E:\2021\NERS AGUSTUS\18--jurnal 247Ayuningtyas, Agustina, Noviasari, Developing Female-Genital Infection Preventive Behavior Tool (FgIPBT) for ... Developing Female-Genital Infection Preventive Behavior Tool (FgIPBT) for Islamic Boarding School Population Based on The Integrated Behavior Model Kanthi Devi Ayuningtyas1, Ika Agustina2, Ita Noviasari3 1,2,3Midwifery Department, STIKes Patria Husada Blitar, Indonesia JURNAL NERS DAN KEBIDANAN (JOURNAL OF NERS AND MIDWIFERY) http://jnk.phb.ac.id/index.php/jnk JNK History Article: Received, 30/06/2021 Accepted, 27/07/2021 Published, 05/08/2021 Keywords: Instrument, Female-genital Infection, Islamic boarding-school, Preventive behavior, IBM Article Information Abstract Female-genital infection in adolescence causes discomfort and may develop into a serious issue. Islamic boarding school female students are a popula- tion at risk of getting a female-genital infection due to the lack of hygiene practice sum up with the lack of parental control. Prevention of female-geni- tal infection through behavioral change is mandatory but the changes in behavior are not an effortless thing. There are underlying constructs that predispose the behavior as described in the Integrated Behavior Model (IBM). Dealing with those constructs will facilitate the change of behavior. However, there was no exact tool for assessing construct that determines the female-genital infection preventive behavior, especially for Islamic board- ing school female-student population. That was the major reason for the Female-genital Infection Preventive Behavior Tool (FgIPBT) development. We generated a tool based on IBM constructs and the Indonesian Society of Dermatology and Venereology (INSDV) recommendation regarding geni- tal infection preventive behavior. A deductive method of item generation, expert judgments, and internal consistency test involved 143 female-student from 3 different Islamic boarding schools was done to generate a valid and reliable tool. Total 177 valid items composed on the first phase and two different arrangements of items has subjected the reliability on the second phase. Items that were arranged based on behavior items and assessed every IBM construct (Type 1) had higher reliability value than items that were arranged based on IBM construct for all behavior items (Type 2). As- sessing different construct for each point of behavior at the same time gen- erate more reliable data than assessing the same construct for all points of behavior. © 2021 Journal of Ners and Midwifery 247 Correspondence Address: STIKes Patria Husada Blitar – East Java, Indonesia P-ISSN : 2355-052X Email: kanthideviayuningtyas@gmail.com E-ISSN : 2548-3811 DOI: 10.26699/jnk.v8i2.ART.p247–254 This is an Open Access article under the CC BY-SA license (http://creativecommons.org/licenses/by-sa/4.0/) https://crossmark.crossref.org/dialog/?doi=10.26699/jnk.v8i2.ART.p247-254&domain=pdf&date_stamp=2021-08-15 https://doi.org/10.26699/jnk.v8i2.ART.p247-254 248 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 247–254 INTRODUCTION Female-genital infection is a pathological con- dition that commonly happens during a women’s lifetime. This infection is mostly caused by yeast infection with the common pathogen is Candida albicans. Nevertheless, some other pathogens such as bacteria viz. Gardnerella vaginalis, Chlamy- dia trachomatis, and Mycoplasma; protozoan parasite i.e. Trichomonas vaginalis (Deligeoroglou et al., 2004); even pox virus namely Molluscum contagiosum, inflict infection on the genital area (Vilano & Robbins, 2016). The presence of patho- gens in the female sensitive area is not always re- lated to sexually transmitted infection. The female-genital infection known as vul- vovaginitis is the most common gynecological com- plaint among child and adolescent girls (Loveless & Myint, 2018), yet causes discomfort and elicits serious concern for parents due to its sensitive lo- cation. The etiology of vulvovaginitis in the pre-pu- bertal or sexually inactive adolescent is not spe- cific, possibly associated with hygiene practice (Loveless & Myint, 2018). Infr equently handwashing, do not thoroughly wiping after uri- nate or bowel movement, wearing tight-fitting syn- thetic clothing and underwear, also contact with chemicals contain in soap, detergent (Zuckerman & Romano, 2016), or sanitary pad, lead up to vul- var infection. Furthermore, some type of pathogen specifically Molluscum contagiosum which is com- mon in children, transmitted skin to skin through sharing of towels or any other bathing items (Vilano & Robbins, 2016). One of the populations at risk of getting a fe- male-genital