Attitudes and Beliefs of Nursing Students Towards the Childhood Overweight Scale

1. Abstract

The Attitudes and Beliefs of Nursing Students Towards the Childhood Overweight Scale is a specialized psychometric inventory developed and validated by Semerci, Çelik, and Kudubeş (2023) to evaluate implicit and explicit cognitive appraisals, stereotypical perceptions, and causal attributions concerning pediatric obesity among undergraduate nursing students. Adapted from the pediatric adaptation by Tsai et al. (2018), which evolved from the seminal work of David B. Allison (1995) on the Attitudes Toward Obese Persons (ATOP) and Beliefs About Obese Persons (BAOP) scales, this 19-item measurement tool operationalizes weight bias specifically in pediatric nursing contexts. The instrument is partitioned into two major conceptual components: the Attitudes Towards Obese Persons children’s adaptation (comprising two distinct latent dimensions: Self-Concept and Social Relations) and the Beliefs About Obese Persons children’s adaptation (a unidimensional construct evaluating locus of control and controllability attributions). The adaptation into Turkish followed formal cross-cultural translation protocols with explicit authorization from Dr. Lauretta Luck.

Psychometric evaluation of the instrument across third- and fourth-year nursing students revealed outstanding content validity, with an item-level content validity index (I-CVI) ranging from 0.91 to 0.99 and a scale-level content validity index (S-CVI) of 0.97. Construct validity was corroborated via exploratory factor analysis (EFA), which isolated a two-factor solution for the ATOP component explaining 49.3% of the variance and a unidimensional structure for the BAOP component accounting for 55.92% of the variance. Confirmatory factor analysis (CFA) demonstrated good model fit indices for both subscales (ATOP: χ²/df = 2.151, RMSEA = 0.073, GFI = 0.932, CFI = 0.924; BAOP: χ²/df = 2.190, RMSEA = 0.074, GFI = 0.969, CFI = 0.976). Internal consistency reliability was confirmed with Cronbach’s α coefficients exceeding 0.70 across all subscales. The scale serves as a diagnostic, educational, and empirical instrument designed to illuminate implicit bias, refine pediatric nursing curricula, and mitigate weight stigma in pediatric healthcare environments.

2. Keywords

Attitudes Toward Childhood Obesity, Nursing Students, Pediatric Weight Stigma, Attitudes Toward Obese Persons, Beliefs About Obese Persons, Self-Concept, Social Relations, Psychometrics, Nursing Education, Weight Bias

3. Authors

The Turkish adaptation and psychometric validation of the Attitudes and Beliefs of Nursing Students Towards the Childhood Overweight Scale was conducted by a team of nursing scholars specialized in pediatric health and psychiatric nursing:

• Remziye Semerci, PhD, RN — Department of Pediatric Nursing, Faculty of Nursing. Corresponding Author. Email: [email protected].
• Özge Mengi Çelik, PhD, RN — Department of Pediatric Nursing, Faculty of Health Sciences.
• Aslı Akdeniz Kudubeş, PhD, RN — Department of Pediatric Nursing, Faculty of Health Sciences.

The scale traces its conceptual lineage to the pediatric adaptation by Tsai et al. (2018) and the foundational work of David B. Allison (1995), with cross-cultural translation permissions formally authorized by Dr. Lauretta Luck.

4. Purpose

Pediatric obesity is globally recognized by the World Health Organization (WHO) as one of the most pressing public health challenges of the 21st century. Beyond the physiological sequelae—including metabolic syndrome, type 2 diabetes mellitus, non-alcoholic fatty liver disease, and orthopedic complications—children with overweight and obesity navigate pervasive weight stigma, social exclusion, teasing, and emotional distress. Crucially, empirical literature indicates that healthcare environments are not immune to weight bias; healthcare professionals, including registered nurses and nursing students, often harbor implicit and explicit negative attitudes toward individuals with obesity, frequently stereotyping them as unmotivated, undisciplined, or non-compliant.

When directed toward children, healthcare-associated weight bias can have catastrophic clinical consequences. Children experiencing bias from healthcare providers report heightened medical avoidance, avoidance of preventative screenings, decreased physical activity, exacerbation of depressive symptoms, and elevated risks for developing disordered eating behaviors. In nursing education, students frequently receive robust didactic training regarding nutritional requirements and energy balance calculations, but rarely undergo formal self-reflection regarding their implicit prejudices, sociocultural stereotypes, or causal attributions regarding body weight.

