Abstract
The Knowledge-Attitude-Practice (KAP) Questionnaire could help investigate whether there are misconceptions, positive attitudes, and adequate practice in people with gout about exercise and exergames. The study aims to develop and validate the KAP questionnaire regarding exercise and exergames for obese patients with gout to understand gout ‘patients’ awareness level of exercise and perception of exergames. The development and validation of the questionnaire involved two phases: (1) development of the instrument and (2) judgment of the instrument through calculating the content validity by the expert panel and using SPSS version 28 to examine the test-retest reliability, internal consistency, and structural validity of the instrument. After the first phase of instrument development, an initial questionnaire consisting of six parts with 35 items was identified. After the content validation of the second phase, 11 items with a content validity ratio (CVR) value below 0.99 were eliminated, 3 items were rephrased, 2 items that mixed two statements were divided, and 15 items were added based on the original instrument. In addition, in the factor analysis, five items within the knowledge domain with factor loadings below 0.4 were removed. The final questionnaire was examined and demonstrated acceptable content validity, test-retest reliability, internal consistency, and construct validity.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-024-20076-w.
Keywords: Gout, Obesity, Exercise, Exergames, Knowledge, Attitude, Practice
Introduction
Gout remains a leading cause of inflammatory arthritis worldwide, and the main risk factor for gout is persistent hyperuricemia [1]. Hyperuricemia predisposes to monosodium urate crystals (MSU) deposition in and around the joints [2]. Furthermore, hyperuricemia may increase the risk factors for hypertension, coronary heart disease and diabetes [3]. The prevalence of gout is on the rise globally [4]. Obesity is a risk factor associated considerably with gout development [5]. Obese patients have increased urate production and decreased excretion, increasing serum uric acid (SUA) concentrations [6]. Previous studies have demonstrated that weight reduction effectively reduces serum uric acid [6].
Exercise can effectively manage obesity associated with gout [7]. Previous studies have demonstrated an inverse association between activity and the prevalence of hyperuricemia [8]. Among people with hyperuricemia who were physically active, the mortality risk could be reduced by 11% [9]. Exercise has more sustained effects and fewer side effects than drug therapy and can be recommended as an alternative treatment for patients with gout [9]. However, reducing the risk of gout by controlling weight through exercise has been degraded and ignored [10]. Therefore, it is necessary to identify practical and acceptable strategies to increase exercise levels in patients with gout.
Traditionally, Video games have been considered one of the leading causes of inactivity and obesity in people [11]. Therefore, exergames that can help people convert their interest in electronic screens into physical activities are constantly being developed. Recently, exergames such as Nintendo Wii and Xbox Kinect have been proven to provide users with a more enjoyable exercise experience through advanced technology [12]. The future possibility of exergames is that people’s attention to exercise can be distracted by more attractive electronic games, thereby promoting better exercise adherence [12]. Previous research has also shown that exergames could significantly decrease weight and cardiovascular risks [13, 14]. To evaluate the feasibility of exergames as an innovative weight and cardiovascular risk factor management tool in patients with gout in the future, it is necessary to obtain data on the perception of exergames in patients with gout.
Knowledge, Attitude, and Practice study (KPA) is a widely recognized instrument to identify the knowledge, misconceptions, and attitudes, in health-related behaviors and health-seeking practices [15]. Then, further analyze and understand the interest level of the target population in the field. Finally, develop relevant interventions based on existing needs, barriers and misperceptions [15]. The KAP survey could help investigate whether there are misconceptions, positive attitudes, and adequate practice in people with gout about exercise and exergames. Misunderstandings, negative emotions, and inadequate training can potentially interfere with creating effective awareness, create barriers to effective behaviour change, and interfere with intervention planning [16]. Therefore, to improve the compliance of gout patients with exercise, it is significant to collect clinical statistics to evaluate gout patients’ KAP of exercise and exergames. However, although some exercise-related KAP instruments have been developed, no questionnaires specifically address exercise and exergames in patients with gout.
