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Journal for Specialists in Pediatric Nursing

ORIGINAL ARTICLE

Initial development and testing of a questionnaire of parental

self-efcacy for enacting healthy lifestyles in their children
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147..158

Jonathan W. Decker
Jonathan W. Decker, PhD, ARNP, FNP-BC, is an Assistant Professor, University of Central Florida College of Nursing, Orlando, Florida, USA

Search terms
Child, obesity, parent, psychometric,
self-efcacy.
Author contact
Jonathan.Decker@ucf.edu, with a copy to the
Editor, roxie.foster@UCDenver.edu
Acknowledgements
This research was funded in part by a grant from
the Florida Nurses Foundation.
Disclosure: The author reports no actual or
potential conicts of interest.

Abstract
Purpose. The purpose of this study was to develop and test a questionnaire
to assess parental self-efficacy for enacting healthy diet and physical activity
behaviors in their 6- to 11-year-old children.
Design and Methods. A 35-item questionnaire was developed and tested
with 146 U.S. parents.
Results. Participant responses resulted in a 34-item questionnaire with
two subscales (dietary behaviors and physical activity behaviors), which
were valid and reliable in the study sample.
Practice Implications. This new measure will serve as a tool for the
assessment of parental self-efficacy for enacting healthy lifestyles in their
children 611 years old.

First Received February 24, 2011; Revision

received August 22, 2011; Accepted for
publication November 13, 2011.
doi: 10.1111/j.1744-6155.2012.00330.x

The problem of childhood overweight and obesity

has reached epidemic proportions in the United
States. The consequences of obesity are well known,
with effects that are physical, psychosocial, and
financial (Hodges, 2003; Tershakovec, 2004; Wang &
Dietz, 2002). Childhood is an important period for
the prevention of overweight and obesity, as many
diet and physical activity behaviors are learned
during this time and carried on into adulthood
(Jenkins & Horner, 2005; Trudeau, Laurencelle, &
Shephard, 2004). Parents play a key role in the
learning and development of behavior patterns in
children, acting as role models for their children and
mediators of the household environment and
should thus be targeted for intervention (Hodges,
2003; McCaffree, 2003; Ornelas, Perreira, & Ayala,
2007). In particular, targeting parents of children
611 years old is critical as preadolescent children
are more reliant upon their parents than older children for food choices available at home and when
dining out (Baranowski, Cullen, & Baranowski,
1999). As Kelder, Perry, Klepp, and Lytle (1994, p.
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

1121) stated, . . . early consolidation and tracking

of physical activity [and] food preference . . . implies
that interventions should begin prior to sixth grade,
before behavioral patterns are resistant to change.
The U.S. Department of Agriculture (USDA) provides Americans with guidelines for a healthy lifestyle via the MyPyramid Food Guidance System
(Pyramid; USDA, 2008a). The Pyramid, since its
original release in 1992, is one of the most wellknown and utilized healthy lifestyle guides of all
time (Britten, Haven, & Davis, 2006; Goldberg et al.,
2004; Nestle, 1998). Despite being recognized by
more than two thirds of U.S. adults (Nestle, 1998),
many Americans do not use the guidelines in their
daily lives (Britten et al., 2006; Goldberg et al.,
2004), and they state that they do not know how,
nor do they possess the belief in their own ability or
self-efficacy, to apply the recommendations (Britten
et al., 2006). In fact, findings have long shown that
knowledge of healthy diet and physical activity
behaviors do not translate into healthier behavior
(Povey, Conner, Sparks, James, & Shepherd, 1998;
147

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

Stevenson, Doherty, Barnett, Muldoon, & Trew,

2007). According to Bandura (1997), people are
more likely to perform a behavior if they possess
confidence in their ability to perform that behavior,
achieve a positive outcome, and overcome barriers.
This confidence, or self-efficacy, is the moderator
between knowing how to perform a behavior and
actually engaging in that behavior. Parents are often
well informed and possess knowledge of healthy diet
and physical activity recommendations, yet state
they have difficulty and lack self-efficacy for translating that knowledge into their family lifestyle
(Hart, Herriot, Bishop, & Truby, 2003; Hesketh,
Waters, Green, Salmon, & Williams, 2005).
Thus, it is evident that interventions need to focus
upon increasing parental self-efficacy to engender a
family ethos espousing healthy diet and physical
activity for their children. To determine the effect of
a self-efficacy intervention, there must be a means to
measure change or improvement in the self-efficacy
beliefs of the parent and how that may change across
time. However, extensive review of the literature
shows a lack of instruments to measure this phenomenon. Therefore, the purpose of this study was
to develop and test a questionnaire that assesses
parental self-efficacy beliefs to engender a family
ethos espousing healthy diet and physical activity for
their children ages 611 years.
METHODS AND PROCEDURES
Sample

