Formulating A Tool to Measure Motivational Values of Women towards Gender of A Child

Introduction:

Declining sex ratio at birth (SRB) has been observed to be an area of concern in India since past few decades.’^(1-3) Preference towards male child dictates prenatal sex determination and becomes an underlying reason for female feticide and ultimately reflected as a low SRB. ^(4,5) The ratio has varied across geographical boundaries with skewed distribution. ^{(2, 6, 7)} Ultrasound to detect gender of a child has been observed to be associated with the birth order and gender of first child.^{(1, 5)} Across districts of India, sex selection leading to abortions has been reflected in the declining trend in total fertility rate (TFR) which in turn is associated with decling SRB. ⁽⁸⁾ Non preference of female child found to be influenced by the socio-economic factors with a cultural value.⁽⁹⁾ Involvement of mother-in-law in the decision-making process has been observed to be associated with process of birth. ^{(10, 11)} Education, tradition, peer network, and spouse support also observed to be related with the extent of female participation in family planning. ^{(12, 13)}

Subjective value has direct implications towards decision-making process of a health event. Provision of desired and necessary information to the stakeholders influence the decision-making process, and sometimes a particular health event e.g., termination of pregnancy.^{(14, 15)} Pregnancy as a context requires autonomy and acknowledgment of significant others for an informed decision making.⁽¹⁶⁾ Nature of health event, available information, and social support play a pivotal role in assigning value to and making a choice for the health event. Considering a society with a preference towards a particular gender, assignment of value towards the gender of child influences the decision making process for sex-selection practices.

Suboptimal and skewed SRB as an outcome indicator are reflective of prevailing norms, attitude, and practices in the society. They influence value system of women towards gender of child. The effect of society on gender preference can be well managed by a person's own personality, which is shaped by the quality of education and a general character. Current study hypothesized that the subjective value assigned to gender of the child explains participation of women in decision-making process towards pregnancy and its outcome. Literature review have not suggested any mechanism for measuring subjective values towards the gender of a child. Shalom H Schwartz has suggested theoretical model of motivational values explaining nature and extent of attitude of person towards an event.⁽¹⁷⁾ With this background, the current study was planned to measure motivational values towards the gender of a child and to design and assess feasibility of administration of questionnaire to measure motivational value towards the gender of the child amongst women.

Methods :

The study was conducted in June to December 2017, wherein, an interviewer-administered questionnaire was developed to quantify the value towards gender of the child at birth. It was based on 10 motivational values as suggested by the seminal work of Shalom H Schwartz.⁽¹⁷⁾ It formed the basic theoretical construct with ten components. Components were identified as motivational values were: a) Power: Social status and prestige, control or dominance over people and resources; b) Achievement: Personal success through demonstrating competence according to social standards; c) Hedonism: Pleasure and sensuous gratification for oneself; d) Stimulation: Excitement, novelty, and challenge in life; e) Self-Direction: Independent thought and action-choosing, creating, exploring; f) Universalism: Understanding, appreciation, tolerance, and protection for the welfare of all people and for nature; g) Benevolence: Preservation and enhancement of the welfare of people with whom one is in frequent personal contact; h) Tradition: Respect, commitment, and acceptance of the customs and ideas that traditional culture or religion provide the self; i) Conformity: Restraint of actions, inclinations, and impulses likely to upset or harm others and violate social expectations or norms; and j) Security: Safety, harmony, and stability of society, of relationships, and of self.⁽¹⁷⁾ To develop the questionnaire based on the theoretical construct, an expert group of six members was formed inclusive from following disciplines; public health, social sciences, higher education discussions were carried out to discuss and finalize; 10 motivational values, value specific questions, and method of scoring (quantification) for questions. It was followed as; Firstly, a consensus was built on the utility of motivational values for assessment of parental value system towards the gender of a child. Experts agreed to all the dimensions of motivational values — of the theoretical construct. It was agreed that some dimensions were important than the others like power, self-direction, universalism, tradition, and security were more stressed upon. Secondly, it was disucssed that the questionnaire needs to be administered by research staff as the questions intend to measure laid values. It was decided due to giving chance to respondents to seek clarifications from the research staff, if any. Thirdly, questions were framed by research team and presented to experts for their validity and clarity. Experts assessed validity of questions for their subjectively coherence with the dimensions. Every question was also looked for its simplicity, shortness, addressal of single issue, and familiar vocabulary. Research team made neccassary changes and presented to experts to gain a subjective agreement over questions and to avoid redundancy of responses. In the group meetings, finalization of a number and type of questions for each motivational value was done. Thirdly, questions were decided to be close ended wherein method of scoring of questions were discussed. It was decided that response of every question is to be coded in the Likert scale from score 1 to 5; completely disagree, disagree, agree, partially agree, and completely agree. The questionnaire was translated into Hindi and then back to English. Conveniently, 26 women with last children less than one year age were selected to assess feasibility of administering questionnaire. Median score for overall and each motivational value with inter-quartile range was reported. The statistical significance in difference of scores between mothers with and without male child was tested by Mann-Whitney U test for independent samples and exact p value was reported.

