Reliability and Validity of the Arabic Version of Attitudes Towards Intellectual Disability Questionnaire-Short Form (A-ATTID-S)

Introduction

There are several neurodevelopmental diseases that are linked with cognitive impairment because of abnormalities in dendrites and dendritic spines. This is known as intellectual disability. Recently, intellectual disability has been defined as a condition characterized by significant limitations in both intellectual functioning and adaptive behavior that originates before the age of 22.² According to DSM-5 impairment of general mental capacity affects adaptive functioning in three domains: intellectual, social, and practical.³

In an environmental approach, intellectual disability would be correlated with the degree of support needed by a person to ensure their social adaptation.^4–6 Social adaptation is the complicated challenge faced by some PWID,⁷ so an inclusive environment would be essential. Most societies boast of being inclusive and they encourage citizens to collaborate in the social integration of PWID.^8–10 However, despite actions that support the social inclusion of PWID at the individual, organizational, and governmental levels,¹¹ these people commonly suffer from marginalization,¹² harassment,¹³ and social exclusion.¹⁴ Because PWID may face such challenges they are often denied their rights to education, employment, and family life.¹⁵

Attitudes towards PWID are recognized as the major obstacle to their social integration in Arab world.^16–18 In this regard, authors highlighted existing inequalities in Arab countries between PWID and other people. It is therefore essential to learn more about these attitudes to promote the desired social change.¹⁹ An attitude is a partially permanent set of feelings^20,21 that refers to what the person feels in relation to an attitudinal subject.^20,22 It focuses on beliefs,^20,22–25 expectations, and opinions held by a person in relation to an attitudinal subject^1,23,26 and behavioral predispositions^27–29 that reside with the intention of behaving in a certain way when faced with an attitudinal object.³⁰ Attitude studies have several perspectives, ranging from the genesis and process of attitude change to the effects of attitudes on individual behavior and interactions with others.³¹ In all perspectives, the assessment of attitude remains essential. Several instruments to assess attitudes towards people with disabilities have been developed. However, those regarding attitudes towards PWID are minimal.³²

The most commonly used among the assessment scales of attitudes towards the PWID are the Mental Retardation Attitude Inventory,^33,34 which is a scale of 29 items divided into four factors (integration-segregation, social distance, private rights and subtle derogatory beliefs), the Community Living Attitude Scale,³⁵ which is a scale of 40 items divided into four factors (empowerment, similarity, exclusion and shelter), and the Attitude Towards Intellectual Disability questionnaire,²⁶ which is a scale of 64 items divided into five factors (discomfort, sensibility or tenderness, knowledge of causes, knowledge of capacity and rights, and interaction). Among these three tools, only the attitude towards intellectual disability (ATTID) questionnaire respects the tripartite attitude formation. Moreover, the ATTID questionnaire is the only questionnaire based on a multidimensional model of attitudes (cognitive, affective and behavioral), which is recognized as a standard of good practice.¹ Due to time constraints (22 minutes to administer) and resources, a short version of ATTID was designed and validated.¹ Although there are many studies on attitudes towards PWID,^17,34,36,37 Arabic psychometric tools remain insufficient.

Including a student with a PWID in school or social group activities is less common than including a student with a physical handicap, according to previous research.³⁸ However, it is critical to assess professional’s attitudes toward people with intellectual disabilities in the educational setting. Previous studies have shown that the attitudes of teachers have an effect on students’ interactions.³⁹

However, to our knowledge, there is only one validated scale in Arabic for assessing attitudes toward intellectually disabled people (the Arabic version of the Behavioral Intention to Interact with Peers with Intellectual Disability Scale).⁴⁰ However, the two-factor scale, which measures behavioral intentions in and out of school, was designed to assess only student attitudes.

The objective of this study was to adapt and validate an Arabic version of ATTID-S and to examine the impact of demographic characteristics on the attitudes toward PWID in Tunisia.

Materials and Methods

Ethical Declaration

This research has been approved by the local ethics committee of the Higher Institute of Physical Education and Sports of Kef, code 041/2021. Prior to the start of our research, participants provided written informed consent. In accordance with ethical principles, confidentiality and anonymity were ensured by assigning an identification code to each questionnaire. The data was stored in a secure database to which only the research group had access. This study was realized according to the principles enshrined in the Declaration of Helsinki (3rd edition 2013) and in accordance with the Medical Research Involving Human Subjects Act (WMO).

