 (Wide Set) 2.66 ! 1.11 3.40%
Q-3 (Deep Set) 2.21! 1.08 3.40%
Q-4 (Close Set) 2.48 ! 1.15 6.90%
Nose Q-1 (Average) 3.97 ! 1.18 65.50%
Q-2 (Narrow) 3.31! 1.13 27.60%
Q-3 (Wide) 1.79! 1.04 6.90%
Lip Q-1 (Average) 3.83! 1.19 62.10%
Q-2 (Thin) 2.76 ! 1.15 17.20%
Q-3 (Full) 2.76.! 1.40 20.70%
The independent sample t test answered the research question one by analyzing if the
London and NYC samples with one interview visit differed on the boys’ seven facial categories.
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53
The means of each 23 question items for each gender were transformed through added
computations of each mean item for a total score of each facial feature variable category and then
statistically analyzed by using the independent sample t test. These analyses examined the
differences of each of the facial feature categories. The researcher determined that seven of the
boys’ facial features did not demonstrate statistical significance; hence, there was a preference
consensus in the seven boys’ facial features categories of both countries (see Table 10).
Table 10 Independent t Test Comparing London to NYC Boys’ Facial Features
Variable N df t p Hair London NYC
17 12
9.64 9.25
27 .627 .536
Hairline London NYC
17 12
9.25 8.58
27 2.02 .054
Face London NYC
17 12
12.00 11.75
27 .328 .745
Eyebrow London NYC
17 12
9.00 9.85
27 -1.82 .079
Eyes London NYC
17 12
11.29 12.41
27 -1.40 .173
Nose London NYC
17 12
9.00 9.16
27 -.340 .737
Lips British NYC
17 12
9.17 9.58
27 -.693 .494
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Research Question 2
Scale validation
Descriptive statistics and parametric tests of the Independent sample t test and paired t
test were used to investigate the second research question: What is validity and reliability of the
BPSS to measure the mothers’ perceptions of silhouettes figures from thin to heaviest and body
size weight categories? Scale validity was investigated by two forms of content validity,
assessment of the objectivity of age and silhouette outfit for the girls, and inter and intra rater
reliability statistics.
Scale validation was determined by the following; (1) two forms of content validity
which included agreement about the ordering and weight classification of the silhouettes by
content experts of Bangladeshi mothers in London and NYC; (2) assessment of the agreement of
the silhouette child figures’ age and silhouette outfits for the girls (shorts versus bodysuits); (3)
an inter and intra-rater reliability statistics.
Content validity
The first scale validation of the BPSS was accomplished by the mothers ordering the
three sequences of the silhouettes comprised of girls with top and shorts (sequence A), girls with
bodysuits (sequence B) and boys with tops and shorts (sequence C) silhouettes from thinnest to
heaviest. The first analysis of the content validity was the percentage of correct ordering of the
silhouettes by a point system of all correct ordering of the silhouettes equals one point and
incorrect ordering equals zero (see Table 11). Subjects had to correctly order all the silhouettes
to receive one point for their total score. If subjects misclassified any of the silhouettes they
received a zero score. The London (n = 17) sample had a larger percentage of ordering the boys
silhouettes correctly than the two girls sequences. The NYC sample had a higher percentage of
55
sequence A girls with shorts than the other two silhouette sequence. Both London and NYC
samples with one interview visit had a higher percentage ordering the sequence A girls with
shorts than sequence B girls with bodysuits. The London sample of nine scored higher
percentages of ordering all three sequences correctly after the second interview visit.
Table 11 Content Validity I: Percentage of Subjects Who Ordered the Silhouettes Correctly- Sequence A, B, and C (G-F-E-D-C-B-A)
Cities
N (38) Sequence A Girls-shorts
Sequence B Girls-bodysuits
Sequence C Boys-shorts
London* 17 58.82% 47.05% 76.47%
NYC * 12 75.00% 41.66% 66.66%
London & NYC 29 65.51% 44.82% 72.41%
London** 9 77.77% 88.88% 100% * London Subjects 1-17 and NYC Subjects 1-12 who received one interview visit ** London Subjects 9-17 who received a second interview visit
The descriptive statistics revealed the percentage of the 29 subjects that had one
interview visit in London and NYC who correctly ordered the three silhouette sequences (see
Table 12). The lowest percentage of ordering the individual silhouettes correctly was in the
sequence B, girls in bodysuits between silhouette F and E which were both normal weight by
BMI five or greater percentile (see Appendix D).
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Table 12 Content Validity II: Percentage of Subjects Who Correctly Ordered the Silhouettes from Thinnest to Heaviest: Sequences A, B, and C (G-F-E-D-C-B-A) Correct Ordering
of Silhouette Sequence A Girls-Shorts ( n =29) %
Sequence B Girls- Bodysuits
(n =29) %
Sequence C Boys- Shorts (n = 29) %
G 86.21 82.76 86.21
F 65.52 51.72 82.76
E 72.41 58.62 86.21
D 96.55 96.55 96.55
C 100.00 100.00 100.00
B 100.00 100.00 100.00
A 100.00 100.00 100.00
The descriptive statistics revealed the percentage of the 29 subjects that had one
interview visit in London and NYC and nine London subjects that had a second interview who
correctly ordered sequence A, girls with shorts and sequence B, girls with bodysuits (see Tables
13 and 14). The London subjects who had the first interview visit had lowest percentage of
ordering the individual silhouettes F and E correctly which were both normal weight by BMI
percentile of five or greater (see Appendix D). All of the subjects that had second interview
visits increased their percentage of correct ordering of the silhouettes (see Tables 4.9 and 4.10).
All of the subjects correctly sequenced the silhouettes B and A that were the heaviest.