The target population for this study was U.S. parents

of children 611 years old. Eligibility requirements
were (a) parent of a child 611 years old, (b) able to
read and write in English, and (c) available computer with Internet access. A convenience sample
with recruitment via the Internet was used to identify a sample of parents with children in that age
group to which research findings may apply (Wyatt,
2000). Recruitment via the Internet included postings to numerous parenting discussion groups and
websites, such as http://www.parents.com. The
postings contained a brief introduction to the study
and its purpose, as well as a link to, or URL address
for, the questionnaire. Additional recruiting
methods included sending e-mails to several parental, professional, and healthcare organizational
membership lists, posting fliers at several local
pediatrician and pediatric dentists offices, and postings to an Internet-based social networking site
(Facebook). Word-of-mouth also aided recruit148

J. W. Decker

ment because eligible participants could easily

e-mail and forward information about the study to
other eligible individuals within their personal
network. Finally, a small incentive, a $5 electronic
gift card (e-gift card) to a national retail store chain,
was offered for each completion of the questionnaire. The use of incentives may increase response
rates in Internet-based surveys (Heerwegh, 2006). If
the incentive was desired, the participants were
asked to enter a valid e-mail address where they
wished to receive this incentive.
An initial sample of 15 participants was recruited
to pilot test and refine the questionnaire (Wilson,
2002). Following this pilot test, a separate sample of
145 participants was recruited to fully test the questionnaire. A sample size of 130 was suggested for a
confidence interval of .10, with a = .05 and an
expected reliability coefficient of .70 (Streiner &
Norman, 2003, p. 151). An additional 15 participants were oversampled to compensate for refusals,
incomplete data, and attrition (Oman, Krugman, &
Fink, 2003). The final sample consisted of 146 participants. The participants were mostly female
(88%) and primarily non-Hispanic or Latino ethnicity (91%) and Caucasian race (82%). Most participants were married (84%), employed full-time
(64%), and well educated (97%), with at least some
college education. Total annual household income
varied, but most participants (53%) came from
households earning more than $75,000 annually.
Demographic data are presented in Table 1.
A subsample of 25 participants completed the
questionnaire again in 510 days to evaluate test
retest reliability. This timeframe was considered long
enough to ensure that participants would not recall
previous responses, yet short enough that their
self-efficacy would not have changed (Streiner &
Norman, 2003). Participants were not able to print
or save their previous answers and were not given
the opportunity to view their previous responses.
Willing participants were asked to enter a valid
e-mail address where they wished to receive a
reminder e-mail and link to the questionnaire sent.
Data collection

The University of Central Florida Institutional

Review Board approved the conduct of this study.
Because this study was conducted via the Internet
and no identifying information was required from
participants, a waiver of documentation of consent
was requested, and granted, for this study. As such,
the informed consent statement, appearing prior to
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

J. W. Decker

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

Table 1. Demographics
Category

Gender
Male
Female
Race
White
Black
Asian
More than one race
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Marital status
Single, never married
Living with partner, not married
Married
Separated
Divorced
Widowed
Highest education level
High school or equivalent
Some college
Associates degree
Bachelors degree
Masters degree
Doctoral degree
Work status
Full time
Part time
Full-time homemaker
College/university student
Self-employed
Retired
Not employed
Total annual household income
< $25,000
$25,00049,999
$50,00074,999
$75,00099,999
$100,000

145
16
129
145
119
16
4
6
144
133
11
146
7
3
123
1
9
3
146
5
23
20
47
36
15
146
93
26
10
6
7
1
3
142
5
20
40
25
52

99.3
11
88.4
99.3
81.5
11.0
2.7
4.1
98.6
91.1
7.5
100
4.8
2.1
84.2
.7
6.2
2.1
100
3.4
15.8
13.7
32.2
24.7
10.3
100
63.7
17.8
6.8
4.1
4.8
.7
2.1
97.3
3.4
13.7
27.4
17.1
35.6

the questionnaire, included the statement that

completion of this questionnaire implies consent
to participate in this study (Eysenbach & Wyatt,
2002). All participants who completed the questionnaire did so anonymously in an encrypted
environment via SurveyMonkey (http://www.
surveymokey.com), a secure Internet survey design
and response collection website. The study was
made available for participants for a period of 4
months, from August to November 2008. All e-mail
addresses provided to receive the incentive were
kept separate from all other data (Nosek, Banaji, &
Greenwald, 2002). All data were stored on a
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

password-enabled flash drive stored in a locked

drawer when not in use, and only the investigator
had access to the drawer.
Measures