Therefore, this study aims to develop and validate the KAP questionnaire regarding exercise and exergames for obese patients with gout to understand gout ‘patients’ awareness level of exercise and perception of exergames. The outcome will allow researchers to understand whether knowledge gaps, negative attitudes and inadequate practice patterns among gout patients may limit the prevention and control of gout symptoms. Moreover, to examine whether exergames are acceptable as a tool to promote physical exercise in patients with gout.
Methods
This cross-sectional study was conducted among patients with gout in Pulau Pinang in June 2023. The participants in the study have met our inclusion criteria: (1) be coded as having gout in their computerized GP record, including tophi, tophus, or podagra. Researchers will check the diagnosis to ensure the validity of the diagnosis (2), familiar with English (3), have ages range from 18 to 70. All participants gave informed consent before completing the test. This study has been approved by Human Research Ethic Committee USM (USM/JEPeM/22090586).
All participants were required to complete an online questionnaire. Doctors shared the link to the questionnaire in Pulau Pinang. Furthermore, eligible participants were screened out at the Advanced Medical and Dental Institute (AMDI), Universiti of Sains Malaysia (USM), and a link to the questionnaire was sent to them through WhatsApp.
The development and validation of the questionnaire involved two phases: [1] development of the instrument and [2] judgment of the instrument through calculating the content validity by the expert panel and using SPSS version 26 to examine the test-retest reliability, internal consistency, and structural validity of the instrument.
Phase 1: development of the instrument
After clarifying the research objectives, a panel group of two exercise rehabilitation therapists, a gout specialist, and a rehabilitation researcher was established. The research group reviews the literature in four databases, including Web of Science, PubMed, Google Scholar and Scopus. The search keywords included ‘gout’, ‘exercise’, ‘physical activity’, ‘exergames’, ‘knowledge’, ‘attitudes’, ‘practice’ and exercise. First, we identified the operational definitions and key variables of the questionnaire through review the literature, thereby determining the primary content to be measured. Second, based on these operational definitions and variables, we generated specific questionnaire items that could effectively address the research questions, Finally, the expert group refined and reviewed the items and approved the preliminary version of the questionnaire. Malaysia is a multiethnic country, mainly including Malays, Chinese and Indians, with a complex language environment. Since English is the common and one of the official languages in Malaysia, the questionnaire is constructed in English.
Phase 2: Judgment of the instrument
Content validity
The assessment of content validity plays a vital role in the judgement of the instrument [17], which relied on a panel of experts to provide constructive comments on the representativeness and clarity of each item of the newly developed tool [18]. It is recommended that at least 5 experts in the relevant fields are required to review the instrument to enable adequate control over the chance agreement [19]. The content validity of this study was confirmed by a panel of 5 experts, including an obesity specialist, a gout specialist, an exercise scientist and two physiotherapists. Experts are required to use quantitative methods to evaluate the content validity of the questionnaire through two rounds of evaluation. A cover letter indicating the instrument’s purpose, content, and scoring methodology and an appraisal sheet for each round was sent to the experts through email. In addition to scoring each item according to the scoring criteria, experts were required to give specific revision opinions in a separate box. There is no communication between the experts. The judgement is completed with an independent attitude. This study calculated three indices, including content validity ratio (CVR), scale-level content validity index (S-CVI/Ave) and item-level content validity index (I-CVI), to quantify the content validity of this questionnaire.
CVR is a widely utilized method of evaluating content validly invented by Lawshe (1975). It quantifies whether an item is necessary for the instrument [20]. In the first round of evaluation, experts must divide each item’s significance into three levels: not required, helpful but not essential, and essential scoring 1, 2, and 3 points, respectively [19]. The formula of the content validity ratio developed by Lawshe (1975) is CVR=(ne-N/2)/(N/2), ne represents the number of experts marked as ‘essential,’ and N denotes the overall number of panellists, and the value calculated by this formula ranges from + 1 to -1 [20]. Since the panel size of this study is 5, the acceptable CVR value is 0.99 according to the recommendation of the Lawshe Table [21].
