Pongkiatchai et al.

Nutrition Journal (2019) 18:35

https://doi.org/10.1186/s12937-019-0463-1

RESEARCH Open Access

Evaluation of a questionnaire to assess

nutritional knowledge, attitudes and
practices in a Thai population
Rungnapa Pongkiatchai1, Rewadee Chongsuwat1*, Nopporn Howteerakul2, Patcharanee Pavadhgul1,
William Ollier3 and Artitaya Lophatananon3

Abstract
Background: The rapid increase in non-communicable chronic diseases in people of working age has had a major
effect on health care utilization, productivity and economy. Lifestyle and diet are recognized as being major risk
determinants involved. Disease prevention strategies need to be based on people’s understanding of nutritional
knowledge, attitudes and practice. This study evaluates the validity of a new nutritional knowledge and practice
questionnaire specifically developed for assessing individuals of working age in a Thai population.
Methods: The questionnaire was constructed and based on previous relevant literature and its content validity
was scrutinized by an expert panel. An exploratory factor analysis (EFA) was performed to reduce the number of
questions included. Subsequently, data from a cross-sectional study of 1,032 participants were used to evaluate the
reliability and validity of this questionnaire. The validity of the questionnaire constructed for assessing knowledge and
attitude was evaluated using Confirmatory Factor Analysis (CFA). For the practice component, set criteria were applied
to determine the final variables used.
Results: CFA of the nutritional knowledge component suggested that all the variables in the model fitted with the
data (χ2 = 80.17, df = 66, p > 0.05, CFI = 0.99, RMSEA = 0.01, SRMR = 0.02). The CFA final model for the nutritional
knowledge included three factors (food recommendation, nutrients related to diseases, and healthy diet) with
a total of 14 questions. For nutrition attitude, CFA also revealed a good fit (χ2 = 178.14, df = 93, p < 0.001, CFI =
0.99, RMSEA = 0.03, SRMR = 0.03). The final CFA model for nutritional attitude included three factors (food choice,
healthy diet and food recommendation) with a total of 16 questions. For practice items, the number of questions
was reduced from 76 to 60.
Conclusions: Questionnaire development should use a logical, systematic and structured approach. Results from our
evaluation process demonstrates the construction validity of the nutritional knowledge and practice questionnaire
developed. This questionnaire can be further modified for use in other countries within the region.
Keywords: Chronic disease, Nutritional knowledge, Nutritional attitude, Nutritional practice, Working age

* Correspondence: [email protected]
1
Department of Nutrition, Faculty of Public Health, Mahidol University, 420/1
Ratchawithi RD., Ratchathewi District, Bangkok 10400, Thailand
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 2 of 10