Participants

Randomly selected a total of 812 participants were voluntarily education professionals participated in the present study. All the subjects are teachers and civil servants, have a higher level of education (at least bachelor degree) and exercise their professions in several university establishments in Tunisia.

Subjects, who are Arabic native speakers, worked in schools and universities, and lived in Tunisia and were assigned to two samples. The exploratory sample consisted of 223 subjects divided into male (n = 121, 54.26%) and female (n = 102, 45.74%) with an age range of between 18 and 64 (mean = 32.7 ±9.2 years).

The confirmatory sample comprised 589 participants, male (n = 357, 60.61%) and female (n = 232, 39.38%), with a mean age of 31.61 (SD = 12.43). All of the respondents volunteered to participate in the study.

Instrument

The ATTID-S¹ is a 36-item questionnaire that measures the attitudes of the general population towards people with intellectual disabilities. Participants are asked to answer the questions using a 5-point Likert scale, ranging from “strongly agree” (1) to “strongly disagree” (5). The items measure the cognitive (15 items), affective (14 items) and behavioral (7 items) dimensions. The assessment of the affective and behavioral dimensions is preceded by two vignettes, one featuring a person with PWID with a higher level of functioning (Dominique) and the other, a PWID with a lower functional level (Raphaël). The first names of the two PWID in the thumbnail have been modified to suit the Arab context (eg, Anis instead of Dominique and Kaïs instead of Raphaël). ATTID-S has demonstrated robust validity and reliability.¹ The conceptual validity of ATTID-S was examined by a principal component analysis which revealed five factors: discomfort and sensitivity or tenderness; these two factors make up the affective dimension; knowledge of ability and rights; and knowledge causes (both in the cognitive dimension) and interaction (behavioral dimension). The five-factor solution accounted for 47.6% of the explained variance. The Cronbach’s alpha coefficient ranges from 0.67 to 0.89, which is considered acceptable for good internal consistency.⁴¹

Adaptation

A cross-cultural translation of ATTID-S was carried out in cooperation with two Tunisian psychologists who used English fluently in their scientific activities and who were blind to the studies purpose. The first translated the English version into Arabic, and the second translated this Arabic version back into English. The re-translated version was compared to the original version of ATTID-S by a committee of English-speaking Tunisian clinical psychologists (authors are not included in this committee). Following the discussion, and to keep the functional conformity of the Arabic version, changes and corrections concerning some words and expressions were proposed by the committee of appointed psychologists. These corrections and changes have been made (eg ambiguities on the term Electronic store in the Arabic context have been raised), and the final version of the A-ATTID-S has been approved.

Procedure

Respondents were not given any further instructions on how to answer the questions other than those already included in the questionnaire. The A-ATTID-S was distributed in five schools and three universities over a period of one week. The average response time to the questionnaire was 12 minutes.

Statistical Tools

As a preliminary analysis, visual inspection was used to check for missing values and analyze the data. The Kurtosis and Skewness were used to examine the normality of the data distribution. Unweighted least squares with a direct Oblimin rotation were used for the exploratory analysis. The Kaiser–Meyer–Olkin (KMO) statistic was used to assess whether the data was suitable for factor analysis. The KMO value must be greater than 0.50 in order to accept the factorial solution.⁴² The chi-square value of the Bartlett sphericity test was also calculated,⁴³ which should not be significant. The factors were retained when the eigenvalues were greater than 1, and the scree plot was examined. In addition, if an item’s factor loading was less than 0.5, it was deleted.^42,44 Confirmatory factor analyses were used to evaluate the instrument’s factor structure. The instrument’s reliability was assessed using the Cronbach’s coefficient. Differences between genders with age as Covariate were realized by analysis of Covariance ANCOVA.

Descriptive statistical analyses, exploratory factor structure and internal consistency indices were performed with SPSS for Windows, version 26 (IBM Corp), whereas confirmatory factor analysis was established with Amos software for Windows, version 23 (IBM Corp).

Results

Descriptive Statistics and Exploratory Factor Analysis

The normality of the distributions was supported by the skewness and kurtosis coefficients shown in Table 1 with the descriptive statistics, and the lambda factor loadings.

