Cultural adaptation and validation of SATAQ-4 “Sociocultural Attitudes towards appearance Questionnaire-4” for the Peruvian population

ABSTRACT

Eating disorders (anorexia and bulimia) have been increasing worldwide and nationally. Prior to the development of this disorder, adolescents’ present body dissatisfaction, whose study through the ¨Tripartite Influence Model¨ gives us three main pressures: Pressure from parents, media and peers. Factors that are studied through SATAQ-4. We conduct a study to validate the Peruvian version of SATAQ-4 "Sociocultural Attitudes Toward Appearance Questionnaire-4". Methods: A cross-sectional study was carried out in 2015. It was started by culturally adapting the test. Subsequently, validity was determined through the validity of the construct, and reliability through internal consistency assessment and intra-observer reliability (test-retest). Results: We obtained a culturally adapted instrument which presented a mean greater than 3 in the Delphi method, an intraclass correlation equal to 0.83 and an internal consistency (Cronbach alpha) of 0.90. The confirmatory factor analysis supported the original five-factor structure and the convergent validity analysis (r Pearson) when compared with BSQ a correlation of 0.70. Conclusions: The instrument adequately measures the construct for which it was created and can be applied in the Peruvian university environment.

INTRODUCTION

According to the World Health Organization (WHO), in the last 50 years there has been an increase in eating disorders (ACT), with anorexia nervosa (0.9 to 4.1%) and bulimia (0.5 to 1%) being the disorders that most affect the young female population ¹. The appearance of these disorders occur more frequently between adolescence and early adulthood, and represent a health risk, given their progressive clinical course and their tendency to become chronic (25-33% of patients), which can lead to death ^{1, 2}. In Peru, according to the registry of the Ministry of Health (MINSA), the number of new cases of eating disorders multiplied by eight between 1998 and 2008 ³ and, in a study carried out by the Pontificia Universidad Católica del Perú (PUCP) in school-age adolescents from Metropolitan Lima, 16.4% of them were at risk of developing eating disorders ⁴.

In addition to the change in weight perception, abnormal eating behavior and other comorbidities and/or disorders (obesity, substance abuse, depression, and anxiety), patients with eating disorders suffer a disturbance in the perception of body shape ⁵ and a negative visualization of this mental representation leads to the development of body dissatisfaction ^{6, 7}. However, it has been observed that not only patients with eating disorders present an altered body perception, but also young women who do not have this medical condition ⁸. Body dissatisfaction is influenced by a culture of thinness, where people who are thinner are seen as people with greater success, beauty, youth, and attractiveness compared to their peers ^9,10. A recent study showed a positive relationship between women who were overweight and obese and a greater dissatisfaction in body image and a negative perception of it ¹¹. Contrary to what was believed, this phenomenon occurs in a similar way in different societies. In a study carried out in Brazil and Argentina, where the body dissatisfaction of Latina university students was compared to that of American university students, it was found that these three groups of young people presented similarities in their body appreciation: they had a negative self-esteem and pursued an ideal of thinness ¹².

The sociocultural factors that influence the development of body dissatisfaction are diverse, but it was found that those that influenced in a deeper and more rooted way were those explained through the "Tripartite Influence Model," which is the model that has the most empirical support and is based on sociocultural forms that would explain body dissatisfaction and eating disorders ¹³. This model shows three main pressures on young people, which are exerted by the media, parents, and peers ^14,15. Firstly, the constant exposure of young women to the mass media (magazines, internet, television) that promote Western values of beauty and an ideal of unattainable thinness leads young women to feel their bodies are not beautiful ¹⁶. Secondly, feedback given by the family group (parents, siblings) within the home about the body, diet and weight of adolescent girls and young women influence how they internalize their body ideal ¹⁷. Lastly, peers influence young women through comments about their weight, discussions about the best diet, and discussions about their preconceived ideal of beauty ¹⁸.