The questionnaire to assess parental self-efficacy to

engender a family ethos for healthy diet and physical
activity (Table 2) was developed using the USDA
Pyramid guidelines for healthy diet and physical
activity behaviors for children (USDA, 2008b) as
well as outcome expectancies and environmental
factors identified during the literature review. This
questionnaire consisted of 35 questions covering
two domains: diet and physical activity. A composite
score was derived from summated scores on the total
questionnaire, as were diet and physical activity subscale scores.
The questionnaire was sent to eight content
experts: four nurse researchers with experience in
one or more content areas: obesity research, clinical
obesity care, self-efficacy theory, or psychometrics;
three dieticians; and one physician with childhood
obesity clinical and research experience. These
experts were asked to evaluate the questionnaire for
face validity and to rate each item on a 4-point scale
from totally irrelevant (1) to extremely relevant (4)
for content validity assessment (DeVon et al., 2007;
Lynn, 1986; Streiner & Norman, 2003; Waltz, Strickland, & Lenz, 2005). The plan for evaluating experts
ratings was to either rewrite or remove items ranked
less than 3 by more than one content expert.
However, none of the content experts ranked any of
the items less than 3. The content validity index
(CVI) of the questionnaire was .97, with an average
rating of 3.41 for the items on the 4-point scale
(DeVon et al., 2007; Lynn, 1986). Thus, the CVI was
adequate, and content validity of the questionnaire
was deemed acceptable. All content experts also
noted that the questionnaire appeared to be measuring what it purported to measure (face validity).
Subsequently, the questionnaire was pilot tested
with 15 participants from the target sample. The
questionnaire asked respondents to rate their confidence in their ability to perform certain tasks related
to healthy diet and physical activity in their children.
They rated their confidence on an 11-point scale,
from not at all confident (0) to mostly or totally
confident (10), derivative of a 100-point scale
(0100) recommended by Bandura when constructing self-efficacy scales (Bandura, 2006). The internal
reliability (Cronbachs alpha) calculated for data
from the pilot sample was satisfactory (.95), so no
149

150

Note: The questionnaire was developed by the author.

Below is a list of behaviors and strategies that parents might use while trying to get their children to adopt healthy diet or physical activity behaviors. Please rate how certain you are that your
611-year-old child will engage in the behaviors described below. If you have more than one child in this age range, rate all of your children who are 6 to 11 years old.
012345678910
Not at all confident
Moderately confident
Totally confident
1. How confident are you that your child eats only 3 servings of grains (i.e., bread, cereal, rice, pasta) every day? (1 serving bread = 2 slices, 1 serving cereal, rice or pasta = 1 cup)
2. How confident are you that at least half of your childs total grain servings each day are whole grains? (i.e., Cheerios, oatmeal, whole-wheat bread)
3. How confident are you that your child eats at least 2 servings of vegetables every day?
4. How confident are you that your child will eat vegetables, even if they do not enjoy the taste?
5. How confident are you that your child eats only 3 servings of starchy vegetables (i.e., white potatoes, corn, French fries) each week?
6. How confident are you that your child eats a variety of vegetables (i.e., green, orange, yellow or red)?
7. How confident are you that your child eats 2 servings of whole fruit or 100% pure fruit juice every day?
8. How confident are you that the juice your child drinks contains 100% fruit juice?
9. How confident are you that the juice your child drinks is limited to one small glass (3/4 cup) per day?
10. How confident are you that your child eats at least 2 servings of milk or an equivalent dairy product (i.e., yogurt, cheese) every day?
11. How confident are you that the dairy products your child eats are fat-free (skim) or low fat (1%)?
12. How confident are you that your child eats 2 servings of meat, beans, or eggs every day? (1 serving meat = small deck of playing cards, 1 serving beans = 1 cup, 1 serving egg = 1 egg)
13. How confident are you that the meats or poultry (chicken or turkey) your child eats are low-fat or lean?
14. How confident are you that if cooking with oils, you use vegetable oils? (i.e., canola oil, olive oil)
15. How confident are you that your child eats very few solid fats (i.e., butter, margarine, shortening, lard) and foods that contain these?
16. How confident are you that your child eats very few saturated fats (found in dairy, meat, butter, and chocolate) or trans fats (partially hydrogenated oils)?
17. How confident are you that your child eats foods with low sodium (salt) content or added sodium (salt)?
18. How confident are you that your child eats very few foods with added sugar (i.e., candy, cakes)?
19. How confident are you that your child drinks very few drinks with added sugar (i.e., soda, juices)?
20. How confident are you that the cereals that your child eats are unsweetened?
21. How confident are you that your child drinks mostly water or fat-free milk and not fruit juice, soda, or sports drinks?
22. How confident are you that you eat meals together as a family?
23. How confident are you that your child chooses healthy foods at a fast-food restaurant?
24. How confident are you that your child chooses healthy foods at a sit-down restaurant?
25. How confident are you that your child chooses healthy foods at school?
26. How confident are you that your child chooses healthy foods when eating with friends?
27. How confident are you that there are limited unhealthy snacks (i.e., candy, cookies, cakes, chips) in your home for snacks or meals?
28. How confident are you that your child plays outside or is active in sports for a total of at least 60 min on most days of the week?
29. How confident are you that your child is physically active, even if the weather is bad?
30. How confident are you that your child is physically active, even if you have excessive demands at work?
31. How confident are you that your child is physically active, even if there are no gyms, parks, or playgrounds nearby?
32. How confident are you that your child is physically active, even if you are concerned about safety?
33. How confident are you that you can limit your childs screen time (i.e., TV, video games, computer) to no more than 2 hr per day?
34. How confident are you that your child is physically active when with friends?
35. How confident are you that your child is physically active, even if they have homework?