Results :

After iterative discussions for agreement for dimensionality of construct, format of questionnaire, mode of administration, question development and method of scoring questions were prepared. At the beginning, based on importance of dimensions, a set of 105 questions were formed and out of these 52 non-redundant questions were finalized. The dimension wise distribution of questions was as; 6 for power, 3 for achievement, 2 for hedonism, 5 for stimulation, 9 for self-direction, 9 for universalism, 5 for benevolence, 3 for tradition, 4 for conformity, and 6 for security. (Table: 1)

It was assessed for feasibility in a small set of 26 women with the mean and median age of 29 years varying from 23 to 39 years. Assessment of feasibility for administering the questionnaire was done to check the understanding about questions amongst respondent women. Of these women, 3 were members of village level social organization. Twenty- two women were homemakers, 3 were government employee, and one was a daily wage worker. None of the women were illiterate and most ⁽²⁰⁾ of them were educated up to secondary level. Parity status observed that 10 women had one and rest had two living children. Seventeen women had at least one male child. It took an average of 25 minutes to assess the women using the formulated questionnaire.

The first assessed motivational value was power, it had 6 questions with the minimum score of 6 and a maximum score of 30. It had a median score of 24.0 (IQR: 20.0-27.0) for all women with a statistically insignificant difference (p=0.833) between women with [24.0 (IQR: 20.5-28.0)] and without [22.0 (IQR: 20.0-27.0)] male child. Assesment of value for achievement had minimum score of 3 and maximum of 25, observed a median score 13.0 (IQR:12.0-15.0) , without a statistically significant difference (p=0.312) between mothers with male child [with male child: 15.0 (IQR: 12.0-15.0); without male child: 13.0 (IQR: 9.0-15.0)]. Hedonism (minimum: 2, maximum: 10) had a median score of 10.0 (IQR:8.0-10.0), that too had no statistically significant (p=0.287) difference between mother with a male child [10.0 (IQR:8.0-10.0)] and without male child [9.0 (IQR: 7.0-10.0)]. The value for stimulation had five questions, where last four questions were conditional to the first question, so it had a minimum score of 1 and a maximum score of 25. It had a median score of 5.0 (IQR: 3.0-10.0), with a median score of 5.0 (IQR: 2.0-9.0) in women with male child and a score of 4.0 (IQR: 3.0-7.0) without male child (p=0.396). There are 9 questions for self-direction as a value, the response to one questions was conditional, with a score ranging from 8 to 45. Median score for self-direction was 24.5 (IQR:21.0-28.0) without a significant difference between two groups of mothers [with male child: 25.0 (IQR: 21.0-27.0); without male child: 24.0 (IQR: 18.0-29.0); p=0.958]. With a score range from 9 to 45, universalism as a value had a median score of 39.0 (IQR:36.0-43.0) with a significantly (p=0.039) low score among women with male child [38.0(IQR:36.0-41.0) ] as compared to women without male child [43.0 (IQR:39.0-44.0)]. All five questions to assess benevolence were conditional with a minimum possible score from 0 to maximum score of 25. It had a median value of 5.0 (IQR:3.0-6.0) without any significant difference in a score of two group of women [with male child: 5.0 (IQR: 3.0-7.0); without male child: 5.0 (IQR: 3.0-6.0); p=0.672]. Tradition had 3 questions with a possible score range from 3 to 15, it had a median score of 3.0 (IQR: 3.0-4.0) without a significant difference (p=0.958) for scores of women with male child [3.0 (IQR: 3.0-4.0)] and without male child [3.0 (IQR: 3.0-4.0)]. Conformity had four questions, all conditional, with a minimum and maximum score of 0 and 20 respectively. It had no significant difference (p=0.833) for median score in women with a male child [4.0(IQR: 3.0-6.0)] and without male child [4.0 (IQR: 3.0-5.0)], with an overall median score of 4.0 (IQR: 3.0-5.0). Security was assessed by 6 conditional questions with a minimum score of 0 and a maximum score of 30. It had a median score of 6.0 (IQR:4.0-8.0) without any significant difference in score amongst women of two groups [with male child: 6.0 (IQR: 3.0-7.0) ; without male child: 6.0 (IQR: 3.0-8.0); p=0.833]. (Table: 2).