Starting in 1994, the first version of the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-1) began to study the various factors that influence body image dissatisfaction in adolescent and young women ^{19, 20}. Attempting to improve the results obtained, new versions were made; version 3 of the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ-3) effectively evaluated the influence of the media on the ideal of thinness, but not the other factors that influence body dissatisfaction ^{21, 22}. Thus, a new version, Sociocultural Attitudes Toward Appearance Questionnaire 4 (SATAQ-4) ²³, where the three pressures mentioned above (peer pressure, parental pressure, and media pressure) are evaluated based on a better study of body dissatisfaction in young women, was created and validated in Spanish by Llorente et al., in a Spanish university ²⁴.

In Peru, there are no publications on this subject, and the studies in which it is mentioned are scarce ^{25, 26, 27}. A study carried out at a Peruvian university using the Body Shape Questionnaire (BSQ), showed a positive association between BMI and body dissatisfaction, with a percentage of women who had high body dissatisfaction and similar to that of other countries ²⁵. However, the BSQ only evaluates body dissatisfaction, so it is important to have an instrument that accurately evaluates the sociocultural pressures that influence its development. Therefore, it is necessary to assess the Peruvian version of the SATAQ-4, which will allows us to conduct further studies on the subject.

METHODS

We conducted a cross-sectional validation study from August to December 2015 at the Universidad Peruana de Ciencias Aplicadas (UPC) (UPC) in Lima, Peru. It was divided into the following phases: (a) cultural adaptation, (b) intra-observer reliability, (c) internal consistency and construct validity, and (d) convergent validity.

(a) Cultural Adaptation
The translated and validated version of SATAQ-4 ²² for the Spanish population was used to translate the instrument culturally, and seven experts (two linguists, two bio-statisticians, two psychologists, and one psychiatrist) were employed, who used the Escobar-Perez instrument for the Delphi method ³⁰. The category of cultural adaptation was added to this instrument, giving a total of five categories to be evaluated: Sufficiency, clarity, coherence, relevance, and cultural adaptation. The items were evaluated with a score from one to four. Observations were collected and the method was completed when all the experts scored each of the items of the final version delivered with 3 or more.

(b) Intra-observer reliability
With the culturally adapted instrument, intra-observer reliability was then evaluated, and the instrument was applied twice seven days apart ²⁸ to a population of thirty university students of legal age who agreed to participate freely, did not have a history of eating disorders, and had signed an informed consent form. With this group, the stability of the entire instrument and by domain was evaluated through the intraclass correlation test (ICC).

(c) Internal Consistency and (d) Construct Validity
After evaluating intra-observer reliability, internal consistency and construct validity were evaluated next, applying the instrument to older UPC university students who did not have a history of eating disorder, signed the informed consent form, and did not participate in the intra-observer reliability assessment. The number of items on the scale and the relationship of people included per items were taken into consideration. It was estimated that 20 subjects per item would have a better classification of the items in each domain ²⁹. Since the scale has 22 items, it was calculated that 440 students with complete data were necessary. An error rate of 10% was estimated; therefore the number of students surveyed through a non-probability sample was 484. To evaluate both global and domain internal validity, Cronbach's alpha was calculated. For construct validity, we performed a confirmatory factor analysis (CFA).

(e) Convergent validity
Convergent validity was evaluated in 484 surveyed students, to whom the Body Shape Questionnaire (BSQ) was applied together with the new version of SATAQ-4 through Pearson's r coefficient. Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) The SATAQ-4 has 22 items that use a Likert-type scale from 1 to 5, ranging from "completely disagree" to "completely agree". These items are divided into five domains or subscales: Two are for internalization that have 5 items each. Within the internalization of the ideal of thinness, the desire to have a body with little body fat is measured. Within the internalization of the athletic ideal, the desire to have a muscular and toned body is measured. Likewise, the three are pressure subscales have 4 items each, which assess the pressure exerted by family, friends, and the media to have a slim and toned body in each of the subscales. The Spanish version of SATAQ-4 shows a high internal consistency in the population where it was applied (university women), having a Cronbach's alpha for the global scale of 0.93, and a Cronbach's alpha between 0.88 and 0.97 for each of the domains ²⁴.

Body Shape Questionnaire (BSQ)
The BSQ is an instrument that measures the degree of body dissatisfaction ³¹. It was created and initially validated in English and validated for the Peruvian population in 2006 ³². It consists of 34 direct questions with six options, ranging from "never" to "always."