CVI has always been regarded as the most widely used index to evaluate the content validity of the questionnaire, which is divided into S-CVI and I-CVI [22]. In the second round of evaluation, experts are required to rate items of the instrument in terms of clarity and its relevancy on a 4-point Likert scale (1-not relevant/clear, 2-item need some revision, 3-relevant/clear but need minor revision, 4-very applicable/clear). Then, calculate I-CVI according to the formula: (Number of experts rating 3 or 4)/(number of experts). According to the previous study, the acceptable I-CVI value for this study is 0.79. If the I-CVI value is between 0.7 and 0.79, the items will be modified, and items below 0.7 will be eliminated [19, 23]. Moreover, this study calculated S-CVI/Ave based on I-CVI. The calculation formula is: (sum of I-CVI scores)/(number of items).
Test-retest reliability
The test-retest reliability after a two-week interval was used to reflect the stability and consistency of the instrument across time. Previous study has shown that the optimal period for measuring test-retest reliability is 1 to 4 weeks [24]. Since an insufficient period may allow patients to retain the impression of the initial response, and an exceeded period may introduce the effects of lifestyle changes, previous studies have widely taken two weeks to measure test-retest reliability [25, 26]. Therefore, two weeks after the patient completes the first test, the online retest questionnaire will be resent to the patient via email or WhatsApp, which the patient must fill in at the first test.
The intraclass correlation coefficient (ICC) was used to calculate the test-retest reliability of the questionnaire. ICC Values below 0.5 suggest poor reliability, Values between 0.5 and 0.75 indicate moderate reliability, values ranging from 0.75 to 0.9 signal good reliability, and values exceeding 0.90 represent excellent reliability [27]. According to Kennedy, a test-retest reliability test requires a sample size of at least 100 to achieve strong reliability [28]. Therefore, this article must collect at least 100 questionnaires to meet a sufficient sample size for test-retest reliability.
Structure validity
The structure validity of the instrument is examined by exploratory factor analysis (EFA). This study first checks whether the sample meets the prerequisites for factor analysis through the Kaiser–Meyer–Olkin (KMO) test and Bartlett’s Test of Sphericity. According to the previous study, the acceptable KMO value of this study is more significant than 0.8 [29].
According to Bryman and Cramer, the sample size calculation of construct validity (factor analysis) is based on the number of items in the instrument with a subject-to-variable ratio of 5:1 [30]. Therefore, the required sample size for 41 items is 205.
Internal consistency
The internal consistency of the instrument is measured with Cronbach’s alpha. It is commonly recommended that Cronbach’s alpha greater than 0.7 is considered acceptable internal consistency [31].
Exploring the internal consistency coefficient of the scale, set α = 0.05, power = 0.80, and the internal consistency coefficient of the scale reaching 0.7 was set as meaningful, and the allowable error was specified as 0.07, K = 2, calculated by SPSS version 21.0 (PASW Statistics for Windows, Chicago: SPSS Inc.), the estimated sample size requires 290 cases.
Results
Results of phase 1
After the first phase of instrument development, an initial questionnaire consisting of six parts with 35 items was identified. The first part is 11 questions related to Sociodemographic information and anthropometric parameters. The second part consists of 7 dichotomous questions that require answering “yes” or “no” to investigate general knowledge about the exercise of patients with gout. The third part contains 6 inquiries about the attitude towards training, which participants must answer through a traditional 1-to-5 rating Likert scale (Strongly disagree, disagree, neither agree nor disagree, Agree, strongly agree). The fourth part is 3 open questions about exercise practice in patients with gout. The fifth and sixth parts are set as questions related to Exergames. Participants were required to answer questions related to awareness of Exergames (3 items) and perception of Exergames (5 items) through dichotomous questions (“yes” or “no”) and1-to-5 rating Likert scale (Strongly disagree, disagree, neither agree nor disagree, Agree, Strong agree) respectively. As The Nintendo Ring Fit Adventure (Nintendo, Kyoto, Japan) is the most popular and widely researched Exergame software in the field of health promotion, this study focuses on Nintendo’s exergame software. In the section of the questionnaire related to exergames, a brief introduction to the features and operation of the exergame (Nintendo Ring Fit Adventure) will be provided, and participants will be asked to read it carefully before responding.