Table 1 Exploratory Factor Analysis of the a-ATTID-S (N=223)

Based on the results of KMO and Bartlett test of sphericity, The A-ATTID-S was found to be appropriate for factorial solution (KMO=0.946; Chi2 = 6288.25; df = 595; P<0.001). Exploratory factor analysis revealed a five-factor solution that explained up to 68.74% of the total variance, with items having lambda factor loadings ranging from 0.53 to 0.90. The five factors explained 43.44%, 9.75%, 5.65%, 5.34%, and 4.55% of the total variance, respectively. Furthermore, the scree plot supports the five-factor solution; a clear change in the slope can be seen in Figure 1. The emerging factors were Discomfort (Items: 09, 10, 11, 12, 13, 14, 15, 16), Knowledge of capacity and rights (items: 01, 02, 03, 04, 05, 06, 07, 08), Interaction (30, 31, 32, 33, 34, 35), Sensitivity or tenderness (Items: 17, 18, 19, 20, 21) and Knowledge of causes (Items: 22, 23, 24, 25, 26, 27, 28, 29).

Figure 1 Scree plot for the principal component analysis of A-ATTID-S.

Reliability

The internal consistency reliability of each of the subscales was investigated using reliability analysis. Cronbach’s alpha scores for discomfort (0.94), the knowledge of capacity and rights (0.89), interaction (0.92), sensitivity or tenderness (0.93) and knowledge of causes (0.87) subscales were satisfactory (see Table 1).

Confirmatory Factor Analysis

Figure 2 gives an overview of the confirmatory factor analysis model for the A-ATTID-S; we notice that all items contributed effectively to the pre-established theoretical constructs, as suggested by^43,44 and that factorial weight greater than 0.71 can be considered excellent. The results of the confirmatory factor analysis supported the A-ATTID-S five-component structure.

Figure 2 The final confirmatory factor analysis (CFA) of the A-ATTID-S.

After adjustment of some errors in the established first order model (errors: e15-e16 for knowledge capacity, e16-e21, e17-e21 for the interaction factor, e27-e28 for the sensitivity and e34-35 for the knowledge causes), fit indexes were acceptable. As a matter of fact, the chi-square value (Chi2) was 5408.803 (p<0.01), DDL = 1431, the considerable ratio X2/DDL was 2.27 lower than the cut-off value 3.00 is acceptable. In addition, the incremental indices GFI, and AGFI proved values higher near the norm with a value of 0.88 and 0.90, respectively.⁴⁵ Moreover, passementerie, the comparative fit index (CFI) and the Tucker Lewis index TLI values, which are 0.95 for both adjustment indices demonstrated an adequate cut-off values with 0.95 for each index. Finally, the root mean square error of approximation (RMSEA) displays an acceptable value of 0.046 < 0.1 and shows that the measurement errors are tolerable,⁴⁶ the model gives an adequate adjustments index and conformed to theoretical thresholds.

Differences in Age and Gender

For testing differences among participants by gender and age, we conducted a multivariate analysis of covariance of the scale factors. Subsequently, we realized group differences with a covariance univariate analysis Ancona. The first step in this analysis gives descriptive statistics by gender with age as covariate. Descriptive statistics are illustrated in Table 2, whereas comparison results are shown in Table 3.

Table 2 Descriptive Statistics of a-ATTID-S Factors by Age and Gender

Table 3 Differences in Age and Gender

Results of multivariate test showed a Wilks’ Lambda =0.98, multivariate F _{(5582) =}2.22, p=0.51 and η²p = 0.02 for interaction age × gender. Since the multivariate test was non-significant, a univariate analysis of covariance was performed to examine differences between sex and age on the five subscales.

The findings also revealed a partial significant age effect for the “Knowledge of capacity and rights” (F _(5;586) = 7.20, p = 0.007) and “Interaction” (F _(5;586) = 4.1, p = 0.043) subscales (see Table 3). However, differences in gender showed significant differences for all subscales. In fact, differences are significant at p<0.01 F _(5;586) =8.82 (η²p =0.015) and F _(5;586) =8.46 (η²p = 0.014) for Discomfort and Interaction, respectively. Likewise, differences for Knowledge of capacity and rights (F _(5;586) =4.48; η²p = 0.08), rights Sensitivity/tenderness (F _(5;586) =6.20; η²p = 0.010) and Knowledge of causes (F _(5;586) =3.96; η²p = 0.07) showed a significant value at p<0.05.

Discussion

The aim of this study was to adapt and validate the ATTID-S questionnaire¹ using an Arab population in order to assess its factor structure and reliability.

