Development and psychometric properties of the Mothers' Sex Education Ability Questionnaire (SEDA)

Background Preschool sex education can prevent sexual abuse and promote the sexual health and well-being in children. Mothers have vital role in this regard. This study was conducted to develop and psychometrically evaluate an instrument for assessing mothers’ sexual education ability. Methods The study included two phases: qualitative ad quantitative. In qualitative phase, a sample of mothers who had a child aged 3-5 years old in nursery schools was interviewed in order to generate an item pool. Then preliminary questionnaire was provided. Consequently, content and face validity were assessed. Finally, a qualitative study was conducted and sample of women completed the questionnaire to explore the factor structure of the instrument. Reliability (internal consistency and stability), was also evaluated using the Cronbach’s alpha coecient and intraclass correlation coecient. Results A 51-items questionnaire was developed during the qualitative phase. After content and face validity, the items were decreased to 48. Then 250 women completed the questionnaire. The results obtained from explanatory factor analysis indicated a ve-factor solution (attitudes, skills, cognitive issues, situational consideration) that jointly accounted for 87.5% variance observed. The Cronbach's alpha for 5 factors ranged from 0.68 to 0.96 and the stability of the questionnaire varied from 0.80 to 0.82. During the quantitative phase overall 9 items were removed and the nal instruments consisted of 46 items. Conclusion The ndings suggest that the Mothers' Sex Education Ability Questionnaire (SEDA is a valid and reliable questionnaire. It is simple and easily scored and compromises signicant concept for assessing mother’s sexual education ability.


Background
The pre-school age is the time of encounter, education and communication of children with the world outside the home. This age is important because learning of the child during this period is fast. In this period environment has greatest in uences on children leading to form attitudes, habits and behaviors on later life [1]. In this era of childhood, due to the formation of personality, a child needs to receive guidance from reliable sources on the evolution of different parts of the body, including sexual organs [2]. Sexual evolution is part of human life that begins at birth [3].
In general, the aim of sex education is to provide relevant sex information and sexuality and improve knowledge and skills for making appropriate decisions [4]. However, child sex education aims to promote sexual health and wellbeing of children and also prevent children from sexual abuse during this period or later [5]. Hanbing and Yongjie believe that the goals of sex education for preschool children should be focused on gender recognition, gender role validation, and gender analysis [6]. Furthermore, early sex education leads to healthy interpersonal relationships and enjoying sex in later periods of life [7,8] In this regard, parents are considered as the rst and foremost sex education teachers. In Iran parents are not well trained in this eld [3] and most of them are reluctant to answer the sexual questions of their children [9].
Among parents, the role of mothers in the sex education of preschool children is even more prominent [10,11]. Most mothers are afraid to talk to their children about sex, and they believe that these conversations can lead to early exposure to sexual issues among their children [12].
In a review of behavior change theories in sex education the most commonly used framework was social cognitive theory (SCT) [13,14]. Indeed, successful educations were more likely to use behavioral change theories accordance with SCT, including methods to enhance self-e cacy (SE) in caregivers.
Caregivers self-e cacy (PSE) referring to one's beliefs in their capabilities to engage in e cient behavior to reach desired goals for the child. An example of PSE is a mother's beliefs in her capabilities to promote healthy sexual behaviors in her child. SCT is based on an agentic perspective on human development, adaptation, and change, which means that individuals are intentionally in uencing their functioning and life conditions [15]. According to SCT, SE is the leading mechanism of human agency, and thus the foundation of human motivation and action [16]. The perceived SE depending on contextual factors, e.g. Knowledge, comfort, skills and con dence are all factors related to self-e cacy and behavioral capability.
Valid instruments provide various information on factors compromised a range of behaviors, and personal and situational condition that may in uence on successful behavior.
Review of the literatures has shown that most of the tools used in this eld have examined the knowledge and attitudes of mothers [17] or other people in contact with the child [18], or they examine the effectiveness of maternal sex education programs. For example, a study among 55 mothers with preschool children showed that knowledge of mothers and their attitudes after intervention has been a signi cant improvement [19]. In Iran, talking about sexual issues is taboo and family and other child caregivers are not well educated about sexualityrelated issues. Furthermore, there is lack of school-based sexual education [20]. With skillful sexual education, children' sexual development goals will be attained [3]. Due to theory of psychosexual development; age 4-5 is the time when libido center transfers to genital area. Children's attention is paid to their genital and they become curious about issues like birth, sex and the differences. Thus measuring mothers' ability or other caregivers in sex education is an important issue in health education and health promotion However, since there were no such instruments available we aimed to develop an instrument for measuring mothers' ability in sex education for preschool children. We also aimed to evaluate the psychometric properties of this instrument among a sample of mothers with preschool children based on theory of psychosexual development.