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Table 13 Content Validity II: Percentage of Subjects Who Correctly Ordered the Silhouettes Sequence A girls–shorts (G-F-E-D-C-B-A)
Silhouette Letter London 1st Visit* (n = 17)
London 2nd Visit** ( n = 9)
NYC 1st Visit* ( n = 12)
G 88.24% 100.00% 83.33% F 52.94% 77.78% 83.33% E 58.82% 77.78% 91.67% D 94.12% 100% 100% C 100% 100% 100% B 100% 100% 100% A 100% 100% 100%
* London Subjects 1-17 and NYC Subjects 1-12 who received one interview visit **London Subjects 09-17 who received a second interview visit Table 14 Content Validity II: Percentage of Subjects Who Correctly Ordered the Silhouettes Sequence B Girls–Bodysuits (G-F-E-D-C-B-A)
Silhouette Letter London 1st Visit* (n = 17) %
London 2nd Visit** ( n = 9) %
NYC 1st Visit* ( n = 12) %
G 82.35% 100.00% 83.33% F 52.94% 88.89% 50.00% E 52.94% 88.89% 66.67% D 94.12% 100% 100% C 100% 100% 100% B 100% 100% 100% A 100% 100% 100%
* London Subjects 1-17 and NYC Subjects 1-12 who received one interview visit **London Subjects 09-17 who received a second interview visit
The descriptive statistics revealed the percentage of the 29 subjects that had one
interview visit in London and NYC and nine London subjects that had a second interview who
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correctly ordered sequence C, boys with shorts (see Table 15). The London subjects who had the
first interview visit had a slightly reduced percentage of ordering the individual silhouettes F and
E correctly which were both normal weight by BMI percentile of five or greater (see Appendix
D) than the other silhouettes. All of the subjects that had second interview visits increased their
percentage of correct ordering of the silhouettes. All of the subjects correctly sequenced the
silhouettes B and A that were the heaviest.
Table 15 Content Validity II: Percentage of Subjects Who Correctly Ordered the Silhouettes Sequence C Boys –Shorts (G-F-E-D-C-B-A)
Silhouette Letter London 1st Visit (n = 17)
London 2nd Visit* (n = 9)
NYC 1st Visit (n = 12)
G 82.35% 100.00% 91.67% F 82.35% 100.00% 83.33% E 88.24% 100.00% 83.33% D 94.12% 100.00% 100.00% C 100.00% 100.00% 100.00% B 100.00% 100.00% 100.00% A 100.00% 100.00% 100.00%
* London Subjects 1-17 and NYC Subjects 1-12 who received one interview visit **London Subjects 09-17 who received a second interview visit
Correctly ordering of the three silhouettes scales - London and NYC First Visit
Cronbach's alpha is a measure of internal consistency which relates to a set of items as a
group (Munro, 2005). It is considered to be a measure of scale reliability. A "high" value for
alpha does not imply that the measure is unidimensional. Additional analyses can be performed
such as an Independent t test and Paired t test to explore dimensionality. Note that a reliability
coefficient of α = .80 or higher is considered "acceptable" in most social science research
situations (Wood & Ross-Kerr, 2011). The computation of the Cronbach’s alpha coefficient
59
revealed that the ordering of the all the sequences of the silhouettes by the London and NYC
sample that received a first interview visit (n = 29). The London & NYC sample scored the A
sequence of girls with shorts with a significant Cronbach alpha of α = .952, the B sequence of
girls with bodysuits revealed a significant α = .964, and the C sequence of boys with shorts
revealed a significant α = .917 (see Table 16).
Table 16 Cronbach‘s Alpha Coefficient Findings of Ordering the Silhouettes from the Samples of London and NYC
Cronbach's Alpha Silhouette Sequences City Samples (n =29)
.952 A-girls with shorts London & NYC
.964 B- girls with bodysuits London & NYC
.917 C- boys with shorts London & NYC
Independent sample t test for ordering of the silhouettes
The correct ordering of the three sequence of gender set of A, B, and C between the two
cities of London and NYC who had one visit was analyzed by computing the independent
samples t test (see Table 17). The independent sample t test answered the research question two
by analyzing if the London and NYC samples with one interview visit differed on ordering the
silhouettes from thinnest to heaviest. The three sequence A, B, and C scales from thinnest to
heaviest revealed non-statistical differences between the samples as p > .05.
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Table 17 Independent Sample t Test Comparing the Samples from London and NYC Ordering the Silhouettes of the Three Sequences A, B and C
Variable N df t p Sequence A London NYC
29 17 12
.59 .75
27
-.883
.385
Sequence B London NYC
29 17 12
.47 .42
27
.278
.783
Sequence C London NYC
29 17 12
.76 .67
27
.565
.577
Paired sample t test for ordering of the silhouettes The correct ordering classifications of the three sequence of gender set of A, B, and C
between the London first and second visits within a week was analyzed by computing the paired
sample t test (see Table 18). The paired sample t test answered the research question two by
analyzing if the London samples with two interview visits differed on ordering the silhouettes
from thinnest to heaviest. The three sequence A, B, and C scales from thinnest to heaviest
revealed non-statistical differences between the samples as p > .05.
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Table 18 Paired t Test Comparing London Sample (first and second visits) Ordering of the silhouettes of the Three Sequences A, B and C
Variable N df t p Sequence A A1 score A2 score
9 9
.67 .78
8
-4.26
.681
Sequence B B1 score B2 score
9 9
.56 .89
8
-2.00
.081
Sequence C C1 score C2 score
9 9
.78 1.00
8
-1.51
.169
Assignment of weight classifications of the silhouettes
The BPSS content validity was further analyzed by inter and intra-rater reliability as the
subjects classified the weight status (underweight = U, normal weight = N and overweight = O)
of the three silhouette sequences A, B and C. Descriptive statistics was applied to measure the
percentages of subjects that classified the weight status correctly. The percentages of (n =29)
subjects with first interview visits from both countries London & NYC and London Subjects (09-
17) who received second interview visits who correctly classified the weight class status of the
silhouettes Sequence A, B, and C correct ordering of the silhouettes (G=U, F=N, E=N, D=N,
C=N, B=O, A=O) was analyzed (see Table 19).