The factor structure of A-ATTID-S appeared to be identical to that of ATTID-S. It respects the tripartite structure of attitude (affect, cognition, and behavior). Indeed, Cronbach’s alphas for the internal consistency of the five subscales were satisfactory. The exploratory factor analysis generated a five-factor structure, namely: (1) discomfort and (2) tenderness or tenderness (which constitute the affective dimension), (3) knowledge of capacity and rights, and (4) knowledge of the causes (which constitute the cognitive dimension) and (5) the interaction (behavioral dimension). The five factors of the A-ATTID-S preserved 36 items of the original questionnaire.¹ Confirmatory factor analysis revealed consistency between the observed model and the theoretical model.

The ATTID-S questionnaire has been cited in recent studies.^47–50 To our knowledge, until the writing of this article, there has been no study on the adaptation or validation of this version of ATTID-S. However, several recently published studies have used the original version of ATTID.^{1,21,26,51–54} Other authors have also selected long-form ATTID items to measure attitudes.^32,55 The original ATTID questionnaire was adapted for a sample of Italian teachers.⁵⁶ The Italian version respects the tripartite attitude and consists of five factors divided into 70 items. Fit indices were acceptable for RMSEA and SRMR but poor for the CFI and TLI. Construct validity was also investigated by calculating the cross-correlation coefficients for the five dimensions of ATTID, which produced results very similar to those reported by the original version.

In addition, other scales that measure attitudes towards intellectual disability have been developed and validated. The Mental Retardation Attitude Inventory (MRAI)³³ is a four-factor scale (integration-segregation, social distance, private rights, and subtle derogatory beliefs) divided into 29 items. Although this scale has acceptable reliability,^57,58 the validity of its factor structure has been questioned in other cultural contexts.^59–61 The second scale which is The Community Living Attitude Scale (CLAS) contains 40 items that make up the four subscales, namely: empowerment, similarity, exclusion, and accommodation.³⁵ Studies with different samples from different countries have reported stable reliability.^{33,58,60,62–66} However, these two scales present factors identical to those of ATTID even though they have different names, such as “the private rights of people with mental retardation” in MRAI, named “similitude” in CLAS, and the subscale “knowledge of capacities and rights” in ATTID. Nevertheless, the crucial “discomfort” factor when interacting with PWID in ATTID is not taken into consideration when developing MRAI and CLAS. Previous research has shown that repeated contact and a good quality of relationship with PWID were significantly correlated with less discomfort in the presence of PWID.^{56,63,66–69}

The present study also aimed to assess the differences in attitudes based on socio-demographic characteristics such as age and gender. Agreeing with our results, in a non-Arabic context, previous research showed that gender is a serious influential factor of attitudes towards PWID.⁷⁰ The authors suggest that women have more positive attitudes towards PWID than men. Gender differences exist among siblings as well. For instance, it was found that women felt that they had grown more in terms of increased empathy compared to men towards siblings with disabilities.^71,72 Regarding age, our results about “Knowledge of capacity and rights” and “Interaction” partially corroborates the studies of^26,66,73 to confirm the existence of effect of age on the attitudes towards PWID. However, no significant differences are shown for “Discomfort”, “Sensitivity or tenderness”, and “Knowledge of causes”. These results are in agreement with other studies that have not found an age effect on attitudes towards PWID.^74,75

Limitations

This research has some limitations. Participants’ responses, based on self-report, may arguably increase the risk of socially desirable responses^67,76 and thus fail to report their exact attitudes towards PWID. In addition, this study investigated the impact of gender and age on attitudes towards PWID people. Other characteristics, such as education level and personality type, may have an impact on attitudes regarding PWID, and we did not consider them in our study. Indeed, previous studies have shown personality traits as serious moderators of attitude.^29,77–80 Additionally, earlier study has established that high level of education is a significant predictor of positive attitudes toward PWID^{26,76,81–85}. Further research may include personality traits and level of education to assess the attitudes of an Arab population towards PWID.

Conclusion

The aim of this study was to adapt, validate, and assess the factor structure, internal reliability, validity, sensitivity, and convergent validity of the Arab attitude towards intellectual disability. Based on the good loadings of the EFA factor, CFA fit indices, correlation matrix, sensitivity analysis and excellent internal consistency, A-ATTID-S showed robust psychometric properties. The instrument can be used to quantitatively assess the attitude of professionals in an educational context towards intellectual disability in the Arabic-speaking world.

Given the aforementioned limitations, more research on the subject is urgently needed, including generalization of the tool to the whole population, investigations into the relationship between attitudes towards intellectual disability and other psychological and contextual.