Table 2. Parental Self-efficacy Questionnaire

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children
J. W. Decker

Journal for Specialists in Pediatric Nursing 17 (2012) 147158

2012, Wiley Periodicals, Inc.

J. W. Decker

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

revision was necessary for use with the larger study

sample. Additionally, participants did not express
any difficulty with either comprehension of questionnaire items or completion of the questionnaire.
Finally, no issues with the use of SurveyMonkey
arose in the collection or download of data from the
website.
No identifying data were required as a part of the
questionnaire. In order to characterize the sample,
sociodemographic data were collected and included
age, race, ethnicity, gender, marital status, highest
educational level achieved, work status, household
income, zip code of primary residence, parental
contact, and number of children, with their ages,
height, and weight.
Two existing surveys were used to estimate concurrent validity. Because no existing surveys to
measure parental self-efficacy for enacting healthy
diet or physical activity in their children were
located in the literature, questionnaires regarding
self-efficacy of the parents for their own diet and
physical activity behaviors were selected. These
were chosen because data have shown that parental
behaviors and self-efficacy beliefs were related to
similar behaviors in their children (Bois, Sarrazin,
Brustad, Trouilloud, & Cury, 2005; DiLorenzo,
Stucky-Ropp, Vander Wal, & Gotham, 1998; Moore
et al., 1991; Oliveria et al., 1992). Therefore, it was
expected that if parents had higher self-efficacy
beliefs for their own eating and physical activity
behaviors, they would have higher self-efficacy
beliefs in their ability to provide the same environment for their children. Two surveys frequently
used in obesity research (Folta et al., 2009; Hagler,
Norman, Radick, Calfas, & Sallis, 2005; IeversLandis et al., 2003; Nothwehr & Peterson, 2005;
Nothwehr & Stump, 2002; Resnicow, McCarty, &
Baranowski, 2003; Resnicow et al., 2001; Walker,
Pullen, Hertzog, Boeckner, & Hageman, 2006; White
et al., 2004; Zabinski et al., 2006), the Self-Efficacy
for Exercise Behaviors Scale (SEB-Ex) and SelfEfficacy for Eating Behaviors Scale (SEB-Eat), were
used (Sallis, Pinski, Grossman, Patterson, & Nader,
1988). Both the SEB-Ex and SEB-Eat asked individuals to rate their confidence in their ability to
motivate themselves to do certain activities consistently for at least six months. The 5-point Likerttype scale of each survey ranged from 1 (I know I
cannot) to 5 (I know I can). The SEB-Ex consists of
12 items on two subscales, resisting relapse and
making time for exercise, which each showed
a satisfactory internal consistency (a = .85 and
a = .83, respectively). Testretest reliability for both
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

subscales was r = .68, p < .001, after 12 weeks. The

SEB-Eat consisted of 61 items on five factors: resisting relapse, reducing calories, reducing salt, reducing fat, and behavioral skills. All of the SEB-Eat
subscales demonstrated satisfactory internal consistency (a = .85.93). Testretest reliabilities of the
five subscales ranged from r = .43 to r = .6, after
1 or 2 weeks.

Data analysis

All data from the questionnaire responses were

downloaded directly from the SurveyMonkey
website. Once data were checked for completeness,
all analyses were completed using SPSS version 15.0
(SPSS, Inc., Chicago, IL, USA). Responses from the
questionnaire were summed to create a total parental self-efficacy score. Subscales for healthy diet and
physical activity self-efficacy were summed to create
subscale scores.
The determination of the factors present within
the 35 items was conducted using maximum likelihood factor analysis. Three criteria were used to
determine the number of factors to rotate: the a
priori hypothesis that the measure had two dimensions, the screen test and the interpretability of the
factor solution. Item analysis was performed by calculating the correlation of each item with its own
subscale (with the item removed) and with the other
subscales using a Bonferroni correction. Thus, a p
value of less than .005 was required for significance.
Concurrent validity was assessed by computing
Pearsons correlation coefficients between the new
questionnaire total scores with the SEB-Ex and SEBEat total and subscale scores. Pearsons correlation
coefficients were also computed between the dietary
behaviors (DB) subscale scores and SEB-EAT total
and subscale scores. Finally, the correlation between
the physical activity behaviors (PAB) subscale scores
and the SEB-Ex total and subscales scores were
calculated.
Demographic data were descriptively analyzed.
Internal consistency reliability was assessed by
computing Cronbachs alpha for each factor
derived from the exploratory factor analysis and for
the total score. Testretest reliability was examined
in a subsample of the total participant sample
willing to complete the questionnaire a second
time, within 510 days. Testretest reliability was
assessed by computing the Pearson correlation
coefficients for each individual item and the total
scores.
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Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