The first analysis of the content validity was the frequencies and percentage of correct
weight assignment of the silhouettes by a point system. The point system assigned included
correct = 1 and incorrect = 0. A score of -1 was assigned for misclassification if mother’s
perceptions reflected the child‘s body size as a adiposity health risk of overweight or
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underweight (thin fat phenotype). When compared to the correct assignment of weight
classifications U-N-N-N-N-O-O , the F and E silhouettes of normal weight as per the BMI
assignment of the silhouettes in all three sequence A, B, and C were assigned incorrectly by the
mothers. The F silhouettes of the three sequences were assigned incorrectly and misclassified as
underweight. The F silhouette was on the margin of the BMI 5th percentile. The C and D
silhouettes were misclassified as overweight and subjects scored negative one point for health
risk as the BMI assignment reflected a child body size of normal weight (see Appendix D).
Table 19
Content Validity II: Percentage of Subjects from London and NYC Who Correctly Classified the Weight Categories of the Silhouette Sequences A, B, and C (U-N-N-N-N-O-O)
Silhouette no. Sequence A Girls-Shorts
( n = 29)
Sequence B Girls- Bodysuits
(n =29)
Sequence C Boys- Shorts
(n = 29)
ƒ % ƒ % ƒ %
G- Underweight 26 89.66% 27 93.10% 28 96.55%
F- Normal weight 13 44.83% 16 55.17% 9 31.03%
E- Normal weight 25 86.21% 23 79.31% 26 89.66%
D- Normal weight 22 75.86% 24 82.76% 23 79.31%
C- Normal weight 7 24.14% 4 13.79% 7 24.14%
B- Overweight 29 100% 27 93.10% 27 93.10%
A- Overweight 29 100% 29 100% 29 100%
The total percentage of the sample (n =29) subjects with first interview visits from both
cities London & NYC who correctly classified the weight class status of the silhouettes,
Sequence A, B, and C (U-N-N-N-N-O-O) was computed (see Table 20). The scores revealed
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that the F and E silhouettes were misclassified as underweight compared to the correct weight
classifications assigned to the F and E silhouettes of normal weight as per the BMI assignment of
the silhouettes in all three sequence A, B, and C. The F silhouette was on the margin of the BMI
5th percentile. The C and D silhouettes were misclassified as overweight and subjects scored
negative one point penalties as the BMI assignment reflected a child body size of normal weight
(see Appendix D).
Table 20
Content Validity II: Percentage of Subjects from London and NYC Who Correctly Classified the
Weight Categories of the Silhouette Sequence A Girls –Shorts (U-N-N-N-N-O-O)
Silhouette no. London 1st Visit (n = 17)
NYC ( n = 12)
ƒ % ƒ % G- Underweight 15 88.24% 11 91.67%
F- Normal weight 8 47.06% 5 41.67%
E- Normal weight 15 88.26% 10 83.33%
D- Normal eight 12 70.59% 10 83.33%
C-Normal weight 4 23.53% 3 25.00%
B- Overweight
17 100% 12 100%
A- Overweight 17 100% 12 100%
The total percentage of the sample (n = 29) subjects with first interview visits from both
countries London & NYC who correctly classified the weight class status of the silhouettes
Sequence A, B, and C (U-N-N-N-N-O-O) was computed (see Table 21). The scores revealed
that the F silhouette was misclassified as underweight compared to the correct order of weight
classifications assigned to the F silhouettes of normal weight as per the BMI assignment of the
silhouettes in all three sequence A, B, and C. The F silhouette was on the margin of the BMI 5th
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percentile. The NYC mothers had a lower percentage of correctly classifying the weight
classification of silhouette E as normal weight compared to London mothers. The NYC mothers
classified silhouette E as underweight. The C silhouette was misclassified as overweight and
subjects scored negative one point penalties as the BMI assignment reflected a child body size of
normal weight (see Appendix D).
Table 21 Content Validity II: Percentage of Subjects from London and NYC Who Correctly Classified the Weight Categories of the Silhouette Sequence B Girls – Bodysuits (U-N-N-N-N-O-O)
Silhouette no. London 1st Visit (n = 17)
NYC ( n = 12)
ƒ % ƒ % G- Underweight 16 94.12% 11 91.67%
F- Normal weight 11 64.71% 5 41.67%
E- Normal weight 15 88.24% 8 66.67%
D- Normal eight 14 82.35% 10 83.33%
C- Normal weight 1 5.88% 3 25.00%
B- Overweight 16 94.12% 11 91.67%
A- Overweight 17 100% 12 100%
The total percentage of the sample (n =29) subjects with first interview visits from both
countries London & NYC who correctly classified the weight class status of the silhouettes
Sequence A, B, and C (U-N-N-N-N-O-O) was computed (see Table 22). The percentage scores
revealed that the F silhouette for both cities were misclassified as underweight and C silhouettes
of both cities were misclassified as overweight compared to the correct weight classifications
assigned to the F and C silhouettes of normal weight as per the BMI assignment of the
silhouettes in all three sequence A, B, and C. The F silhouette was on the margin of the BMI 5th
percentile. The C silhouette was misclassified as overweight and subjects scored negative one
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point penalties as the BMI assignment reflected a child body size of normal weight (see
Appendix D).