Other variables
The participants self-reported their age, weight, and height, which allowed the calculation of their body mass index (BMI).

Ethical Aspects
The study was reviewed and approved by the Ethics Committee of Universidad Peruana de Ciencias Aplicadas (CEI/399-10-14); all the participants signed the written informed consent after the study objectives were explained to them. All the surveys were anonymous except in the group that participated in the test-retest.

Statistical Analysis The data obtained from the surveys was entered by double typing in Microsoft Excel ® (Microsoft Corp, USA), and the statistical program STATA v14 ® (Stata Corp, TXT, USA) was used. For the analysis of the results of the Delphi method, the medians of the expert judgments for each item were calculated. For the evaluation of intra-observer reliability (test-retest), the intraclass correlation coefficient (ICC) was calculated globally and by domain; the ICC was interpreted as follows 0 – 0.2 poor correlation; 0.3 – 0.4 good correlation; 0.5 – 0.6 moderate correlation; 0.7 – 0.8 strong correlation; y >0.8 almost perfect correlation. ³³ Also, the Pearson correlation test was used both globally, by domain, and by item to assess stability, expecting to obtain positive results close to 1. On the other hand, Cronbach's alpha was calculated globally and by domain, considering values greater than 0.70 that were adequate to ensure the internal consistency of the test ²⁸. For the validity of the construct, we used structural equation models (SEM), and a confirmatory factor analysis was performed using the RMSEA (Root mean squared error of approximation), the Comparative Fit Index (CIF), and the Index of Tucker-Lewis (TLI) to evaluate the fit of the model. Finally, to assess the convergent validity, the Pearson correlation between the global and domain SATAQ-4 with the BSQ was used.

RESULTS

Cultural adaptation
From the first round of the Delphi, the term "seem" was changed to "shine" and the term "media" to "communication media." Although the terms "lean" and "body fat level" were initially suggested to be changed, since no better terms were found and their understanding was verified, the experts agreed to retain them. The modified instrument was evaluated in a second Delphi round, and a score equal to or greater than three was found in each of the five aspects evaluated, giving a median greater than 3, with the acceptance of the instrument as culturally adapted by each of the experts. The final wording of the items is shown in Table 1.

Table 1: Final items, factor load values and dimension to which they belong for said load, mean of each item, results of Pearson's correlation test-retest analysis (n = 484).
Note: SATAQ-4, Sociocultural Attitudes Towards Appearance Questionnaire.
*test retest (n=30)

Intra-observer reliability With the culturally adapted instrument, two UPC classrooms were surveyed (20 students per classroom); from those who attended on the two days of the survey, 30 students were selected. The instrument was given to solve on two occasions, with a difference of 7 days between each resolution. The mean age was 19.7 with a standard deviation (SD) of 2.2, of which 23.3% were overweight.
The scores obtained at both the item and domain levels in the test-retest evaluated with the Pearson correlation test were positive and close to 1 (see Table 1 and 2). The overall intraclass correlation of the instrument was 0.83, and domains ranged from 0.74 to 0.89 (Table 2).).

Table 1: Reliability, internal consistency and convergent validity of the Peruvian version of SATAQ-4 (Sociocultural Attitudes Towards Appearance Questionnaire-4)
Note: BSQ, Body Shape Questionnaire;
* Spanish version validated by Llorente ²⁴

Construct validity
After checking the stability of the instrument, 531 university students were surveyed, of which 32 surveys were eliminated for presenting positive antecedents for eating disorders and 15 for not completing the survey. The mean age of the surveyed students was 19.7 (SD: 2.4), and the mean weight was 58.4 (SD: 8.5); of which 25% were overweight. The average SATAQ-4 score was 61.2. The average scores for each of the dimensions, thinness ideal, athletic ideal, family pressure, friend pressure, and media pressure were 16.6, 20.8, 10.4, 9.2, and 12.1, respectively.
The SATAQ-4 with its 5 dimensions (thin, muscular, family, friends and media) raised by Schaefer et al., are shown in Figure 1. Confirmatory factor analysis revealed that the model presented showed an adequate fit, Likelihood ratio Chi2 = 936.214, p <0.001; Comparative Fit Index (CFI) = 0.898; Tucker-Lewis Index (TLI) = 0.882; Root mean squared error of approximation (RMSEA) = 0.087 IC95% (0.082 – 0.093). (Table 1)
The adequacy of the sample for the individual elements ranged from 0.52 to 0.91, suggesting that the data is adequate for factor analysis. Likewise, the independent confirmatory factor analysis of the instrument showed a division into five factors, as did the versions of the instrument validated in the United States and Spain ^3.7.