RESULTS
Demographics analyses

Demographic characteristics, summarized earlier,

can be found in Table 1. Correlations between
demographic groups, such as race or income level,
on questionnaire responses or scores did not reveal
any significant results. Participants were primarily
from the Southeastern United States (84%),
although there were responses from the Northeastern (6%), Midwestern (7%), Southern (2%), and
Western (1%) United States.
Construct validity

Factor analysis. Two factors were rotated using a

varimax rotation. The rotated solution yielded two
interpretable factors, DB and PAB. The item means,
standard deviations, and inter-item correlation
matrix were examined (Table available from author
by request). On the 11-point scale, where 0 = not at
all confident to 11 = mostly or totally confident,
the means ranged from 5.27 (item 23) to 9.18 (item
14). Examination of the correlation matrix indicated
that all items correlated .30 with at least three
other items in the matrix (range 330). Nineteen of
the 35 items (54%) had 11 or more shared correlations that exceeded .30. Four items (2831) had
inter-item correlations exceeding .80, suggesting
multicollinearity of the items. The items were
retained for further analysis at this time. Bartletts
test of sphericity was significant (c2 = 3480.996,
p < .01) and the KMO statistic (.87) is considered
meritorious according to Kaisers (1974) criteria.
Dietary behaviors accounted for 25.3% of the item
variance, and PAB accounted for 16.8% of the item
variance. The screen plot confirmed the initial
hypothesis of bidimensionality.
Examination of the rotated factor pattern matrix
(Table 3) revealed that all but one item loaded .35
onto its hypothesized factor. Item 33 loaded more
strongly onto the DB factor, contrary to the a priori
belief that it would be related to physical activity.
However, this item did not load very strongly onto
either factor, with factor loadings of .37 and .35 on
the DB and PAB factors, respectively. Therefore, this
item was removed from the questionnaire and
excluded from further analysis.
Item analysis. In support of the questionnaires
validity, items were more highly correlated with
152

J. W. Decker

their own subscale than with the other subscale,

with one exception: question 33. Items on the DB
subscale correlated more strongly (.31.70) with
other items on the DB subscale versus items on the
PAB subscale (.12.43). Other than question 33, all
items on the PAB subscale (.67.90) correlated more
strongly with other items on the same scale versus
items on the DB subscale (.36.44).
Concurrent validity. Correlations between the
questionnaire total scores and the SEB-Eat (.51) and
SEB-Ex (.35) total scores were both significant (p <
.01). Total score on the questionnaire also significantly (p < .01) correlated with subscale scores of the
five SEB-Eat (.32.48) and the two SEB-Ex (.32 and
.34) subscales. The DB subscale scores significantly
(p < .01) correlated with all SEB-Eat subscales (.38
.50) and the SEB-Eat total score (.55). The PAB subscale correlations were all less than .06 and not
significant with the SEB-Ex total and two subscale
scores.
Internal consistency reliability

Cronbachs alpha coefficients were computed for the

original 35 items, for the 34 items that were retained
after item number 33 was dropped during data
analysis, and for the two subscales (DB and PAB).
The coefficient alpha for the initial 35-item scale was
.94 and remained at .94 after removal of question
number 33, How confident are you that you can
limit your childs screen time (i.e., TV, video games,
computer) to no more than 2 hr per day? The DB
subscale had an alpha of .93, which did not change
with removal of question 33. The PAB subscale had
an alpha of .92. However, when question 33 was
removed, the alpha increased to .94.
Testretest reliability

The subsample of 25 participants used to evaluate

testretest reliability all completed the parental
self-efficacy questionnaire a second time between 5
and 10 days after their initial completion. All item
and score (total and subscale scores) correlations
between participants responses at times 1 and 2
were significant at p < .05. Item responses between
questionnaire administrations correlated significantly
for both the DB (.50.95, p < .05) and PAB (.53.92,
p < .01) subscales. Total questionnaire (.94), DB
(.89), and PAB (.93) scores between times 1 and 2
were also significantly (p < .001) correlated.
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

J. W. Decker

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

Table 3. Rotated Factor Pattern Matrix for the 35-Item Parental Self-Efficacy Questionnaire: Maximum Likelihood Factoring
With Varimax Rotation
Factors

Items (how confident are you that . . .)