Results of phase 2
A total of 290 gout patients, comprising 110 females (37.9%) and 180 males (62.1%), responded to the questionnaire. The average age of the participants is 46.010 ± 14.234. Most participants have received higher education (college: 66.9%, post-graduate: 7.2%). The primary and high school educational levels are 2.4% and 23.4% respectively. Most participants were Bumiputras (50%), 27.6% were Chinese, 16.2% were Indian, and 6.2% were others. Table 1 shows the demographic characteristics of the participants.
Table 1.
Demographic characteristics of the participants
| Demographic characteristics | All participants (N = 290) |
|---|---|
| Age, Mean (SD) | 46.010 (14.234) |
| Gender (%) | |
| Male | 180 (62.1) |
| Female | 110 (37.9) |
| Level of education (%) | |
| Primary school | 7 (2.4) |
| High school | 68 (23.4) |
| College | 194 (66.9) |
| Post-graduate | 21 (7.2) |
| Race (%) | |
| Bumiputras | 145 (50.0) |
| Chinese | 80 (27.6) |
| India | 47 (16.2) |
| Others | 18 (6.2) |
Content validation and adaptation
After receiving the results of the first round of evaluation by the expert panel, CVR was calculated to examine the instrument’s content validity. Table 2 shows the Calculation of CVR. 11 items with a CVR value below 0.99 were eliminated in the first round of judgment. The fourth part was deleted since the CVR value of the three items in the fourth part did not meet the minimum requirements. Based on the advice of the panel, three items were rephrased, two items that mixed two statements were divided, and 15 items were added based on the original instrument. Furthermore, experts judged the face validity of the instrument in this round. Improper grammar and sentence expressions have been revised based on the advice of experts. Table 3 shows the revised questionnaire based on the results of the first round of validity testing.
Table 2.
Calculation of CVR
| Section | Item | Item content | Ne | CVR | Interpretation |
|---|---|---|---|---|---|
| 1. Sociodemographic information and anthropometric parameters | 1.1 | Name | 1 | -0.6 | Eliminated |
| 1.2 | Phone number | 1 | -0.6 | Eliminated | |
| 1.3 | 3 | 0.2 | Eliminated | ||
| 1.4 | What is your age | 5 | 1 | Remained | |
| 1.5 | What gender do you identify as? | 5 | 1 | Remained and rephrased | |
| 1.6 | What is your employment status? | 5 | 1 | Remained | |
| 1.7 | What is your highest level of education? | 5 | 1 | Remained | |
| 1.8 | Please specify your race | 5 | 1 | Remained | |
| 1.9 | Height | 5 | 1 | Remained | |
| 1.10 | Weight | 5 | 1 | Remained | |
| 1.11 | BMI | 3 | 0.2 | Eliminated | |
| 2. General knowledge about exercise | 2.1 | Obesity is a clinically relevant risk factor for gout | 5 | 1 | Remained |
| 2.2 | Exercise rehabilitation can effectively manage obesity-associated with gout | 5 | 1 | Remained and rephrased | |
| 2.3 | Exercise rehabilitation can maintain the range of motion of the joint, flexibility and strength of the muscles and ligaments around the joint in patients with gout | 5 | 1 | Remained and divided two statement | |
| 2.4 | Exercise reduces the risk of cardiovascular disease | 5 | 1 | Remained | |
| 2.5 | Exercise does more good than bad | 2 | -0.2 | Eliminated | |