Discussion:

Feasibility assessment and quantification of motivational values toward sex of a child at birth amongst women showed a promising response. Interviewer-administered questionnaire based assessment of values observed to be a feasible method. Response to questions asked from a very small set of study participants had not observed a significant variation, with a hint for better interpretation and comprehension by the participants. Reporting their responses as a feasibility exercise found that majority of the women had relatively high scores for self-direction, and universalism. Studied women appeared to have self-appraisal for social status and prestige, creative and independent, and an understanding of the peoples' welfare. Relatively, high score for achievement and hedonism reflected that the participants had an average feeling of personal success and sense of self-indulgence. Relative to other, domain values like stimulation, benevolence, tradition, conformity, and security observed with low scores. It reflected that the participants had a low feeling for excitement and challenge, preservation of welfare of close people, acceptance of customs, restraining actions that are likely to be harmful for others.

Limiting the results in a small set of women, it requires further assessment of a questionnaire for reliability and reproducibility. Questions are usually included in a questionnaire and assessed for its face validity amongst experts and study participants. ⁽¹⁹⁾ As in current study, inclusion of limited number of participants sufficed the questionnaire for studying the feasibility and face validity. ⁽²⁰⁾ Subjected structure of values for measuring SRB has not be studied anywhere, but it was studied to measure the strength and structure of relations, where stimulation and tradition were observed to be associated with the behavior.⁽¹⁸⁾

This study has focused on the development and administration of questionnaire that observed variation in scores for a set of values. It indicates a likely association of motivational values with individual behavior towards the gender of a child. So, a well-studied set of motivational values was chosen here to delineate the likely social factors influencing the behavior of women. In the present study, the exercise for formulation of questionnaire was kept simple, where a series of discussion amongst group of experts led to an agreement for motivational values, nature and number of questions, and method of scoring. Internal consistency was not calculated due to less number of study population. Pre-natal sex determination led fetal feticide was observed to be associated with declining SRB in India. ⁽⁵⁾ There has been a substantial effort to reduce the pre-natal sex determination practices in India.⁽²¹⁾ Legal measures have its role in reducing the incidents of female feticide, but skewed SRB has its roots in society that prefer a male child. In an individual, level of motivation attaches a value towards gender of child that describes the behavior. In a society, shared values affect the individual values through family. Therefore, a dynamic interaction of societal factors and self-motivation of individual determine the possessed value towards the event. The attached value might change with time due to improvement of socio-cultural environment and education. Current study intends to develop a feasible questionnaire to study the extent and quantification of values influencing the attitude towards gender of a child at birth. Over the time, it will be useful to assess the changing patterns of values, and realigning the results with awareness campaigns to improve the SRB. Application of such a questionnaire in assessing values has not been practiced anywhere, therefore future studies for validation with sufficient statistical power is required. It will be useful to understand the social dynamics influencing the decision-making process to marry, conceive, and give birth to the child. Lastly, this questionnaire can be well adapted to asses any health event to understand association between level of motivation and specific behavior of an individual.

Funding Support: National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra, Uttar Pradesh.