infection is female students at Islamic boarding schools. These students most likely have poor hygiene practice due to the lack of parental control along with poor knowledge on maintaining female genital organs. Lived in a crowded dormi- tory with limited care from parents or guardians, and not having trusted adults to share their genital problem may let their genital infection unspoken and unhandled. Even though female-genital infection in sexu- ally inactive adolescents especially in the Islamic boarding school population could be prevented by maintaining good hygiene practice, but first we have to understand factors affecting that behavior. As disclosed by Fishbein et al. (2001), understanding why people behave the way they do is the first step to change their behavior. The more we compre- hend the variables behind their action, the more likely behavioral intervention program could succeed. However, there were no valid and reliable instru- ments for assessing female-genital infection pre- ventive behavior and factors affecting that behav- ior in the Islamic boarding school setting. This study aims to develop a valid and reliable instrument for assessing female-genital infection preventive behav- ior and its determinants, especially for the Islamic boarding school population. Integrated Behavior Model (IBM) as published in Montaño & Kasprzyk (2015) was chosen to be an instrument framework regarding its comprehensive variables to predicting behavior. METHOD FgIPBT was developed based on IBM main constructs i.e. attitude toward behavior consists of experiential and instrumental attitude; perceived norm consists of the injunctive and descriptive norm; perceived control and self-efficacy as part of per- sonal agency; knowledge and skill to perform be- havior; the salience of the behavior; environmental barrier; intention to perform the behavior; also the habit/ behavior itself. Deductive methods were used to identify proper questions that fit into the ques- tionnaire. As reviewed by Boateng et al., (2018), the deductive method on item generation could be done through literature review and/or assess the existing scale and indicators. Since there was no existing scale on female-genital infection preven- tive behavior for the Islamic boarding school popu- lation that developed based on IBM’s construct, we merely used literature review to generate question items. Two-phase questionnaire development was conducted in this study. Three types of tests were conducted to generate a valid and reliable ques- tionnaire, viz. content-validity test, face-validity test, and reliability test. The content-validity test was the initial test, done by asked judgment from experts for the appropriateness of the items. A panel dis- cussion with reproductive health and health promo- tion and behavioral science experts was conducted to generate the items pool. The face-validity test was conducted by asked respondents to leave a mark on the item that was difficult to understand or simply left the respond column blank. Items with that mark were then revised and re-tested. Both of content-validity and face-validity test was adminis- tered in the first phase. A list of valid items from 249Ayuningtyas, Agustina, Noviasari, Developing Female-Genital Infection Preventive Behavior Tool (FgIPBT) for ... this phase was then tested in the second phase to assessed their reliability. Two types of items tem- plates were tested in the second phase. The first template arranged questions based on the points of female-genital infection preventive behavior while in the second template, questions were arranged by separating each of the IBM constructs. The re- liability test was done by assessing the internal con- sistency of each scale. As stated by Tavakol & Dennick (2011) that to ensure validity, the internal consistency of a scale should be subjected before it could be employed in the research. The Cronbach’s alpha coefficient was used to evaluate the consis- tency in every scale. Meanwhile, the correlation coefficient was used to check whether each item was quite related to the measured construct. Items with a correlation coefficient less than the minimum value were considered to be excluded. There were three groups of the respondent participated in this study. The first group for the first phase test while the second and third groups for the second phase test. As noted above, the first group clarified the face-validity of the tool, after that, the tool’s reliability was acquired from the sec- ond and third groups based on two different types of items template. Respondents were chosen con- veniently. We specified that the respondent must be