| 2.6 | Exercise is divided into aerobic exercise and anaerobic exercise | 5 | 1 | Remained | |
| 2.7 | Exercise can be rehab-based. | 2 | -0.2 | Eliminated | |
| 3. Attitude towards exercise | 3.1 | Exercise is easy and enjoyable for me | 5 | 1 | Remained and divided two statements |
| 3.2 | It is important to develop the habit of exercise | 5 | 1 | Remained | |
| 3.3 | There is value in spending time for exercise | 5 | 1 | Remained | |
| 3.4 | I need to exercise | 5 | 1 | Remained | |
| 3.5 | I look forward to getting guidance and assistance with exercise | 5 | 1 | Remained and rephrased | |
| 3.6 | I think the advantages of exercise outweigh the disadvantages | 4 | 0.6 | Eliminated | |
|
4. Participation in exercise |
4.1 | 4.1 How many days a week do you exercise? | 5 | 1 | Remained |
| 4.2 | 4.2 How many minutes per day do you spend exercising? | 5 | 1 | Remained | |
| 4.3 |
Which of the following is the most likely reason for you to give up exercising? Time Symptoms of gout Transport Fatigue Lack interest lack of facilities lack of guidance |
5 | 1 | Remained | |
|
5. Awareness of exergames |
5.1 | Do you know what exergames is? | 4 | 0.6 | Eliminated |
| 5.2 | Have you ever tried using Exergames? | 3 | 0.2 | Eliminated | |
| 5.3 | Did you know that exergames can be used to manage obesity? | 4 | 0.6 | Eliminated | |
|
6. Perception of exergames |
6.1 | I feel that Exergames is easy to operate | 5 | 1 | Remained |
| 6.2 | I believe Exergames can help me lose weight | 5 | 1 | Remained | |
| 6.3 | I believe that Exergames can help me manage my gout-related symptoms | 5 | 1 | Remained | |
| 6.4 | I feel very confident about using Exergames | 5 | 1 | Remained | |
| 6.5 | I think I need Exergames | 4 | 0.6 | Eliminated |
CVR = content validity ratio, Ne = The number of experts marked as ‘essential’
Table 3.
The revised questionnaire is based on the results of the first round of validity testing
| Section | Item | Item content |
|---|---|---|
| 1. Sociodemographic information and anthropometric parameters | 1.1 | What is your age? |
| 1.2 | What is your gender? | |
| 1.3 | What is your employment status? | |
| 1.4 | What is your highest level of education? | |
| 1.5 | Please specify your race. | |
| 1.6 | Height | |
| 1.7 | Weight | |
| 2. General knowledge about exercise | 2.1 | Obesity is a clinically relevant risk factor for gout |
| 2.2 | Exercise helps controlling gout | |
| 2.3 | Exercise improves my flexibility | |
| 2.4 | Exercise improves my strength of the muscles | |
| 2.5 | Exercise reduces the risk of cardiovascular disease | |
| 2.6 | Exercise reduces blood pressure | |
| 2.7 | Exercise decreased cholesterol | |
| 2.8 | Exercise should be done continually for developing and maintain fitness | |
| 2.9 | Heart Rate is typically used as a measure of exercise intensity | |
| 2.10 | Exercise needs to reach target heart rate to achieve effective intensity | |
| 2.11 | Exercise is divided into aerobic exercise and anaerobic exercise | |
| 2.12 | Aerobic exercise can help lose weight | |
| 2.13 |
Common aerobic exercises include Hiking, Jogging or running, Cycling, Swimming |
|
| 2.14 | Moderate-intensity aerobic exercise can contribute to decreases SUA level | |