Table 22 Content Validity II: Percentage of Subjects from London and NYC Who Correctly Classified the Weight Categories of the Silhouette Sequence C Boys-Shorts (U-N-N-N-N-O-O)
Silhouette no. London 1st Visit (n = 17)
NYC ( n = 12)
ƒ % ƒ % G- Underweight 16 94.12% 12 100%
F- Normal weight 4 23.53% 5 41.67%
E- Normal weight 16 94.12% 10 83.33%
D- Normal eight 14 82.35% 9 75.00%
C-Normal weight 4 23.53% 3 25.00%
B- Overweight 16 94.12% 11 91.67%
A- Overweight 17 100% 12 100%
Additional data analyses was performed on classifying sequences of A, B, C weight
status correctly using the scale reliability statistics of Cronbach’s alpha coefficient. The scale
reliability of the Cronbach’s alpha coefficient was performed on the three silhouette sequencing
A, B, and C on inter-rater reliability group of the London and NYC total 29 subjects. The
London & NYC sample scored the A sequence of girls with shorts with a significant Cronbach
alpha of α = .960, the B sequence of girls with bodysuits revealed a significant α = .969, and the
C sequence of boys with shorts revealed a significant α = .961 (see Table 23).
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Table 23 Cronbach‘s Alpha Findings of Weight Classification of the Silhouettes-from the Samples of London and NYC
Cronbach's Alpha Silhouette Sequences!
City Samples (n =29)
.960 A- girls with shorts London & NYC
.969 B- girls with bodysuits London & NYC
.961 C- boys with shorts
London & NYC
Independent sample t test for the correct weight classifications of the silhouettes
The correct weight classifications of the three sequences of the gender set of A, B, and C
between the two cities of London and NYC who had one visit was analyzed by computing the
independent samples t test (see Table 24). The independent t test answered the research question
two by analyzing if the London and NYC samples with one interview visit differed on weight
classification of the silhouettes. The three sequence A, B, and C scales scored by the two
samples revealed non-statistical differences between the samples as p > .05. A non-statistical
significance revealed no significant differences between the samples in assigning the correct
weight classification to the silhouettes.
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Table 24 Independent Sample t Test Comparing London to NYC Assignment of the Weight Classifications of the Three Silhouettes Sequencing of A, B and C
Variable N df t p Sequence A London NYC
17 12
4.00 4.16
27
-.271
.788
Sequence B London NYC
17 12
4.05 3.75
27
.648
.523
Sequence C London NYC
17 12
4.12 4.00
27
.319
.752
Paired sample t test for the correct weight classifications of the silhouettes
The correct weight classifications of the three sequence of gender set of A, B, and C
between the two cities of London and NYC who had two visits within a week was analyzed by
computing the independent paired t test (see Table 25). The paired sample t test answered the
research question two by analyzing if the London and NYC samples with two interview visits
differed on the weight classification of silhouettes. The correct weight classification of each
sequence A and B silhouettes revealed non statistical differences between the samples as p > .05.
There was a significant difference in the scores for sequence C boys with shorts silhouette scale
pair C-1 (M =4.56) and C 2 (M = 3.44) conditions; t (8) = 2.44, p = .04 of identifying correct
weight classification of the silhouettes between the samples. The mothers changed their
assignment of weight classes of silhouettes G and D from first visit to second visit. On the first
visit, mothers scored silhouette G as underweight compared to second visit when they changed
assignment to normal weight. Similarly, on the first visit, mothers scored silhouette D as normal
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weight compared to second visit when they changed assignment to overweight. The paired
sample t test revealed that two (A and B) of the three sequences had no significant differences
between the samples in assigning the correct weight classification to the silhouettes.
Table 25 Paired Sample t Test Comparing London Samples (first and second visits) Assignment of Weight Classification of the Three Silhouette Sequences A, B and C
Variable N df T p Sequence A A1 score A2 score
9 9
4.88 3.77
8
1.97
.084
Sequence B B1 score B2 score
9 9
4.33 3.56
8
1.79
.111
Sequence C C1 score C2 score
9 9
4.56 3.44
8
2.44
.040
Determine age of the three sequences of the silhouettes
The Bangladeshi mothers’ perceptions of the ages of the three silhouette sequences A, B
and C ranging three to six years old was evaluated by descriptive analysis of means and standard
deviations. Mothers’ are asked to select a number from the Likert scale of one (strongly disagree
to five (strongly agree) assigned to each age selection (Appendix E).
The twenty nine subjects from spilt cases samples from London and NYC revealed age
five scored the highest means of both cities with London 4.17 with a (SD = 1.01) and NYC
revealed age five had the highest mean (M = 4.75, SD = 0.45) (see Table 26).
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Table 26 Split Cases from the London and NYC Samples of Perceived Ages of the Silhouettes
Age N Minimum Maximum SD
London 17 Age-3 17 1.00 3.00 1.47 .624 Age-4 17 1.00 5.00 2.35 1.16 Age-5 17 1.00 5.00 4.17 1.01 Age-6 17 1.00 5.00 3.11 1.31
NYC 12 Age-3 12 1.00 1.00 1.00 .000 Age-4 12 1.00 5.00 2.58 1.62 Age-5 12 4.00 5.00 4.75 .452 Age-6 12 1.00 5.00 4.16 1.52
Determine clothing preference of the girls’ silhouettes A second question was asked of the preference of clothing for girls’ “Do you like the
girls in tops/shorts or bodysuits? “ (Appendix E). The researcher elected to have an addition of a
second sequence of the seven girls’ silhouettes with body suits to make it more of a cultural
sensitive instrument. The total sample of London and NYC revealed 58% preferred the
bodysuits compared to 42% of the mothers preferring the shorts. The London mothers’ choice of
clothing revealed 53% selected shorts compared to 47% preferring the bodysuits. The NYC
mothers’ choice of clothing revealed that 75% preferred bodysuits compared to 25% preferring
the shorts.
Summary
This chapter reports the analyses and statistical tests that were performed for the two
research questions of the development and validation of Mola Facetool and the BPSS.