pubertal female students aged 10-19 years old (refer to World Health Organization [WHO] - SEARO (2018) categorization of adolescent) who stayed at least six months in the dormitory, then the dormitory caretakers decided on students who took the test based on the dormitory schedule. Informed consent was obtained from all respondents. A pa- per-based questionnaire was distributed to the se- lected respondents and collected right away after it was completed. Data from the completed question- naire was then tabulated into a Microsoft Exel for- mat before being copied and analyzed in version 13 of Stata by StataCorp. RESULT Item Generation FgIPBT was generated in Indonesian. In the first phase, FgIPBT contains 36 question items. However, those questions judged by experts had less appropriateness and could not define IBM con- struct enough. Furthermore, a recommendation from the Indonesian Society of Dermatology and Venereology (INSDV, 2018) on preventing genital infection was used to generate items for behavior and its determinants. There were nine points of pre- ventive behavior on the INSDV recommendation that we elaborated into 17 behavior items for the second phase test. Items for the other constructs (except knowledge and environmental barrier) were developed based on those behavior items. Hence the second phase used developed questionnaire consist of 177 question items. FgIPBT has 11 constructs generally based on IBM’s main construct. The entire construct was directly measured with a modification of the bipo- lar Likert scale. Score range varied from 1 to 4 or 1 to 3 and reversed for items with negative state- ments. This small range of the response option was created based on experts’ recommendations to sim- plify the tool so that it would be more suitable for the targeted subject. Two types of tool templates were tested in the second phase. Those templates used the same ques- tions in a different order. The Type 1 tool that was tested in the second group has 17 sections to as- sesses the IBM’s construct for each female-geni- tal infection preventive behavior plus 2 sections assessing knowledge and skill to perform the be- havior and also the environmental barrier. Mean- while, the Type 2 tool that was tested in the third group has 11 sections assessing each IBM’s con- struct related to entire female-genital infection pre- ventive behavior. INSDV Recommendation FgIPBT Behavior Item Wiping genital thoroughly (1) handwashing before touching genital area; (2) wiping from front area to back when taking bath, (3) after voiding, (4) after a bowel movement, (5) when changing menstrual pad Table 1. Behavior items generation based on INSDV’s recommendation 250 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 247–254 Keep the genital area dry (6) dry wiping genital area before putting underwear; (7) change the underwear immediately when feeling moist on the genital area; (8) change the menstrual pad immediately when feeling moist on the genital area Avoiding panty-liner used (9) avoiding panty-liner to detain vaginal discharge Frequently changing menstrual pad (10) changing menstrual pad every 3-4 hours a day Frequently shaving thorough genital area (11) shaving routinely; (12) using private shaving tools Avoiding tight-fitting underwear (13) avoiding tight-fitting underwear Avoiding insert any (14) avoiding inserting any instrument into the vagina instrument into the vagina Ensure sanitary practice (15) using clean water running directly from pipe to wipe while using a public toilet Immediately do a check-up (16) discussing any genital issues with a trusted adult; when got a genital issue (17) seeking treatment immediately when having genital issues Table 2. Construct identification No 1. 2. 3. 4. 5. 6. Construct Female-genital Infection Preventive Behavior / Preventive Habit Salience of the female-genital preventive behavior Subjective (Injunctive) Norm Descriptive Norm Experiential Attitude (Affect) Instrumental Attitude Definition Certain behavior to prevent female-genital infection The perception that certain behavior is important to do in order to prevent female-genital infection.The key expression used such as “It is important for me to do …” Strong opinion about whether most members of the population agree or disagree to a certain female- genital infection preventive behavior.The key expression used such as “Most female students believe that …” Strong opinion about whether most members of the population perform or not perform a certain female- genital infection preventive behavior. The key expression used such as “Most female students do …” Affective evaluation like a pleasant/ unpleasant