Design and data collection
This was a methodological study [21] and was conducted to design a questionnaire for assessing mothers' sex education ability to preschool children in Iran, in 2018. In this study, only interviews with mothers were used due to the fact that in Iran mothers are culturally responsible for the education of children, although the new educational evidence in the world emphasizes the responsibility of parents in educating children. Data collection was carried out in two phases. The rst phase was conducted to generate an item pool and the second phase was conducted to evaluate the designed questionnaire.

Item generation
In order to generate an item, pool the following steps were carried out: (i)Interview with mothers: First, 293 nursery schools from the city of Karaj (a metropolitan city in the center of Iran) were listed. Then, 20 nursery schools were randomly selected and one mother who had a child from each nursery was selected and interviewed (in total 20 mothers who had 3-5 years old children). It clears for the mothers that they were not going to be 'judged' for their answers the duration of each interview lasted for 45-60 minutes. Each interview was recorded and transcribed immediately after interviews. Accordingly, the unit of (ii) Meanings were identi ed and preliminary collections of items were generated (92 items).
(ii) Delphi Rounds: During Delphi rounds, experts' opinions about the early version of questionnaire were obtained. Delphi is a structured and accepted process for collecting data in specialized domain and reaching consensus among experts [22]. During current study, Delphi rounds continued until the consensus of experts occurred (with three Delphi round and 25 specialists) [23]. For Delphi rounds, items were given to experts, and they were asked to indicate their agreement with each item based on a 5-point Likert scale (strongly agree to strongly disagree). They also speci ed their own suggestion if they felt a correction is needed. The statistical analysis of the responses was performed by calculating the central and dispersion indicators using quartiles, mean and standard deviation. Items with 75 percent or over agreement, kept in questionnaire and the remaining items with a 25 percent or less have been deleted from the questionnaire. Then the second Delphi round was conducted and some items were deleted at this stage. During the third Delphi round, the consensus was achieved. The agreement of 80% of the members was considered as consensus [24]. In all 41 items were deleted during Delphi rounds and 51 items kept in early version of the questionnaire.
(iii) Providing pre-nal version At this stage content and face validity was performed. For content validity a group of experts (10 specialists in public health) evaluated the questionnaire, CVR (content validity ratio) and CVI (content validity index) were computed. In assessing the content validity ratio, the results were compared with the Lawshe's table. The acceptable level of CVR in the Lawshe's table was determined to be 0.62 for 10 panelists; therefore, two items with CVR less than 0.62 were omitted from the instrument and items reached to 49 items. However, during e, the content validity index calculation, all items was maintained in the questionnaire as CVI was more than 0.79. Face validity refers to understanding and perceptions of the target population regarding the scale [25]. In this stage, both qualitative and quantities methods were used. During qualitative section, 10 mothers evaluated the questionnaire with regard to the importance of the items based on a 5-point Liker scale to calculate the Item Impact Score (Impact Score = Frequency (%) × Importance). At this stage 1 item was removed since its impact score was less than 1.5. At qualitative stage, we asked 10 mothers to score items regarding 'relevancy', 'ambiguity' and 'di culties'. At this stage three items were modi ed. All together during content and face validity three items were deleted and pre-nal version of the Mothers' Sex Education Ability Questionnaire (SEDA) consisting of 48 items was provided for psychometric evaluation.

Main Study
A cross sectional study was conducted to assess the psychometric properties of the Mothers' Sex Education Ability Questionnaire. A convenience sample of mothers with 3 to 5 years old child was entered into the study. The sample was randomly selected from 293 nursery schools in Karj, Iran. As such rst 20 nursery schools were identi ed. Then proportion to population size required number of women recruited and completed the questionnaire.

Statistical Analysis
Construct validity was assessed by using explanatory factor analysis (Varimax rotation) and 0.3 was considered as the minimum acceptable degree of correlation between each item and extraction factor [26]. To determine the reliability of the questionnaire, the Cronbach's alpha and Intra class Correlation Coe cient was calculated for each factor. For ICC calculation, 15 mothers were completed the questionnaire two times with ten days' interval.