Descriptive statistics of socio demographic analyses of the samples, and item analysis with
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70
frequencies and percentages, and individual sample t tests of the gender set of the facial features
categories of the Mola Facetool were used. The correct ordering of the three sequences of A, B,
and C silhouettes from thinnest to heaviest and correct assignment of weight classifications of
the three silhouettes sequences were analyzed using descriptive selections percentages. Also,
statistical testing of Cronbach alpha coefficient and inter-rater and intra-rater reliability of the
three silhouettes sequencing ordering of body size and weight classification assignments were
analyzed by using independent sample t test and paired t tests.
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Chapter- 5 Discussion
Introduction
This chapter of the dissertation includes a brief summary of the study’s findings as well
as the discussion of the implications and the limitations of the study. The discussion section
describes the process of instrument development and validation, implications for nursing
practice, nursing research and recommendations for future research.
Through several research reviews and development of propositional statements based on
the Roy Adaptation Model (RAM), the researcher decided to construct an instrument that
measures the perception of mothers. Within the RAM, perception is viewed as the link between
the regulator and cognator or in other words as the integrator. Stimuli from the internal and
external environment act as inputs to the nervous system. Input into the regulator system has a
role in forming perceptions. The cognator subsystem responds through the four cognitive-
emotive channels: perceptual and information processing, learning, judgment, and emotion. The
activities of perceptual and information processing includes selective attention, coding and
memory (Roy and Andrews, 1999, p. 46). Roy’s Adaptation Model guided the researcher in the
formulation of the two research questions to develop and validate an ethnic congruent
Bangladeshi Pediatric Silhouette Scale (BPSS) and the Mola Facetool to assess the mothers’
perceptions of their children’s body sizes, weight categories and facial features.
Summary of the Study
Over the past two decades, the prevalence of an adiposity risk phenotype (thin fat) and
adiposity related health problems are increasing in South Asians, including Bangladeshi minority
groups in London, England and in New York City. The review of the literature highlighted that
there is no ethnic congruent children’s silhouette scale to investigate the Bangladeshi mothers’
72
perceptions of their children’s body sizes. The purpose of this study was to develop and validate
a Bangladeshi Pediatric Silhouette Scale (BPSS) and a facial feature scale which measures the
mothers’ perceptions of children’s body sizes, weight categories, and facial features. This
researcher developed new instruments of the Mola Facetool and the BPSS as an answer to the
paucity of well-validated pediatric silhouette scale that measure the Bangladeshi mothers’
perceptions of their children’s body sizes, weight classification and facial features.
This quantitative, descriptive study utilized scale reliability and parametric testing to
analyze and establish the baseline validity of the newly developed instruments. The socio
demographics revealed the subjects in both countries were of similar ages. All the mothers were
married and the primary care giver of their children. The sample migration status from
Bangladesh to London revealed greater than NYC. The mothers from the Bangladesh sample had
more years of education than the subjects from NYC. The mean age of the London Bangladeshi
mothers having their first child was younger than the NYC sample. The children mode birth
order was two in both countries. The children’s socio-demographic characteristics revealed that
the London subjects had similar mean age of approximately five years old. The mothers reported
that their children, ages four-five were healthy with no acute or chronic illnesses are not treated
with medications for any illnesses.
Content validity was used to measure the degree by which the Mola Facetool and BPSS
instruments had appropriate sample of items of the construct being measured (Polit & Beck,
2012). The scale validity of the Mola Facetool was measured using descriptive statistics,
content validity with inferential statistics to describe and analyze the data of the subjects’
selections of gender set facial features of a Bangladeshi children four-five year old. Inter-rater
reliability is the most common method of testing equivalence among raters in samples (Polit &
73
Beck, 2012). The Cronbach alpha coefficient compares each individual item with each other and
the overall score (Wood & Ross-Kerr, 2011). The Cronbach alpha coefficient was used to
develop the BPSS to determine internal consistency with the inclusion of additional parametric
statistical analyses using independent sample t and paired t testing.
The ethnic congruent Bangladeshi facial features development and validation findings of
the Mola Facetool revealed, six of the seven girls’ facial features did not demonstrate statistical
significance; hence, there was a preference consensus in the six girls’ facial features of both
countries. However, the hair variable revealed a significant difference London (M = 8.82) and
NYC (M = 10.08) conditions; t (27) = -2.42, p = .02. Seven of the boys’ facial features did not
demonstrate statistical significance; hence, there was a preference consensus in the seven boys’
facial features categories of both countries. The independent sample t test answered the research
question one by analyzing if the London and NYC samples with one interview visit differed
consensus on the total of the gender set 14 facial features categories. Further research validation
is warranted for the girls’ hair variable. Further testing of internal consistency will also be
performed on the hair variable when using the newly developed Mola Facetool instrument in a
large scale study.
The scale content validity of correctly ordering the silhouettes (G-F-E-D-C-B-A) from
thinnest to heaviest revealed that the London (n = 17) sample had a larger percentage of ordering
the boys silhouettes correctly than the two girls sequences compared NYC sample ( n = 12) that
had a higher percentage of sequence A girls with shorts than the other two silhouette sequences.
Both London and NYC samples with one interview visit had a higher percentage ordering the
sequence A girls with shorts than sequence B girls with bodysuits. The London sample of nine
scored higher percentages of ordering all three sequences correctly after the second interview
74
visit. The descriptive statistics revealed the percentage of the total sample ( n = 29) that had one
interview visit in London and NYC had the lowest percentage of ordering the individual
silhouettes correctly in the sequence B, girls in bodysuits between silhouette F and E which were
both normal weight by BMI five or greater percentile (see Appendix D). All of the subjects that
had second interview visits increased their percentage of correct ordering of the silhouettes. All
of the subjects correctly sequenced the silhouettes B and A that were the heaviest.