or enjoyable/ unenjoyable to perform a certain female- genital infection preventive behavior. The key expression used such as “I feel comfortable to do …” General evaluation of a certain female-genital infection preventive behavior, like good/ bad or wise/ foolish.The key expression used such as “Doing … is a good thing to do.” Response Opt. Always; Often; Seldom; Never Strongly Relate; Relate; Unrelated; Strongly Unrelated Strongly Agree; Agree; Disagree; Strongly Disagree Strongly Agree; Agree; Disagree; Strongly Disagree Strongly Relate; Relate; Unrelated; Strongly Unrelated Strongly Agree; Agree; Disagree; Strongly Disagree 251Ayuningtyas, Agustina, Noviasari, Developing Female-Genital Infection Preventive Behavior Tool (FgIPBT) for ... 7. 8. 9. 10. 11. Self-efficacy Perceived Behavioral Control Intention to perform female- genital preventive behavior Knowledge and skill to perform female-genital preventive behavior Environmental barrier Belief about own ability to perform a certain female- genital infection preventive behavior.The key expression used such as “I am capable to do …” Perceived control over a certain female-genital infection preventive behavior.The key expression used such as “It is easy for me to do …” Perceived likelihood to perform a certain female- genital infection preventive behavior.The key expression used such as “I intend to …” Skill to perform a certain female-genital preventive behavior based on the right knowledge. The possible boarding school environment constraint that hinders female-genital preventive behavior. Strongly Relate; Relate; Unrelated; Strongly Unrelated Strongly Relate; Relate; Unrelated; Strongly Unrelated Yes; No; Doubt Strongly Relate; Relate; Unrelated; Strongly Unrelated Strongly Agree; Agree; Disagree; Strongly Disagree Table 3. Differences of Type 1 and Type 2 tools Type 1 Number of items: 177 Number of sections: 19 Number of items per section: 9 / 10 / 14 Question details (e.g. section 1):(1) I wash my hand before touching my genital area, (2) It is important for me to wash my hand before touching my genital area, (3) Most female students believe that wash hands before touching the genital area is a must, (4) Most female students wash their hand before touching the genital area, (5) I feel comfortable to wash my hand before touching my genital area, (6) Washing my hand before touching genital area is a good thing to do, (7) I am capable to I wash my hand before touching my genital area, (8) It is easy for me to wash my hand before touching my genital area, (9) I intend to always wash my hand before touching my genital area Type 2 Number of items: 177 Number of sections: 11 Number of items per section: 17/ 10 / 14 Question details (e.g. section 1):(1) I wash my hand before touching my genital area, (2) I use clean water running directly from pipe to wipe, (3) I wipe from front area to back when taking bath, (4) I wipe from the front area to back after voiding, (5) I wipe from front area to back after a bowel movement, (6) I wipe from front area to back when changing the menstrual pad, (7) I dry wipe genital area before putting underwear, (8) I prefer changing underwear frequently to using panty-liner to detain vaginal discharge, (9) I change my underwear immediately when feeling moist on the genital area, (10) I avoid wearing tight-fitting underwear, (11) I shave routinely, (12) I use my personal shaving tool, (13) I change the menstrual pad 3-4 times a day, (14) I change the menstrual pad immediately when I feel moist in the genital area, (15) I avoid inserting any tool inside the vagina, (16) I discuss any genital issue with a trusted adult, (17) I see health provider immediately when I have a genital issue Participant Three groups with a total of 143 female stu- dents who lived in the dormitory were included as respondents in the validity and reliability test for developing FgIPBT. Every group consisted of 41- 60 female students from three different Islamic boarding schools yet have some common charac- teristics. This number met the requirement of a 252 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 247–254 minimal subject for measured Cronbach’s alpha, as formulated by Bujang et al. (2018). The mean age of respondents was 15,1 with a range of 5 years (13-17 years old). The age of menarche varies be- tween 9-15 years old and almost half of respon- dents (41,28%) got menarche at 12 years old. Half of the respondents (52,29%) ever received infor- mation regarding reproductive and genital health from various sources. 