Background inclusion were (i) Thai nationality (ii) living in a selected

Changes in society and the global economy during the area for a minimum of 3 months (iii) being aged between
past two to three decades have resulted in significant 18 and 60 years (iv) ability to read and write Thai (v) being
changes in the nutritional status and health of popula- in good health and not affected with diseases such as can-
tions, particularly in developing countries [1]. Thailand cer and cardiovascular disease (vi) giving informed consent.
is no exception; this country has undergone significant
social and economic changes since 1997 [2]. These Questionnaire development
changes have led to the increasing introduction of a Prior to this study, a nutritional knowledge and practice
western lifestyle where Thai people consume higher fat questionnaire was developed by combining a trawl of
foods and “fast-foods” together with an increasing con- relevant information in peer-reviewed published litera-
sumption of a less healthy diet and a more sedentary life- ture with that gained from discussion with an expert
style [1]. These are major causes of non-communicable panel. The initial questionnaire list of 131 questions/
diseases (NCDs) such as cardiovascular disease, osteopor- items aimed at measuring nutritional knowledge, atti-
osis, and diabetes [3–5]. Thus changes in society have led tude and practice in Thai people working age. The
to subsequent changes in disease prevalence; reciprocally, knowledge component comprised multiple-choice ques-
increases in chronic disease prevalence then changes soci- tions, each with 4 answers. Correct answers scored one
ety further [6]. point and incorrect answers zero points. All answers re-
Level of educational attainment is one of a number of ported as ‘don’t know’ were coded as incorrect. For the
factors that influence nutritional knowledge. Further- “attitude” component a 5-point scale ranging from 1
more, nutritional knowledge and attitude are correlated (strongly disagree) to 5 (strongly agree) was used. A
with each other and both play key roles in influencing Likert scale was used to quantify the results of “attitude”.
nutritional behavior [7]. Given a changing and increasing For “nutritional practice” (P), the response scale was
trend of western lifestyle in Thailand, it is important to classified as: seldom eaten (0-1 days/week), often eaten
gain a clear insight into the population-based knowledge (2–3 days/week) and always eaten (4–7 days/week).
of diet and the changing patterns of behavior, both in-
creasing risk of chronic disease development, especially Validation process
in those of working age [4]. This knowledge will facili- Prior to the validity process, Exploratory Factor Analysis
tate the introduction of interventions that prevent or (EFA) was employed to both identify important factors
reduce future disease development. Epidemiological and to selectively reduce the number of items in the
studies into the relationship between chronic disease de- questionnaire. The process of questionnaire develop-
velopment and nutritional risk exposures can only be ment is depicted in the flow chart (see Additional file 1:
achieved through the appropriate collection of robust in- Figure S1). Results from EFA were used to derive a sub-
formation on the factors that determine our knowledge, sequent version of the questionnaire (see Additional file 2:
attitudes, practices and preferences relating to food and Table S1 and S2). In this article, we present results from
nutrition. Such data can only be generated by the devel- data collected using the refined version of the question-
opment of appropriate questionnaires and these have to naire after EFA analysis. Data were collected from 1080
be validated and assessed within the social context of subjects residing in the Northern, Northeast, Southern,
the populations they are designed for. This study evalu- and Central regions of Thailand. The participants’
ates a questionnaire specifically constructed to assess weight and height were also measured. Body mass index
nutritional knowledge, attitude, and practice in a work- was computed and classified into 4 categories according
ing Thai population. to World Health Organization recommendation on
body-mass index (BMI) cut-off points for determining
Methods overweight and obesity in Asian populations [8, 9]. 48
Study design subjects were excluded due to missing data. Data from
This study was conducted using a cross-sectional ap- 1032 subjects were included in the analysis.
proach. Study approval was gained from the Ethical Re-
view Committee for Human Research, Faculty of Public Data analysis
Health, Mahidol University, Thailand (COA. No. MUPH Descriptive statistics were used to summarize the demo-
2014–189). Data were collected using the nutritional graphic data. Confirmatory Factor Analysis (CFA) was
knowledge and practice self-administered questionnaire used to evaluate and confirm the factorial structure of
for the period from October 2015 to September 2016. nutritional knowledge and attitude collected using the
Participants were recruited from the Northern, Southern, questionnaire. CFA is a technique used to evaluate the
Northeastern and Central regions of Thailand between level of fit of the data to the specific, theory-derived
January and September of 2015. The criteria for study measurement model where items contribute load only to
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 3 of 10