The computation of the Cronbach’s alpha coefficient was used to examine the ordering of
the all the sequences of the silhouettes by the London and NYC sample that received a first
interview visit, (n = 29). The London & NYC sample scored the A sequence of girls with shorts
with a significant Cronbach alpha of α = .952, the B sequence of girls with bodysuits revealed a
significant α = .964, and the C sequence of boys with shorts revealed a significant α = .917. The
independent sample t test answered the research question two by examining if the London and
NYC samples with one interview visit differed on ordering the silhouettes from thinnest to
heaviest. The three sequence A, B, and C scales from thinnest to heaviest revealed non statistical
differences between the samples as p > .05. The independent paired sample t test answered the
research question two by analyzing if the London and NYC samples with two interview visits
differed on ordering the silhouettes from thinnest to heaviest. The three sequence A, B, and C
scales from thinnest to heaviest revealed non statistical differences between the samples as
p > .05.
The scale content validity of the correct assignment of the weight classification (U-N-N-
N-N-O-O) to the three sequences (A, B and C) of the silhouettes revealed that the F and E
silhouettes of normal weight as per the BMI assignment of the silhouettes in all three sequence
were assigned incorrectly by the mothers. The F silhouettes of the three sequences were
75
assigned incorrectly and misclassified as underweight. The F silhouette was on the margin of the
BMI 5th percentile. The C and D silhouettes were misclassified as overweight and subjects
scored negative one point for health risk as the BMI assignment reflected a child body size of
normal weight (see Appendix D). These same results occurred with sequence A, girls with
shorts and sequence C, boys with shorts. In sequence B, girls with bodysuits, mothers also
misclassified silhouette E as underweight instead if normal weight. All the mothers in every
sequence of A, B, and C classified the overweight silhouettes of B and A correctly.
The computation of the Cronbach’s alpha coefficient was used to evaluate the correct
weight classification of the all the sequences of the silhouettes by the London and NYC sample
that received a first interview visit, (n = 29). The London & NYC sample scored the A sequence
of girls with shorts with a significant Cronbach alpha of α = .960, the B sequence of girls with
bodysuits revealed a significant α = .969, and the C sequence of boys with shorts revealed a
significant α = .961.
The independent sample t test answered the research question two by examining if the
London and NYC samples with one interview visit differed on weight classification of the
silhouettes. The three sequence A, B, and C scales scored by the two samples revealed no
statistical differences between the samples as p > .05. The independent paired t test answered the
research question two by evaluating if the London and NYC samples with two interview visits
differed on the weight classification of silhouettes. The correct weight classification of each
sequence A and B silhouettes revealed no statistical differences between the samples as p > .05.
There was a significant difference in the scores for sequence C boys with shorts silhouette scale
pair C-1 (M = 4.56) and C 2 (M = 3.44) conditions; t (8) = 2.44, p = .04 of identifying correct
weight classification of the silhouettes between the samples. The mothers changed their
76
assignment of weight classes of silhouettes G and D from first visit to second visit with
misclassification on the second visit of silhouette G from underweight to normal weight and
silhouettes D from normal weight to overweight. The independent paired t test revealed that two
(A and B) of the three sequences had no significant differences between the samples in assigning
the correct weight classification to the silhouettes.
The twenty nine subjects from spilt cases samples from London and NYC revealed the
perceived preference age was five years old. Age five scored the highest means for London
(M = 4.17, SD = 1.01) and NYC sample (M = 4.75, SD =0.45). The total sample of London and
NYC revealed 58% preferred the bodysuits compared to 42% of the mothers preferring the
shorts.
Discussion
The implications and consequences of excess adiposity and weight related health
problems to the individuals within cultures and across the lifespan is well documented in the
literature. It is well recommended that the surveillance and intervention of this adiposity
trajectory must start from the early ages of childhood in order to decrease the global prevalence
of cardio metabolic health problems across the lifespan (De Onis, et al., 2010).
As children from all races and ethnicities become more frequently overweight, the
perception of what a normal weight child looks like is changing (Spurrier, Magarey & Wong,
2006). This phenomenon of normal weight perception adaptation to current appearances of
typical children can increase the disparity of the thin fat phenotype that predisposes the
Bangladeshi children. If the perception of children’s normal body size is evolving and adapting
to be of a larger size because of obesity trends, than the Bangladeshi child may be perceived as
underweight even though they have a greater percentage of body fat. The Bangladeshi children’s
77
trajectory of weight health related risk, because of their higher adiposity, can actually increase
over time in response to the adaptation of societal perceptions of a larger body size and image of
normal weight. Implications for high risk screening for pre-diabetes can be missed because their
body size appears to be of normal or underweight. The BPSS can be used as an educational tool
to guide Bangladeshi families in an accurate assessment of their children’s body sizes.
This researcher is a Cardiovascular Adult Nurse Practitioner, who has treated many adult
patients with cardio metabolic disorders. Adult cardiovascular patients, if educated at an early
age regarding cardio metabolic risk of poor weight management, could have had a positive
impact on preventing these cardiovascular disorders. The family nurtures various core values,
including health values which are perceived and enacted in different ways. The mother as the
guardian of the family health, mediates many healthy activities of the family members (Manios,
et al., 2008; Muhammad, et al., 2008). The mothers’ perceptions of their children’s body sizes
are of the greatest relevance to enact an early foundation of healthy choices for the child across
their lifespan. It is important for mothers to make a distinction between levels of adiposity in
order to provide and adapt a healthy lifestyle for their children (Moschonis, Iatridi, Siatitsa,
Mavrogianni, Parashevi-Eirini, Kyriakou, Dede, et al., 2011).
The review of the literature for this study highlighted that there is no ethnic congruent
children’s silhouette scale to investigate the Bangladeshi mothers’ perceptions of their children’s
body sizes. The validation of the Mola Facetool which provided the facial features for the
validated ethnic congruent BPSS instrument, provides a vital visual instrument to assess the
Bangladeshi mothers’ perceptions of their children’s body sizes and weight classifications in
light of their children’s adiposity risk for thin fat phenotype. The validation of the BPSS will
add an assessment tool to the body of nursing science regarding the importance of understanding
78
racial and ethnic disparities of Bangladeshi children body compositions at early ages. The
awareness of the Bangladeshi maternal perception of their children’s body sizes will add
population level data for analysis of trends in growth patterns and obesity in this population.