41 Female students in group 1 were asked to give their response on how clear every item in the tool is written. Another 42 and 60 female students in the second and third groups re- spectively, were asked to complete different tem- plates of FgIPBT. Validity and Reliability The type of validity test that was used in FgIPBT development was the content and face validity. There were two experts in reproductive health and one expert in health promotion and be- havioral science who gave their opinion and con- tent validation on the question items. The next step was the face validity done by asking the Islamic boarding school female students’ opinions on how clear the questions were written. Unclear question items were modified and corrected two times to be impeccable. Each item in every construct of every tool was tested for reliability. Item reliable and considered to be valid if its correlation coefficient is greater than the minimum value. The minimum value of the cor- relation coefficient used in this study was based on the r table critical value for a certain number of samples i.e. 0,26 and 0,21 for the second and third groups respectively. Cronbach’s alpha coefficient with an acceptable threshold was 0,70 used to de- termine the reliability of every construct of the tool. Construct Type 1 Type 2 Type 1 Type 2 Behavior / Habit 17 0,45 0,35 0,76 0,49 Salience of the behavior 17 0,55 0,46 0,85 0,76 Subjective (Injunctive) norm 17 0,61 0,45 0,89 0,74 Descriptive norm 17 0,59 0,54 0,88 0,84 Experiential attitude (Affect) 17 0,63 0,51 0,90 0,81 Instrumental attitude 17 0,66 0,54 0,91 0,84 Self-efficacy 17 0,60 0,54 0,89 0,84 Perceived behavioral control 17 0,61 0,51 0,89 0,82 Intention to perform behavior 17 0,53 0,37 0,83 0,56 Knowledge and skill to perform behavior 14 0,62 0,45 0,87 0,68 Environmental barrier 10 0,69 0,56 0,88 0,75 Table 4. Reliability test Total Item Average of Correlation The numbers of items that should be deleted from the tools based on the correlation coefficient were in contrast. There were 2 items from Type 1 i.e. intention to wiping the genital area from front to back when taking bath (r = 0,22), and intention to wiping the genital area from front to back when changing menstrual pad (r = 0,26). Meanwhile, from Type 2 there were 11 items considered to be de- leted viz. 4 behavior/ habit items (behavior/ habit on handwashing before touching the genital area, avoiding tight-fitting underwear, using private shav- ing tools, and discussing any genital issues with a trusted adult), a subjective norm item i.e. subjec- tive norm on avoiding panty-liner to detain vaginal discha r ge, 5 intention items (intention to handwashing before touching genital area, using clean water running directly from pipe to wipe genital area, intention to shaving routinely, and intention to avoiding inserting any instrument into the vagina), and an item from knowledge and skill to perform behavior i.e. wearing tight-fitting underwear. Those unacceptable items either from Type 1 or Type 2 were different. There was no single item that was unacceptable in both types. Coefficient (r) Cronbach alpha 253Ayuningtyas, Agustina, Noviasari, Developing Female-Genital Infection Preventive Behavior Tool (FgIPBT) for ... DISCUSSION All scales in FgIPBT are based on the Likert scale, as its purpose to distinguish the attribute of the respondent. Krabbe (2017) noted that the Likert scale is a type of scale that focuses on the subject, known as subject-centered scaling or subject-cen- tered approach. One’s response on every scale dif- ferentiates them from another individual. We made a modification to the Likert scale that was used in this tool. Usually, the Likert scale has odd response categories with the distance between every point of categories assumed to be linear. So, there al- ways be a neutral option on the Likert scale. This situation might be unfavorable for data collection, as respondents naturally choose that neutral option when there was a question that was hesitant to be answered. That was the major reason FgIPBT mostly used an even number of response catego- ries. We clearly distinguish options as strongly posi- tive, strongly positive, negative, or strongly nega- tive. The only construct in FgIPBT that used odd response categories on its item was the intention to perform behavior. This construct has three options in the response column i.e. “Yes – No – Doubt”. FgIPBT also has narrow response categories, mostly 4 points and 3 points for a single construct as mentioned before. This decisiveness due to the characteristics of the targeted population. This tool was developed especially for the Islamic boarding school female-student population which is pubertal adolescents who study equally at the middle or se- nior high