Internal consistency
Cronbach's alpha was used to assess the internal consistency of the instrument. The global result was 0.90. For the subscales, it was good. It varied between 0.82 and 0.95 (Table 2). These values are similar to the validation carried out in Spain, which indicates that the instrument has good internal consistency.

Convergent validity
The correlation between SATAQ-4 and BSQ was high, with a Pearson's r of 0.70. When evaluating each subscale, the correlation varied between 0.49 and 0.56 (Table 2).

DISCUSSION

This work presents the validation and cultural adaptation of the SATAQ-4 for the female Peruvian university population. Basing its importance on studies previously conducted in other countries, where SATAQ was applied in its various versions and where the risk posed by the various sociocultural factors in the development of eating disorders and body dissatisfaction was verified ³⁴.
The reliability and validity of the SATAQ-4 presented an optimal psychometric property, the values of the sample adequacy, and the Cronbach's alpha for the general scale and the five subscales were good. The pilot sample adequacy showed values > 0.53 that are lower than those obtained in Spain by Llorente et al. (> 0.70), but similar (> 0.41) to the original study carried out by Schafer et al., ⁹. On the other hand, the Cronbach's alpha of the sample obtained results superior to 0.69, values similar to those obtained by Llorente et al., ²³ and Schafer et al. ²², in their respective studies. Therefore, it can be concluded that the construct validity and the internal consistency of the instrument are adequate.
The pattern of eigenvalues resulted in a five-factor model; this result was similar to that obtained in studies conducted in other countries ^{23, 24, 34}. Furthermore, the confirmatory factor analysis for the subscales showed an adequate fit to the five-factor structure for all items similar to the Spanish validation ²⁴ and the two validations performed by Schafer et al., ^{23, 34}. We use the BSQ for the evaluation of convergent validity. The majority of the subscales showed a good correlation with the BSQ. However, the muscular internalization subscale showed a low correlation, as reported in the Spanish version of SATAQ-4 ²⁴. Our study has some limitations; the instrument was self-applied, so there may be an information bias in the female population. Nevertheless, the study conducted by Schafer et al. ³⁴, who worked with the male and female population, reported similar results for both populations. Therefore, in subsequent studies, the male population should be included. The study did not find university students with obesity, despite the fact that in recent years there has been an increase in the rates of overweight and obesity worldwide ³⁸ with groups that present a higher risk of unhealthy behaviors for weight control ³⁹.

Currently, an increase in eating disorders ^{1, 35, 36} and body dissatisfaction ^4.7 has been observed; therefore, it is critical to conduct this validation study, which will allow us to understand the influencing factors in body satisfaction and identify these factors in order to create prevention and control strategies. Our study only sought to validate the SATAQ-4 in the undergraduate population of a Peruvian private university. However, it would be important to validate it in other populations, such as adolescents, men, different socioeconomic levels, and other Spanish-speaking countries.

In conclusion, the version of the SATAQ-4 for the Peruvian population is culturally adapted, with adequate construct validity, high internal consistency, and right temporal stability; it adequately measures the construct for which it was created and can be applied in the Peruvian university environment.

Figure 1: Five-factor model for SATAQ-4 (Sociocultural Attitudes Towards Appearance Questionnaire-4) obtained from the Confirmatory Factor Analysis

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ACKNOWLEDGEMENTS

The researchers thank each of the university students participating in the study for their collaboration, and the professors and authorities of the university who provided all the facilities for the execution of the study.
Jorge L. Maguiña is a doctoral candidate studying Epidemiological Research at the Universidad Peruana Cayetano Heredia under the FONDECYT/CIENCIACTIVA grant and supported by the D43 TW007393 training grant from the Fogarty International Center of the National Institute of Health of the United States.