Participants
In all 250 mothers with 3-5 years of aged child were studied. The mean age of mothers was 34.7 ± 5.54 years. The characteristics of mothers are listed in the Table1.

Construct validity
To investigate the construct validity, exploratory factor analysis was used. The sampling adequacy was tested by Kaiser-Meyer-Olkin (KMO); and a value of 0.919 was obtained [27]. Bartlett's test was signi cant with X 2 = 7606.534, df = 1176, P < 0.001. Due to communalities table, two items were omitted due to value less than 0.3 [20]. Considering Eigenvalue above one, ve factors were identi ed that jointly explained 87.57% of the variance observed (46items). Based on the arrangement of the factors, they labeled as attitude (28 items), skill (3 items), self e cacy (5 items), cognitive issues (5 items) and situational considerations (5 items). The results are shown in Table 2 Reliability assessment The Cronbach's alpha for 5 factors ranged from 0.68 to 0.96 and the stability of the questionnaire as assessed by interclass correlation coe cient (ICC) varied from 0.80 to 0.82. The results are shown in Table 3.

Discussion
Sexual health is one of the main indicators in the children and teenager developmental process, which is depends on the proper acquisition of information, the appropriate formulation of attitudes, beliefs, values, desirable directions for gender identity and communication [28] is believed that preschool sex education is one of the social and cultural challenges worldwide [29]. The children and teenagers receive various quality sex information and messages from different sources during daily life (media, religious organizations, schools, parents, care givers, etc.) [30,31,32] Studies have shown that parents who have enough skills in talking to their children have more sexual knowledgeable children [33]. Mothers have a key role in the sex education [34,35]. In the Iranian culture and various cultures talking about sexual issues is not usual and thus mothers refuse sexual conservation with their offspring [36] On the other hand parents used inappropriate methods for sexual education, because of lack of knowledge and skills. Inability to distinguish normal behaviors related to children's growth and sexual development and abnormal behavior confused the parents for employing the use of appropriate educational strategies for their children [36,37] Assessing the ability of mothers in this eld is an essential principle, which requires a valid and reliable instrument current study developed an instrument to respond to the needs for having a proper instrument in this eld and compromised from 46 items with 5 factors (attitude, skill, self-e cacy, cognition issues, and situational consideration).
Attitudes refer to parents' point of views, approaches, feedbacks and the ways they think about child developmental. It is argued that parenting attitudes are in uenced self-e cacy, which has been broadly de ned as the level of parents' self-belief about their ability to succeed in the parenting role [38] Evidence indicates that a number of obstacles for sex education including lack of knowledge and communication skills exist [39]. There are various studies worldwide that focused on mothers' knowledge and attitude about sexual education, but in these studies, parents 'and other caregivers' awareness and attitudes are often assessed using ad hoc instruments. Thus the contribution of the current study might be considered very important both for research settings and for practice. Obviously, providing a coherent and comprehensive instrument taking into account all dimensions of knowledge, attitude, self-e cacy and different cultural and environmental situations and communication skills of parents is almost impossible. This study was performed only on mothers due to lack of access to fathers, which is one of its limitations. However, this questionnaire can also be used to assess the ability of fathers. Second Given that this study was conducted among Iranians mothers, the ndings of this study might not be generalized to all mothers in the world and this instrument should be validated in other cultures and countries.

Conclusion:
This study performed to design and validate a questionnaire related to mothers' sex education ability. The SEDA showed good validity and reliability. The SEDA now can be used by health education and health promotion specialist to assess mothers' ability and perhaps develop proper interventions.

Acknowledgement
We sincerely thank all participants who willingly took part in this study.

Funding
The Research deputy of Alborz University of Medical Sciences funded the study.

Competing interest
The authors declare that they have no competing interests.

Data availability
All datasets in this study are available from the corresponding author in request.

Authors' contributions
MS was the main investigator, analyzed the data and involved in drafting the Manuscript. LS has supervised the study; contributed to the study design and conducted the analysis. AM critically evaluated the manuscript, helped in writing process and edited the paper. All authors read and approved the nal version of manuscript.

Ethical consideration:
The ethics committee of Alborz University of Medical Sciences approved the study (Ethical Code: IR.ABZUMS.REC.1396.95). For audio taping interview content, the participants' permission was obtained. All the participants were informed about the purpose of the study and if any participant was not willing to participate in study, he/she was excluded. Written consent form was signed by each participant and it was clear for the participants that they were not going to be 'judged' for their answers. All participations were assured regarding their privacy.