the factors they were designed to measure [10]. Further- Table 1 General characteristics of participants
more, these factors should be correlated. Finally, errors Characteristics Cross-sectional (n = 1032) %
across variables should be uncorrelated. It is noted that Sex
smaller factor loadings result in larger error variances, Male 397 38.5
however this can be improved by re-specification of the
Female 635 61.5
model. To estimate the parameters of the model, the
model itself must be properly defined. “Goodness-of-fit” Age (years)
measures underlying the analysis of the CFA [11], in- 18–32 310 30
cluded chi-square (X2) which shows the difference be- 33–47 526 51
tween observed and expected covariance matrices; 48–62 196 19
values closer to zero indicate a better fit. Researchers BMI (kg/m2)
may fail to reject an inappropriate model where sample
Standard (< 23.0) 551 53.4
sizes are small and reject an appropriate model where
sample sizes are large. Consequently, other measures of Overweight (23.0–24.9) 222 21.5
‘goodness of fit’ have been developed. Comparative fit Class I obesity (25.0–29.9) 230 22.3
index (CFI) analyzes the model fit by examining the dis- Class II obesity (≥30.0) 29 2.8
crepancy between the data and the hypothesized model, Marital status
while adjusting for the issues of sample size inherent in Single 339 32.8
the chi-squared test of model fit, and the normed fit
Married 614 59.5
index. The standardized root-mean-square residual
(SRMR) is the square root of the discrepancy between Divorce/separated 79 7.7
the sample covariance matrix and the model covariance Education
matrix. The root mean square error of approximation High school and lower 289 28
(RMSEA) avoids issues due to sample size by analyzing Diploma / Vocational school 215 20.8
the discrepancy between the hypothesized model, with Bachelor degree and higher 528 51.2
optimally chosen parameter estimates, and the popula-
Occupation
tion covariance matrix. The accepted approach for asses-
sing goodness of fit requires that the chi-square (X2) Employee 301 29.2
analysis should have a non-significant p-value and a X2/ Private company staff 207 20.1
df value that is at 3 or below. It is important to consider Government staff 276 26.7
that the modified X2 from re-specification is usually up- Self employed 108 10.5
wardly biased with sample size [12, 13]. The calculated Agricultures 140 13.6
value for CFI should lie between 0 and 1, with a value over a
Salary (THB)
0.90 indicating a good fit. A value for SRMR should be at
0.08 or below. RMSEA values of approximately 0.06 or < 15,000 282 27.3
below indicates an acceptable fit, with values 0.05 or less, 15,000-25,000 547 53
indicating good fit [14]. If the analysis indicated a possible 25,001- 35,000 142 13.8
data-model misfit, model modification was applied. This 35,001-45,000 42 4.1
modification involved further re-specification by (i) adding 45,001-60,000 19 1.9
a parameter in the model with a large modification index a
(1 USD = 35.2 THB)
(MI) and (ii) deleting a parameter from the model with a
non-significant path. completed the nutritional knowledge and practice ques-
For the “practice component”, the items included were tionnaire, (response rate 95.6%). Most of participants
based on a food frequency questionnaire (FFQ) [15]. The were female (62%), married (59.5%) and had attained an
criteria used to exclude food items included: (i) food items undergraduate university degree or higher (51.2%). The
deemed as being seasonal food, (ii) any food item that was participants’ age ranged from 18 to 62 years with a mean
consumed in less than 60% of our subjects, (iii) food items age of 38 years. For BMI, 21.5% of subjects were classi-
that had never been consumed by study subjects. This fied as overweight, 22.3% were class I obese and 2.8%
process was used to reduce and refine of items included. were class II obese.

Results CFA results for nutritional knowledge

Demographic characteristic The initial fitted hypothesized model (3 factors; food rec-
Demographic characteristic of the population sample are ommendation, nutrient related to diseases and healthy
summarized in Table 1. 1,032 out of 1,080 participants diet, with a total of 31 items) suggested a model misfit
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 4 of 10

Fig. 1 Standardized estimated factor items loading, error variances for nutritional knowledge 3 factors, 31 items Legend: A = basic nutritional
knowledge, B = food based dietary guidelines, C = diet related disease knowledge
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 5 of 10

(χ2)3178.83, df = 434, p-value = 0.000, CFI = 0.59, RMSEA = model for “nutritional knowledge” was composed of three
0.08 and SRMR =0.14 with χ2/df = 7.32, (Fig. 1). The modi- factors (food recommendation, nutrient related to diseases
fication indices (MIs) showed the expected parameter and healthy diet) with a total of 14 items. Parameter estima-
change statistics for each item. The model was re-specified tion results after model modification revealed a good fit for
and eventually 9 items with a low factor item loading from the model as indicated by a reduced chi-square value (from
three factors were excluded. To ensure the model fitted 465.5 to 80.2 with 66 degrees of freedom, p-value> 0.05).
well, covariance values were also added. The final CFA The value of CFI, RMSEA and SRMR were 0.99, 0.01 and