Dietary behaviors (DB) items
Q16
Your child eats very few saturated fats or trans fats?
Q24
Your child chooses healthy foods at a sit-down restaurant?
Q26
Your child chooses healthy foods when eating with friends?
Q15
Your child eats very few solid fats and foods that contain these?
Q17
Your child eats foods with low sodium content or added sodium?
Q7
Your child eats 2 servings of whole fruit or 100% pure fruit juice every day?
Q3
Your child eats at least 2 servings of vegetables every day?
Q6
Your child eats a variety of vegetables?
Q8
The juice your child drinks contains 100% fruit juice?
Q18
Your child eats very few foods with added sugar?
Q19
Your child drinks very few drinks with added sugar?
Q23
Your child chooses healthy foods at a fast-food restaurant?
Q25
Your child chooses healthy foods at school?
Q13
The meats or poultry your child eats are low-fat or lean?
Q2
At least half of your childs total grain servings each day are whole grains?
Q21
Your child drinks mostly water or fat-free milk and not fruit juice, soda, or
sports drinks?
Q27
There are limited unhealthy snacks in your home for snacks or meals?
Q20
The cereals that your child eats are unsweetened?
Q4
Your child will eat vegetables, even if they do not enjoy the taste?
Q14
If cooking with oils, you use vegetable oils?
Q9
The juice your child drinks is limited to one small glass (3/4 cup) per day?
Q5
Your child eats only 3 servings of starchy vegetables each week?
Q1
Your child eats only 3 servings of grains every day?
Q11
Your child eats at least 2 servings of milk or an equivalent dairy product every day?
Q12
Your child eats 2 servings of meat, beans or eggs every day?
Q22
You eat meals together as a family?
Q10
Your child eats at least 2 servings of milk or an equivalent dairy product every day?
Physical activity behaviors (PAB) items
Q30
Your child is physically active, even if you have excessive demands at work?
Q31
Your child is physically active, even if there are no gyms, parks, or playgrounds nearby?
Q28
Your child plays outside or is active in sports for a total of at least 60 min on most days of
the week?
Q29
Your child is physically active, even if the weather is bad?
Q35
Your child is physically active, even if they have homework?
Q32
Your child is physically active, even if you are concerned about safety?
Q34
Your child is physically active when with friends?
Q33
You can limit your childs screen time to no more than 2 hr per day?

Dietary
behaviors

Physical
activity
behaviors

SD

.73
.69
.69
.67
.66
.65
.64
.64
.63
.63
.60
.58
.58
.57
.56
.54

.11
.17
.15
-.02
.16
.29
.11
.15
.10
.26
.30
.10
.29
.21
.31
.22

6.36
6.26
5.34
7.11
6.27
7.46
5.84
6.21
7.52
5.43
7.14
5.27
6.36
7.58
6.01
7.23

2.70
2.81
2.74
2.68
2.64
2.95
3.25
3.19
3.21
2.83
3.14
2.99
2.85
2.55
2.89
2.82

.54
.50
.47
.47
.45
.44
.41
.40
.40
.36
.35

.23
.10
.17
.11
.18
.24
.31
.08
.28
.06
.20

7.52
4.97
4.86
9.18
6.46
5.56
6.40
7.33
7.67
8.22
8.42

2.73
3.23
3.33
1.73
3.18
3.07
2.82
3.35
2.53
2.47
2.29

.17
.16
.10

.93
.92
.87

8.09
8.02
8.51

2.30
2.27
2.24

.22
.21
.23
.20
.37

.82
.79
.73
.66
.35

7.58
8.10
7.69
8.30
7.86

2.60
2.19
2.38
2.06
2.60

Note: The questionnaire was developed by the author. SD, standard deviation.

DISCUSSION

This study describes the initial development and

psychometric testing of a new measure of parental
self-efficacy for enacting healthy lifestyles in
their children. Evaluation of responses from 146
parents of children 611 years old resulted in the
removal of one item, resulting in a 34-item questionnaire clustered into dietary and physical
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

activity behavior subscales and a total parental selfefficacy score.

Findings suggest that the questionnaire has
promise for future use. Measures of validity used in
this study suggest the instrument may be a valid
measure of the constructs desired. The initial
evaluation of content and face validity by eight
content experts suggested that the questionnaire, as
designed, appeared to measure what it purported and
153