The Attitudes and Beliefs of Nursing Students Towards the Childhood Overweight Scale was established precisely to fulfill this critical diagnostic and pedagogical void. The primary purposes of the instrument encompass:

• Quantifying Nursing Students’ Attitudes: Measuring the degree to which undergraduate nursing students endorse negative stereotypes regarding the personal attributes, academic potential, personality traits, and psychological resilience of children living with overweight or obesity.
• Delineating Causal Attributions: Evaluating students’ core beliefs regarding the etiology and controllability of pediatric obesity—specifically examining whether students attribute excess weight exclusively to behavioral volition and parental negligence or acknowledge complex genetic, neuroendocrine, socioeconomic, and environmental determinants.
• Curricular Evaluation and Intervention: Providing nurse educators and academic institutions with a validated psychometric metric to assess the baseline prevalence of weight stigma and measure the longitudinal efficacy of educational anti-stigma interventions within clinical simulation, community health nursing, and pediatric clinical practicums.
• Minimizing Disparities in Pediatric Clinical Care: Assisting future nurses in cultivating empathy, self-awareness, and non-judgmental communication strategies prior to entering direct patient care, thereby fostering equitable and dignity-preserving pediatric healthcare delivery.

5. Psychological Construct

The instrument operationalizes two foundational, interdependent psychological constructs drawn from social psychology and behavioral medicine: attitudes and beliefs regarding obesity, contextualized specifically to pediatric populations.

1. Attitudes Toward Obese Persons (ATOP – Children’s Version)

In accordance with Gordon Allport’s classical framework, an attitude represents a learned predisposition to respond in a consistently favorable or unfavorable manner with respect to a given object or group. Within this instrument, attitudes reflect evaluative, affective, and cognitive stereotyping directed toward children with overweight and obesity. The factor analysis of the adapted instrument isolates two sub-dimensions:

• Self-Concept: This sub-dimension captures perceptions regarding the internal self-esteem, self-efficacy, psychological adjustment, emotional well-being, and perceived self-worth of children who have overweight or obesity. It assesses whether respondents assume that excess body weight inherently impairs a child’s internal psychological integrity, rendering them insecure, anxious, or unmotivated. Nursing students harboring negative biases along this dimension might patronize pediatric patients or erroneously assume that depressive symptoms or social withdrawal are inevitable traits of the child rather than consequences of societal marginalization.
• Social Relations: This dimension evaluates expectations regarding the child’s interpersonal functioning, peer relationships, social popularity, and susceptibility to bullying or ostracism. It measures the extent to which nursing students anticipate that children with overweight cannot maintain healthy social bonds, are naturally disliked by peers, or struggle in collective educational and recreational settings. High bias on this subscale reflects an assumption of fundamental social deficit in children with higher body weight.

2. Beliefs About Obese Persons (BAOP – Children’s Version)

The belief construct captures cognitive attributions regarding the etiology, controllability, and modifiability of pediatric obesity. Anchored in attribution theory, this dimension measures the degree to which respondents attribute body weight to internal, controllable behavioral factors (e.g., lack of self-discipline, poor personal willpower, laziness, overeating, poor parental oversight) versus external, uncontrollable physiological and structural factors (e.g., genetic predisposition, metabolic dysregulation, endocrine pathology, neighborhood food insecurity, medication side effects).

In healthcare providers, a strong belief in individual controllability is consistently linked with heightened moral condemnation, diminished clinical empathy, and victim-blaming attitudes. Conversely, recognizing the multi-factorial, polygenic, and systemic nature of pediatric adiposity promotes supportive, evidence-based clinical partnerships.

6. Theoretical Framework

The scale rests upon a confluence of three foundational theoretical models in social and health psychology:

1. Attribution Theory (Bernard Weiner)

Weiner’s Attribution Theory posits that individuals act as naive psychologists, constantly seeking to understand the causes behind behaviors and physical states. These attributions fall along three primary dimensions: locus of control (internal vs. external), stability (stable vs. unstable), and controllability (controllable vs. uncontrollable). When health conditions are appraised as internal and controllable (such as an individual simply ‘choosing’ not to exercise or a parent ‘allowing’ poor nutrition), observers experience affective reactions of anger, blame, and disgust, resulting in discriminatory behavioral inclinations.

Conversely, when a condition is appraised as external and uncontrollable (e.g., genetic vulnerability, neurochemical appetite dysregulation, socioeconomic barriers to nutritious food), observers experience empathy and prosocial helping motivations. The BAOP subscale operates directly on this framework, identifying whether nursing students evaluate childhood overweight through a punitive lens of personal volition or through a comprehensive biopsychosocial etiology.