Fig. 2 Standardized estimated factor items loading, error-variances and covariance for nutritional knowledge 3 factors, 14 items. Legend: A = basic
nutritional knowledge, B = food based dietary guidelines, C = diet related disease knowledge
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 6 of 10

Fig. 3 Standardized estimated factor items loading, error variances for nutritional attitude 3 factors, 40 items. Legend: AT = food based dietary
guideline attitude, BT = balance diet and their variety attitude, CT = food choice attitude
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 7 of 10

Fig. 4 Standardized estimated factor items loading, error-variances and covariance for nutritional attitude 3 factors, 16 items. Legend: AT = food
based dietary guideline attitude, BT = balance diet and their variety attitude, CT = food choice attitude
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 8 of 10

0.02 respectively, indicating a large improvement in the local inventory questionnaires [17, 18]. These studies have
model fit. The parameter estimates of the CFA are shown focused mainly on either the nutritional knowledge,
in Fig. 2. attitudes and practices of undergraduate students or of
elderly populations. In Thailand, previous studies have de-
CFA results for nutritional attitude veloped nutritional knowledge attitude and practice ques-
The first hypothesized model consisted of 3 factors (food tionnaires for specific age groups such as children and the
choice, healthy diet and food recommendation with a elderly [19, 20] however none has reported instrument
total of 40 items), revealed a χ2 value of 5503.0, df = 740, validation process.
p-value = 0.000, CFI = 0.75, RMSEA = 0.08 and SRMR = This study has developed and evaluated the construct
0.11 with χ2/df = 7.4 (Fig. 3). The initial model did not validity of the Thai adult nutritional knowledge, attitude
fit the sample data. Fifteen items were excluded due to and practice questionnaire for just such purposes. Meas-
low factor item loading. Any non-significant paths from uring nutritional knowledge, attitude and practice in
the three factors were also deleted. Covariance values adults is challenging as an appropriate questionnaire has
were added. This procedure significantly improved the not been available. Other research instruments that exist
model. The final CFA model for the nutritional atti- are well established but are unlikely to be appropriate
tude was composed of three factors (food choice, for Thais [21–23]. The nutritional knowledge attitude
healthy diet and food recommendation with a total of and practice questionnaire has social and cultural fea-
16 items). The Chi-square value was reduced from tures that should be considered in a number of dimen-
801.1 to 178.1 with 93 degrees of freedom. The three sions. To obtain information on nutritional behavior in
factor model failed to achieve an exact fit (χ2/df = 1.9, any population, the instrument should include questions
p < 0.05). An acceptable fit was indicated by CFI, related to knowledge and attitudes related to food con-
RMSEA and SRMR values (0.99, 0.03 and 0.03, re- sumption and practice [24].
spectively) [16]. All of the standardized factor load- Confirmatory factor analysis can be used to verify the
ings were greater than 0.4. The parameter estimates structure of a set of observed variables in order to deter-
of the CFA are shown in Fig. 4. mine whether the extracted items show acceptable fit for
the data collected. Cut-off points of model fit criteria
The results of nutritional practice (FFQ) can be set and used to determine acceptable values for
The process of model refinement reduced the food items the model of nutritional knowledge [25–27]. CFA is
(practice) from the original 76 to 60 items, including 6 often used to confirm hypotheses and uses pathway ana-
items on milk and dairy products, 7 items on rice, 10 lysis diagrams to represent variables and factors [28]. In
items on meat and products, 4 items on vegetables, 4 this study, the CFA results helped evaluate the nutri-
items on fruits, 5 items on cereal, 2 items on dessert, 6 tional attitude structure of the questionnaire. The model
items on beverages, 3 items on fats, 13 items on miscel- showed an acceptable fit with indices close to the nom-
laneous (Table 2). inal value. The CFA results for attitude, however, initially
failed to fit the collected data as demonstrated by the
Discussion highly significant Chi-square test for goodness of fit. It
Previous studies both in Europe and China have assessed has been suggested that this test is overly sensitive to
nutritional knowledge, attitude and eating behavior using sample size [13, 25, 26]. The highly significant goodness