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

contained the necessary items to measure these

constructs.
Results of the factor analysis suggested two
factors, DB and PAB, as was intended during item
development. Each factor did have more than four
factor loadings above .60, supporting the reliability
of each factor. However, question 33, How confident are you that you can limit your childs screen
time (i.e., TV, video games, computer) to no more
than 2 hr per day? did not load primarily onto
either factor (diet or physical activity), despite being
conceptually generated as a physical activity item.
Perhaps the specific item as an outlier should
attempt to better convey that limiting screen time
has long been related with increasing physical activity time (Anderson, Economos, & Must, 2008;
Boone, Gordon-Larsen, Adair, & Popkin, 2007). At
this time, this item was removed from the questionnaire for further analysis. The remaining 34 items,
however, all associated fittingly with their conceptually appropriate subscale. Item analysis further supported the two-factor structure and placement of
items on each factor. The inclusion of 27 items on
the DB factor also warrants further refinement of
the questionnaire to either include fewer items or
additional factors.
Although examination of the inter-item correlation matrix did show correlations exceeding .80
for items 2831, these items were retained for
further analysis and kept in the final questionnaire
despite possible multicollinearity. These items are
closely related but concerned with different barriers found in the review of the literature. The
items are concerned with the barriers of time
(item 28), weather (item 29), work demands (item
30), and resources (item 31). Because these barriers are each frequently and distinctly identified,
the items have been retained, despite their
similarities. In addition, the CVI of .97 and item
scores all above 3 (on a 4-point scale) supported
their inclusion.
Evaluation of the concurrent validity was conducted using the SEB-Eat and SEB-Ex scales. It was
hypothesized that the SEB-Eat and SEB-Ex scores,
on which the participants rate their self-efficacy for
their own healthy behaviors, would correlate with
the scores on the parental self-efficacy questionnaire. These scales were selected because previous
research suggested that parental behaviors often
correlate with those of their children. Results of the
analyses confirmed this. The questionnaire total
scores significantly correlated with both the SEB-Eat
and SEB-Ex total scores. However, the moderate
154

J. W. Decker

correlations (.51 and .35, respectively) support the

notion that the questionnaire is, in fact, measuring a
new concept.
Of interest is the strength of the correlation
between questionnaire scores and SEB-Eat and
SEB-Ex scores. The questionnaire total score correlated more strongly with the SEB-Eat (.51) than the
SEB-Ex (.35). This is possibly because physical activity within a household is generally not as consistent
across the family members as is dietary intake. In
general, the parental figures in a household decide
what foods are purchased in a store or restaurant
or prepared for meals, especially for this age group.
In addition, one would expect that dietary choices
within a household are mostly consistent among
family members, as meals are generally prepared for
a group rather than individuals, thus increasing the
likelihood that parents and their children are essentially eating the same food items.
Conversely, parents perception of their own
ability to be physically active is not as strongly
related to their belief in their ability to get their children to be physically active. This author hypothesizes many parents may sacrifice their own time
and physical activity in order to ensure that their
children are physically active. For example, a parent
might enroll a child in an activity or sport, but then
must commit to providing transportation and time
to the childs activity, rather than his or her own.
This notion is further supported by the lack of significant correlation between DB subscale scores and
SEB-Ex total and subscale scores.
Initial reliability estimates in this sample population were satisfactory. The total scale score and DB
and PAB subscale scores demonstrated internal
consistency and the testretest reliabilities for total
scale, and DB and PAB subscale scores were also satisfactory.
The main limitation of this study was the sample
recruited. Primarily there was a lack of diversity in
the sample, especially in race, ethnicity, socioeconomic status, and educational level. This was a
concern when designing the study and may be
attributed to the study being conducted on the Internet. The Internet was used to conduct the study even
with the knowledge that many people do not have
computer and Internet access or computer literacy
(Eysenbach & Wyatt, 2002; Fricker & Schonlau,
2002). A more diverse population sample was
expected as recent data suggested that there were
more than 200 million Internet users, approximately 70.2% of the total U.S. population (United
States of America: Internet usage and broadband
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

J. W. Decker

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

usage report, 2007). A larger number of participants in demographic subgroups, such as African
Americans, Hispanics, or low SES, more than were
anticipated. Although these demographic subgroups
have historically been underrepresented in Internet
studies because of lack of access or computer literacy,
these disparities are lessening (Fricker & Schonlau,
2002). This was not demonstrated in this study.
As a result, the homogeneity of the sample made
analysis of difference between various demographic
groups difficult, as the number of minority participants was too small to identify between-groups differences. Given the results of this study, further
testing of this questionnaire with a more racially and
ethnically diverse sample of parents is warranted.
Additionally, the sample recruited for this study
was unrestricted, although limited by inclusion
criteria, and may not be representative of the larger
population due to self-selection (Braithwaite,
Emery, De Lusignan, & Sutton, 2003; Duffy, 2002;
Eysenbach & Wyatt, 2002). Furthermore, because
the questionnaire was completed at the leisure of the
participant in this study, there was no control over
the environment in which it was completed, possibly allowing random factors or events to influence
the respondent. However, this issue is a concern
with mailed surveys as well and can only be controlled via in-person interviews, which presents a
large burden on participant and investigator (Duffy,
2002; Nosek et al., 2002). There was also the possibility of multiple responses by a single individual
(Bowen, Daniel, Williams, & Baird, 2008; Duffy,
2002; Nosek et al., 2002). Nevertheless, collection of
specific demographic datas, including respondents
and their childrens birth dates, allowed for identification and exclusion of multiple responses (Nosek
et al., 2002), and restriction of multiple responses by
IP address, or the individual identifier of each computer, also prevented multiple responses (Bowen
et al., 2008). Lastly, using the Internet for administration of the questionnaire limits its psychometric
evaluation only to administration using the Internet
or a computer.
Finally, self-report data provided by the participants for the height and weight of their children
yielded such an abnormal distribution that these
data were unusable. For example, the data provided
by the parents suggested a prevalence of children
below the 5th percentile and above the 97th percentile of body mass index (BMI) for age that far
exceeded the U.S. population norms. This suggests
the need for collection of these data by trained data
collectors or healthcare professionals.
Journal for Specialists in Pediatric Nursing 17 (2012) 147158
2012, Wiley Periodicals, Inc.