2. Social Stigma Theory (Erving Goffman)

Erving Goffman’s seminal conceptualization of stigma characterizes it as an attribute that is deeply discrediting, reducing the bearer from a whole and usual person to a tainted, discounted one. Goffman classified stigma into three typologies: abominations of the body (physical deformities or deviations from physical norms), blemishes of individual character (perceived weak will, unnatural passions, or dishonesty), and tribal stigma of race, nation, or religion.

Obesity occupies a uniquely damaging intersection between physical deviations and characterological blemishes; society frequently interprets visible adiposity as an external manifestation of underlying moral and psychological failure. In the context of nursing education, Goffman’s model illuminates how healthcare trainees unconsciously extend negative physical stereotypes into global assessments of a child’s character, intelligence, and social viability, as measured by the ATOP Self-Concept and Social Relations subscales.

3. The Stereotype Content Model (Susan Fiske et al.)

The Stereotype Content Model posits that social perceptions of outgroups are organized along two fundamental dimensions: warmth (intentions: friendly, sincere, trustworthy) and competence (capability: skillful, confident, intelligent). Individuals with obesity are frequently stereotyped as low in competence and moderate-to-low in warmth. When pediatric nurses perceive children with obesity through this lens, they may provide less educational depth, deliver less thorough physical assessments, or demonstrate reduced therapeutic patience, directly impairing pediatric health outcomes.

7. Validity

The validation protocol executed by Semerci, Çelik, and Kudubeş (2023) followed rigorous psychometric standards to establish content, construct, and structural validity within a target cohort of undergraduate nursing students.

1. Content Validity

Cross-cultural translation and linguistic adaptation were executed following standard back-translation methodologies. Subsequently, content validity was formally evaluated by a multidisciplinary panel of academic experts in pediatric nursing, psychiatric nursing, and psychometrics. Experts evaluated each item for linguistic clarity, cultural relevance, and theoretical alignment with pediatric weight bias:

• Item-Level Content Validity Index (I-CVI): Calculated values across all items ranged from 0.91 to 0.99, far exceeding the standard psychometric threshold of 0.78 recommended for retaining items without substantial modification.
• Scale-Level Content Validity Index (S-CVI): The universal agreement S-CVI achieved an exceptional value of 0.97, demonstrating unanimous expert consensus regarding the theoretical fidelity and clinical relevance of the instrument.

2. Construct Validity

Construct validity was established through structural verification using factor analysis. In scale validation, explained variance serves as a core benchmark for construct adequacy; accounted variance exceeding 40% is widely recognized as indicating robust construct representation. For the ATOP children’s version, the two extracted factors collectively accounted for 49.3% of the total variance. For the BAOP children’s version, the unidimensional construct explained 55.92% of the total variance. These findings confirm that the scale captures substantial structural variance in nursing students’ implicit and explicit appraisals.

8. Reliability

The internal consistency and precision of the Turkish adaptation were evaluated using classical test theory metrics:

• Internal Consistency (Cronbach’s α): The scale demonstrated acceptable to good internal reliability across all domains. For both the ATOP children’s version and the BAOP children’s version, Cronbach’s α coefficients were systematically reported to be greater than 0.70 (α > 0.70), satisfying the standard threshold established by Nunnally and Bernstein for health and social science research.
• Inter-Item Homogeneity: High item-total correlations and consistent intra-subscale correlations confirmed that items assigned to respective dimensions measured coherent psychological attributes without internal redundancy.
• Measurement Precision: The robust internal consistency figures ensure that variance in student scores reflects true variance in cognitive and affective bias rather than random measurement error.

9. Factor Analysis

To substantiate the latent architecture of the instrument, Semerci et al. (2023) conducted both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) on empirical data collected from undergraduate nursing students.

1. Exploratory Factor Analysis (EFA)

• ATOP Children’s Version: EFA extracted a clean two-factor structure based on Kaiser’s criterion (eigenvalues > 1.0) and scree plot inspection. Together, these two factors explained 49.3% of the total variance. The two latent dimensions corresponded precisely to Self-Concept (evaluations of the child’s internal psychological resilience, confidence, and self-worth) and Social Relations (perceptions of the child’s interpersonal adaptability, peer relationships, and social acceptance).
• BAOP Children’s Version: EFA corroborated a single-factor structure with an eigenvalue exceeding 1.0. This unidimensional factor accounted for 55.92% of the total variance, confirming that beliefs concerning the controllability and causality of childhood obesity load onto a single cognitive attribution continuum.