Table 2 Food frequency questionnaire with 60 items

Food groups Food items
Milk and dairy products (6 items) Whole milk, fermented milk, low fat milk, sweetened whole milk, yoghurt, cheese etc.
Rice (7 items) Steamed rice, glutinous rice, noodle, instant noodle etc.
Meat and products (10 items) Pork, chicken, beef, fish, egg, bacon etc.
Vegetables (4 items) Chinese kale, bitter cucumber, carrot, sesbania flower
Fruits (4 items) Banana, mango, orange, guava
Cereals and products(5 items) Peanut, mung bean, soy milk, tofu, sunflower seed
Dessert (2 item) Any dishes cooked with coconut milk (such as banana with coconut milk), any dishes
cooked with syrup (such as black grass jelly with syrup)
Beverages (6 items) Fruit juice (40%), soda beverage, cold coffee, green tea frappe, fruit frappe
Fats (3 items) Animal oil, rice barn oil, soy bean oil
Miscellaneous (13 items) Hamburger, bakery, bread, cake, green curry etc.
Pongkiatchai et al. Nutrition Journal (2019) 18:35 Page 9 of 10

of fit test may have been affected by the external factors Authors’ contributions
such as sample size, the number of parameters and the RP and RC conceived the study concept and design. RP and PP conducted
the survey and supervised data collection. RP and AL performed analysis and
degrees of freedom to sample size ratio [13, 29]. Never- interpretation of data. Manuscript was prepared by RP, AL, WO and RC.
theless, the other indices suggested an acceptable fit. It Manuscript revision was done by RP,AL, NH, and WO. All authors read
was concluded that the nutritional knowledge and atti- and approved the final manuscript.

tude components of the questionnaire yielded logical Funding

construct validity. Suan Dusit University in Thailand provided Dr.PH scholarship to the lead author.
With regard to nutritional practice, we applied the food AL is supported by the NIHR Manchester Biomedical Research Centre.
frequency questionnaire to evaluate eating behavior. The
Availability of data and materials
food items reported in the FFQ were covered by five food The datasets used and/or analyzed during the current study available from
groups and dietary guidelines for Thais [30]. We applied 3 the corresponding author on reasonable request.
criteria to reduce the number of items. The remaining
Ethics approval and consent to participate
items are those normally consumed by Thai people. This study was approved by the Ethical Review Committee for Human
Our current study still has some limitations as we did Research, Faculty of Public Health, Mahidol University, Thailand (COA. No.
not stratify our analysis by gender as a variable. Males MUPH 2014–189).

and females may potentially display different knowledge Consent for publication
and attitudes to nutrition. Future studies should investi- Not applicable.
gate this in Thai adults using the nutritional knowledge
Competing interests
and practice questionnaire. Furthermore the age range
The authors declare that they have no competing interests.
for the adult working population is relatively broad and
within this range some variation on attitude and know- Author details
1
Department of Nutrition, Faculty of Public Health, Mahidol University, 420/1
ledge relating to nutrition may also exist.
Ratchawithi RD., Ratchathewi District, Bangkok 10400, Thailand. 2Departments
of Epidemiology, Faculty of Public Health, Mahidol University, 420/1
Ratchawithi RD., Ratchathewi District, Bangkok, Thailand. 3Division of
Conclusion Population Health, Health Services Research & Primary Care, School of Health
This study demonstrates that final version of the ques- Sciences, Faculty of Biology, Medicine and Health, The University of
tionnaire has acceptable levels of constructed validity Manchester, Manchester, UK.
and can be used to assess nutritional knowledge, attitude Received: 23 March 2019 Accepted: 4 July 2019
and practice in a general adult working population of
Thais. This questionnaire can be further modified for
use in neighboring countries in the region that share a References
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