FUTURE RESEARCH AND IMPLICATIONS

The future directions and implications for this

instrument are varied and will add to the growing
arsenal of tools to be used in the fight against the
obesity pandemic. The first step in future research
for this questionnaire will include further testing of
the psychometric properties of this instrument in a
broader and more diverse demographic sample. In
particular, the target sample will focus on participants who are non-Caucasian races and Hispanic or
Latino ethnicity. Variability among other demographic factors, such as marital status, SES, and educational level, will also be sought. This will require
recruitment in communities with a higher prevalence of these demographic subgroups. Administration of the questionnaire via the Internet or
computer will also limit its utility. Examination of
the psychometric properties using paper copies of
the questionnaire will be necessary. Increasing the
utility of the questionnaire will require investigation
of its utility with parents with children in different
age groups, such as 25-year olds or 1217-year
olds. However, this will require changes in the questionnaire items to reflect the different developmental stages of these age groups. Finally, examination
of the questionnaires sensitivity to change over
time will be addressed.
The use of the parent label for the questionnaire
should be reconsidered or given an expanded definition. Future iterations of the questionnaire and
its testing may change this to caregiver or define
parent as the person most responsible for the
dietary and physical activity behaviors of the children. Therefore, the individual most responsible for
the healthy behaviors in the child will be targeted,
whether this is a parent, grandparent, aunt or uncle,
guardian, or even an older sibling.
Additional testing for the relationships between
this questionnaire and behaviors is planned. Future
studies will include measures of dietary intake (i.e.,
24-hr diet recall), physical activity (i.e., physical
activity recall surveys or accelerometers), and body
weight status (i.e., BMI, weight, waisthip ratio).
This will allow examination of the relationship
between scores on this questionnaire and the actual
behaviors or body weight status of the child.
Following refinement and further extensive
examination of the psychometric properties of the
questionnaire, translation into other languages
commonly found in the United States, such as
Spanish or Creole, may be warranted to increase its
utility and understandability among a broader range
155

Initial Development and Testing of a Questionnaire of Parental Self-Efcacy for Enacting Healthy Lifestyles in Their Children

of minority populations. This process will require

that the translated scale demonstrate conceptual,
item, semantic, operational, and measurement
equivalence to the original scale (Streiner &
Norman, 2003). The translated scale would then be
back-translated into English and compared with the
original scale for equivalence. Once the translation
process has been completed, the psychometric properties of the translated instrument will need to be
tested in the target sample.
The overarching goal of the development and psychometric testing of this questionnaire is for its use in
interventional research aimed at increasing caregiver
self-efficacy for promoting these healthy behaviors in
their children. Following further refinement and
psychometric evaluation, this questionnaire can
serve as a tool for assessing change or improvement in
parental self-efficacy from pre- to post-intervention
and fills in a previous gap in the arsenal.
Another area of potential use for this questionnaire is for research investigating the relationships
between factors that play a role in childhood overweight and obesity. Researchers may use parent
scores on this questionnaire to examine relationships with other parental or child measures, such as
dietary intake, physical activity participation, and
measures of fatness (i.e., BMI, weight, waisthip
ratio). This will allow further examination of the
relationship between parental self-efficacy for promoting these healthy behaviors in their children and
actual behaviors and weight status. Finally, if this
questionnaire is valid and reliable for use with
parents with children of other ages, comparisons of
parental self-efficacy can be assessed between
parents with children in different age groups,
perhaps assessing for changes in parental selfefficacy throughout their childs lifespan.
CONCLUSION

This questionnaire to assess parental self-efficacy

for promoting healthy dietary and physical activity
behaviors in their children demonstrates potential to
be a useful tool. It consists of two separate subscales,
composed of items related either to diet or physical
activity behaviors. The content and face validity of
the questionnaire were deemed acceptable and
valid by eight independent content experts. Lastly,
internal consistency and testretest reliability of the
total measure and its two subscales were strong.
These psychometric properties support the need
for further examination and refinement of this
questionnaire.
156

J. W. Decker

How might this information affect

nursing practice?

This study shows the initial development and psychometric evaluation of a new questionnaire to
assess parental self-efficacy for promoting healthy
dietary and physical activity behaviors in their children ages 611 years. The results demonstrate that
this questionnaire shows promise for future use.
However, further refinement and psychometric
evaluation of the questionnaire is necessary and
warranted. With further testing, this questionnaire
may provide an additional tool in the fight against
the childhood obesity pandemic.

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