These findings are relevant for the Bangladeshi mothers because their children may be at risk at
normal weight categories, but if the mothers underestimate their children’s weight at higher BMI
levels, the adiposity risk poses a greater health challenge for cardio metabolic illnesses.
Implications for Practice
Implications to nursing practice
This quantitative, descriptive study and the newly designed and validated Mola Facetool
and BPSS have several implications to nursing practice. The findings of this study will impact
the delivery of care from the perspective of the nurse in her cultural approach to assessing the
Bangladeshi mothers’ perception of their children’s body sizes and weight classifications. The
utility of the BPSS will provide an understanding of the Bangladeshi mothers’ perceptions for
healthcare providers and Bangladeshi parents in order to develop healthy lifestyle care plans to
increase understanding among adults and children about multiple determinants on body sizes and
weight classifications. Other implications to nursing practices using the BPSS will lead to
modifying beliefs about the limits to an individual’s control over their own body size and to
encourage action to confront obesity risk at the individual and community levels (Rees, et al.,
2011).
The utility of the BPSS in school settings, clinics, hospitals will target nursing practice
interventions on the level of accuracy of the mothers’ perceptions of their children’s body sizes
and weight classifications. Therefore, nurses can educate Bangladeshi families about their
weight susceptibility to cardio metabolic risk of hypertension, insulin sensitivity, type II DM and
79
encourage the families to be vigilant in maintaining a healthy weight. Particular attention should
be focused on identifying how Bangladesh perceive the body sizes of their children’s in relation
to the actual body composition of their children. Inclusion of body composition measurements
that measure BMI, WC and body fat percentage should be included in annual physical
examination of Bangladeshi children. As Bangladeshi children’s varying weight categories may
place them at risk for weight related problems even at a normal weight.
Nurses can incorporate the clinical findings of the utility of the BPSS to lead healthcare
reform through public health advocacy and health promotion of cardiovascular preventive
lifestyle behaviors in Bangladeshi preschool children while they are young and their lifestyle
behaviors are still developing.
Implications for nursing research
The BPSS will be an ethnically congruent instrument to be used in nursing research to
study early age childhood weight issues within the Bangladeshi community. This ethnically
specific tool will direct studies to examine Bangladeshi racial and ethnic body composition
patterning in comparison to the accuracy of Bangladeshi mothers’ perceptions of their children’s
body sizes and weight classifications. The validation of the BPSS will promote nursing research
to address Bangladeshi childhood weight management issues and heighten awareness regarding
the adiposity risk of the thin fat phenotype. The implications of the utility of BPSS in nursing
research will provide an assessment tool to evaluate health promotion activities across the
Bangladeshi child’s early age lifespan to increase awareness of Bangladeshi mothers’
perceptions of their children’s body sizes. Bangladeshi mothers’ perceptions, beliefs, attitudes
and discriminatory behaviors associated with Bangladeshi children’s body sizes can be
investigated using the BPSS with other psychometric surveys or questionnaires.
80
The implications for nursing research can be directed and focused to consider initiatives
to address and support the needs of parents, other adults and children in their discussions of
children’s body sizes. Interpretations of the mothers’ perceptions of their children body sizes
will generate exploration of culturally congruent interventions associated with providing
psychological support as well as modifications to exercise and diet of children at risk for
adiposity. Furthermore, research with the BPSS can clarify Bangladeshi mothers’ perceptions of
their children’s body sizes that can promote culturally congruent views on how public health
campaigns and interventions can help children understand the influences of weight categories
inclusive of normal, overweight and obesity, as well as the full range of its negative
consequences.
Conducting nursing research using the facially congruent BPSS, at an early age with
Bangladeshi children can clarify the meanings these children ascribe to the descriptive terms that
they use regarding their body sizes. These findings can then be reported in order to facilitate
more effective health care around nutrition, fitness and ideal body size and weight. Other
nursing research can actively engage children, using the BPSS, in identifying forms of support
around body size that they consider healthiest. Nursing studies that aim for more generalizable
findings about Bangladeshi children’s body sizes can lead to the design of public health materials
and processes that respond effectively to the differing values, aspirations and concerns held by
girls and boys around their own body sizes (Rees, et al., 2011).
Implications for Future Research
Implications for future research using the BPSS would be for nurses and other healthcare
providers to engage in description and analysis of Bangladeshi mothers’ perceptions of their
children’s body sizes. These recommendations may provide further validation to the Mola
81
Facetool for the development and validation of other ethnic congruent pediatric silhouette scale
and continued validation of the BPSS.
1. After this study, a full scale study using the Mola Facetool and the BPSS will be
performed to examine Bangladeshi mothers’ perceptions of their children’s body
sizes in relation to the actual body composition of their children.
2. Additional research is needed to further assess the reliability of the Mola Facetool and
the BPSS.
3. Since this study only recruited one racial group, additional studies are required to
determine further validity and reliability of the Mola Facetool to other ethnic or racial
groups.
4. A future study investigating the context and the association of socio- demographic
determinants which influence the Bangladeshi mothers’ perceptions of their
children’s body sizes using the BPSS would add new knowledge to nursing science.
5. A mixed method research approach of combining the use of the BPSS for
quantitative outcomes and incorporating a qualitative method to explore essential
themes of Bangladeshi mothers perceptions of their children’s body sizes will
illuminate the essences of how the mothers perceive the size of their children
regarding the a healthy body size and weight classifications.