2. Confirmatory Factor Analysis (CFA)

Confirmatory factor analysis was conducted to assess the structural fit of the empirically derived models. Multiple fit indices were evaluated against established psychometric benchmarks:

Both models exhibited χ²/df ratios well below the conservative cutoff of 3.0, Root Mean Square Error of Approximation (RMSEA) values below 0.08, and Goodness-of-Fit (GFI) and Comparative Fit Index (CFI) values exceeding 0.90 (with BAOP exceeding 0.95), confirming excellent construct validity and structural fidelity.

10. Instrument / Measurement Tool

• Instrument Name: Attitudes and Beliefs of Nursing Students Towards the Childhood Overweight Scale (incorporating the adapted ATOP and BAOP Children’s Versions).
• Original Instrument Type: Self-report inventory / psychometric questionnaire.
• Target Population: Undergraduate nursing students (specifically tested and validated on 3rd and 4th-grade university nursing students), general nursing trainees, and pediatric healthcare professionals.
• Age Group: Adults (18 years of age and older).
• Item Count: 19 items across two composite instruments.
• Structural Subscales:
  • Attitudes Towards Obese Persons (ATOP – Children’s Version):
    • Subscale 1: Self-Concept (evaluates cognitive perceptions of the child’s internal psychological resilience, emotional balance, and self-esteem).
    • Subscale 2: Social Relations (evaluates assumptions regarding the child’s interpersonal relationships, peer acceptance, and social functioning).
  • Beliefs About Obese Persons (BAOP – Children’s Version): Unidimensional construct assessing causal attributions, locus of control, and perceived controllability of childhood obesity.
• Response Scale & Format:
  • ATOP Component: Items are rated on a 5-point Likert scale: 1 = Strongly disagree, 2 = Disagree, 3 = Undecided, 4 = Agree, 5 = Strongly agree.
  • BAOP Component: Items are evaluated on a 5-point Likert-type scale measuring agreement regarding causal controllability factors.
• Administration Time: Approximately 8 to 12 minutes.
• Scoring and Interpretation: Individual item scores are summed or averaged across subscales according to standardized keying protocols. Higher scores on the ATOP subscales represent more positive, non-stigmatizing attitudes toward children with overweight, whereas lower scores indicate higher levels of implicit and explicit weight bias. On the BAOP scale, higher scores reflect an understanding of obesity as driven by physiological, biological, and uncontrollable environmental factors, whereas lower scores reflect strong attributions of personal blame, behavioral negligence, and individual controllability.

11. Permissions & Fee and Test Year

• Test Year: 2023.
• Original Authors / Translators: Remziye Semerci, Özge Mengi Çelik, and Aslı Akdeniz Kudubeş.
• Prior Adaptation Authors: Tsai et al. (2018), adapted from the original instruments by David B. Allison (1995).
• Permissions & Accessibility: The scale was adapted into Turkish under written permission granted by Dr. Lauretta Luck. The complete assessment instrument, full item roster, and authorized scoring keys are copyrighted intellectual property. Researchers and nurse educators wishing to utilize the tool for academic, non-commercial research, or curricular evaluations must obtain formal approval from the corresponding author, Dr. Remziye Semerci ([email protected]).
• Commercial Status / Fee: The instrument is not commercially licensed for automated test battery platforms; academic use typically incurs no fee upon receiving institutional and author authorization.

12. References

• Allison, D. B., Basile, V. C., & Yuker, H. E. (1991). The measurement of attitudes toward and beliefs about obese persons. International Journal of Eating Disorders, 10(5), 599–607. https://doi.org/10.1037/0022-3514.82.6.878
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity, 17(5), 941–964. https://doi.org/10.1038/oby.2008.636
• Semerci, R., Çelik, Ö. M., & Kudubeş, A. A. (2023). Investigation of psychometric properties of Turkish version of nursing students’ attitudes and beliefs towards Childhood Obesity Scale. Archives of Psychiatric Nursing, 43, 65–70. https://doi.org/10.1016/j.apnu.2022.12.029
• Tsai, M. C., Strong, C., Chen, Y. L., & Lin, C. Y. (2018). Validation of the Attitudes Toward Obese Children Scale and Beliefs About Obese Children Scale in Taiwanese healthcare students. Disability and Rehabilitation, 40(12), 1450–1456. https://doi.org/10.1080/09638288.2017.1300627
• Weiner, B. (1985). An attributional theory of achievement motivation and emotion. Psychological Review, 92(4), 548–573. https://doi.org/10.1037/0033-295X.92.4.548

13. Items of the Scale