school. A board of response categories would be perplexed them and that would affect the accuracy of the response. FgIPBT is a tool contain 12-13 pages that could be completed within 45 minutes. As shown in Table 3, 2 types of tools consist of different number of sections, rated the reliability in this study. To com- pute the alpha coefficient as a reliability score of a tool that contains multiple constructs measured at the same time, recommend by Nimon et al. (2012) to be done at the construct level rather than on a global test level. Based on that recommendation, the reliability test in this study was done for each IBM construct (Table 4) despite the items being arranged differently. Reliability defines as the ratio between the true score variance of the scale and observed variance which is the true score plus the error score. If the reliability value is 1, means that there was no single error on the measurement. However, it is hard to get perfect reliability in educational and psychological research (Nimon et al., 2012). The reliability value of the scale is linear with the reliability of the mea- surement; it is important to use a high-value reli- ability scale to produce reliable research. A tech- nique that is frequently used to increasing the reli- ability value of the scale is increasing the number of items. A scale consist <10 items tend to has a lower reliability value (Bolarinwa, 2015). Another way to increase the reliability value is by increasing the sample size. As reviewed by Nimon et al. (2012), studies that used a small sample size and new in- strumentation likely had a reliability value equal to 0,70 or < 0,60. Nevertheless, a high score of reli- ability sometimes means unfavorable. Scholtes et al. (2011) noted the upper threshold of the reliabil- ity value i.e. 0,95. A reliability value that is higher than that point indicates a high level of item redun- dancy as it has items that assessing the same as- pect of a construct. A contrast reliability value is shown in Table 4 from both types of tools. Based on the correlation coefficient between every item in every construct, Type 1 has a higher average score and less number of deleted items than Type 2. The value of Cronbach alpha also likely indicated better reliability on Type 1. Even 3 scales (viz. Behavior/ Habit, Intention to perform behavior, and Knowledge and skill to per- form behavior) did not meet the reliability criteria i.e. the score of Cronbach alpha less than 0,70. Practical reasons came up with this condition. As Type 2 consists of items that are arranged based on the same construct, it was written in similar open- ing sentences so respondents tend to read the items carelessly and simply choose the same response as the early items. Another problem caused by arrang- ing items based on construct was respondents natu- rally choose the expected response rather than a response that fit their condition. Keszei et al. (2010) noted that random responses from the respondent or their tendency to not giving the true answer caused an error on the measurement because items mostly answered/ responded in one way or the other that decreased the variance. CONCLUSION Despite FgIPBT did not provide a construct validity test, this tool was rated to be valid for as- sessing IBM’s construct on female-genital infec- tion preventive behaviors. Approval from the ex- perts and items enhancement based on the subject’s 254 Jurnal Ners dan Kebidanan, Volume 8, Issue 2, August 2021, page 247–254 response, also the measurement of the tool’s inter- nal consistency made it quite reliable to be used. We highly recommend to used Type 1 of FgIPBT in order to gain reliable data, with the same number of items it has minimum risk of bias. SUGGESTION Regardless of the validity and reliability of this tool, progressive research should be done to im- prove the expediency of FgIPBT. A broad sample size could precede a precise validity measurement such as CFA (Confirmatory Factor Analysis). More- over, this tool could be a reference for further tool development with the complete item generation method through both deductive and inductive meth- ods. Last, another way of construct measurement which is indirect measure is worth doing. ACKNOWLEDGMENT We gratefully acknowledge the funding from Badan Riset dan Inovasi Nasional Republik Indo- nesia – BRIN. REFERENCES Boateng, G. O., Neilands, T. B., Frongillo, E. A., Melgar- Quiñonez, H. R., & Young, S. L. (2018). Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Frontiers in Public Health, 6. https://doi.org/10.3389/ fpubh.2018.00149 Bolarinwa, O. (2015). 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