6. Future research by nurses and other healthcare providers using the BPSS in assessing
the mothers’ perceptions of their children’s body sizes and weight classifications in
association to the levels of children's physical activity, sedentary behavior and dietary
patterns of both mother and child can examine the need for public health awareness of
the benefits of physical activity to maintain healthy weight management.
82
7. The BMI and WC cut-offs serve an important role in population health management.
As the BMI and WC cut-offs are applied within populations, specifically SAs, a
proportion of the population with a high risk of health consequences associated with
different body compositions will be identified for a public health interventions. This
public health surveillance will inform healthcare policy to design effective prevention
programs and measure the efficacy of these interventions (WHO Expert Consultation,
2004). The identification of Bangladeshi mothers’ perceptions of their children’s
body sizes by the utility of BPSS will contribute to this public health effort.
Limitations
The researcher of this study acknowledged several limitations. (1) The instrument was
tested only in select sample – Bangladeshi mothers (25 to 40 years of age) and Bangladeshi
children (four to five years of age). (2) the study was conducted in two urban metropolitan
settings, (3) the Mola Facetool Tool and BPPS was administered not in a controlled laboratory
environment, (4) subjects were recruited from personal referrals in community based settings, (5)
the researcher is not of Bangladeshi descent and did not speak Bengali or Sylheti, (6) financial
funding constraints prevented the researcher to conduct a full-scale study. Therefore,
generalization is limited only to Bangladeshi mothers and children living in London and NYC.
Conclusions
The importance of this study was the design and validation of the instruments, the Mola
Facetool and the BPSS. The Mola Facetool validated the facial features of the ethnic congruent
BPSS. The Mola Facetool analyses of the gender set of facial features revealed preference
consensus and no differences between the London and NYC samples in 13 of 14 facial feature
categories which were statistically not significant. The BPSS was validated by studying the
83
three gender set sequences of A, B and C scales of ordering the silhouettes from thinnest to
heaviest and weight classifications assignments of the silhouettes. The Cronbach alpha
coefficients were significant and independent sample t tests and paired t test revealed no
differences with sequence silhouettes A and B subjects, achieving a p > .05. There was a
significant difference between the London first visit and second visit subjects in the scores for
identifying correct weight classification of sequence C silhouette scale, boys with shorts with the
conditions; t (8) = 2.44, p = .04. The BPSS has provided a cultural congruent adiposity risk tool
in the Bangladeshi community.
The validation of the ethnic facial congruent BPSS with the Mola Facetool may be
applied and adapted for ethnic congruent silhouette scale development and research in other
diverse cultures nationally and internationally to address the global implications of early age
childhood obesity. The analyses of mothers’ perceptions of their children’s body sizes using an
ethnic congruent silhouette rating scale can increase the public health awareness of social
constructs in the formation of early age adiposity risk.
84
APPENDICES
85
Appendix A
Socio-demographic Survey
Socio-demographic Questionnaire - Unique ID:_________________
The following information is requested so we can describe the general characteristics of the
people participating in our study. The information will remain confidential and your name will
not be used in any way. Please answer each question as it applies to you.
Mother’s Demographics
1. I am _____ years old at my last birthday.
2. Country of Nationality ______ Bangladesh_____England_____American __________
3. Country of Birth: Bangladesh________ England ___________United States_______
4. How many years have you been living in the England________United States_______.
5. How many years of education do you have? _______________
6. What type of work do you do now? __________________
7. Marital Status:
___ Single
___ Married
___ Divorced/Separated
___ Widowed
___ Co-habituate (living with a significant partner)
8. How old were you when you had your first child? _________
9. How many children do you? ____________________
10. What are the ages, gender, weight at birth and current weight of your children starting
with your oldest?
86
A- Age gender weight at birth current weight
B- Age gender weight at birth current weight
C- Age gender weight at birth current weight
D- Age gender weight at birth current weight
11. Who is the primary care taker of your child?
12. What is your current yearly income? If you do not want to answer this question, please move
to question 13.
A)_____ less than $10,000
B)_____ between $10,001-$20,000
C)_____ between $20,001-$30,000
D)_____ between $30,001-$50,000
E)_____ greater than $50,000
13. Do you think the family income is adequate for your daily living cost of food, shelter, clothes
and healthcare? Yes________ No____________
14. Smoking history: pack per days_____________ years__________
A)___ current smoker (smoking within 1 month of the today)
B)___ recent (stopped smoking between 1 month and 1 year before today)
C)___ former (stopped more than 1 year before today)
D)___ never smoked
15. Does anyone in the household smoke? Yes or No If yes how much do they smoke?
______ cigarettes per day
Child’s Demographic Characteristics
1. Age at last birthday ______ Date of Birth____________
87
2. Gender ____ boy _____ girl
3. Child height _______ inches or cms Child’s weight at birth _____lbs/oz or _____kg
4. Child’s birth order ________
5. Recent weight changes within the past 3 months _____lbs/oz or _____kg
6. Current medications _______________________________________________
7. Current illness or disabilities ________________________________________
88
Appendix B
CUNY IRB Letters
89
90
91
92
Appendix C
LMU IRB Letter
93
Appendix D
Assignment of Weight Categories and Point System
Sequences A- Girls with Shorts
Sequence B – Girls with Bodysuits
94
Sequence C- Boys with shorts
95
Appendix E
General Assessment Silhouette Scale Questions
General Bangladeshi Pediatric Silhouette Scale (BPSS) Questions
1) Circle your answer for each age. What age does the child on the card
represent?
- 3 years of age Strongly Disagree 1—2—X—4-- 5 Strongly Agree
- 4 years of age Strongly Disagree 1—2—X—4-- 5 Strongly Agree
- 5 years of age Strongly Disagree 1—2—X—4-- 5 Strongly Agree
- 6 years of age Strongly Disagree 1—2—X—4-- 5 Strongly Agree
2) Do you like the girls in the top/shorts or body suits?
top/shorts ________
bodysuits ________
96
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