| 2.15 | Lactic acid produced by anaerobic exercise will hinder the excretion of uric acid | |
| 2.16 | High-Intensity exercise may cause short-term increases in uric acid | |
|
3. Attitude towards exercise |
3.1 | Exercise is easy for me |
| 3.2 | Exercise is enjoyable | |
| 3.3 | It is important to develop the habit of exercise | |
| 3.4 | There is value in spending time for exercise | |
| 3.5 | I need to exercise | |
| 3.6 | I look forward to getting guidance with exercise | |
| 3.7 | Doing regular exercise will improve my symptoms of gout | |
| 3.8 | Exercise is not expensive | |
| 3.9 | I am dissatisfied with my weight | |
| 4. Participation in exercise | 4.1 | How many days a week do you exercise? |
| 4.2 | How many minutes per day do you spend exercising? | |
| 4.3 |
What is the typical intensity you exercise? light intensity moderate intensity vigorous intensity |
|
| 4.4 |
Which of the following is the most likely reason for you to give up exercising? Time Symptoms of gout Transport Fatigue Lack interest Lack of facilities Lack of guidance |
|
|
5. Perception of exergames |
5.1 | I feel that Exergames is easy to operate |
| 5.2 | I believe Exergames can help me lose weight | |
| 5.3 | I believe that Exergames can help me manage my gout-related symptoms | |
| 5.4 | I feel very confident about using Exergames | |
| 5.5 | I think Exergames are more interesting than traditional exercise |
Five panellists scored on the relevancy and clarity of the remaining 41 items in the second round of content validity testing. Then, CVI and S-CVI/Ave were calculated. Since the I-CVI of all 41 items in the questionnaire is above 0.8, and the S-CVI/Ave values are high (S-CVI/Ave = 0.99). All items were considered excellent and appropriate. Table 4 shows the calculation results of CVI.
Table 4.
Calculation of CVI
| Item | Relevance | Clarity | Interpretation | ||
|---|---|---|---|---|---|
| Nr | I-CVI | Nr | I-CVI | ||
| 1.1 | 5 | 1 | 5 | 1 | Appropriate |
| 1.2 | 5 | 1 | 5 | 1 | Appropriate |
| 1.3 | 5 | 1 | 5 | 1 | Appropriate |
| 1.4 | 5 | 1 | 5 | 1 | Appropriate |
| 1.5 | 5 | 1 | 5 | 1 | Appropriate |
| 1.6 | 5 | 1 | 5 | 1 | Appropriate |
| 1.7 | 5 | 1 | 5 | 1 | Appropriate |
| 2.1 | 5 | 1 | 5 | 1 | Appropriate |
| 2.2 | 5 | 1 | 5 | 1 | Appropriate |
| 2.3 | 5 | 1 | 4 | 0.8 | Appropriate |
| 2.4 | 5 | 1 | 5 | 1 | Appropriate |
| 2.5 | 5 | 1 | 5 | 1 | Appropriate |
| 2.6 | 5 | 1 | 5 | 1 | Appropriate |
| 2.7 | 5 | 1 | 5 | 1 | Appropriate |
| 2.8 | 5 | 1 | 5 | 1 | Appropriate |
| 2.9 | 5 | 1 | 5 | 1 | Appropriate |
| 2.10 | 5 | 1 | 5 | 1 | Appropriate |
| 2.11 | 5 | 1 | 5 | 1 | Appropriate |
| 2.12 | 5 | 1 | 5 | 1 | Appropriate |
| 2.13 | 5 | 1 | 5 | 1 | Appropriate |
| 2.14 | 5 | 1 | 5 | 1 | Appropriate |
| 2.15 | 5 | 1 | 5 | 1 | Appropriate |
| 2.16 | 5 | 1 | 5 | 1 | Appropriate |
| 3.1 | 4 | 0.8 | 5 | 1 | Appropriate |
| 3.2 | 5 | 1 | 5 | 1 | Appropriate |
| 3.3 | 5 | 1 | 5 | 1 | Appropriate |
| 3.4 | 5 | 1 | 5 | 1 | Appropriate |
| 3.5 | 5 | 1 | 5 | 1 | Appropriate |
| 3.6 | 5 | 1 | 5 | 1 | Appropriate |
| 3.7 | 5 | 1 | 5 | 1 | Appropriate |
| 3.8 | 5 | 1 | 5 | 1 | Appropriate |
| 3.9 | 5 | 1 | 5 | 1 | Appropriate |
| 4.1 | 5 | 1 | 5 | 1 | Appropriate |
| 4.2 | 5 | 1 | 5 | 1 | Appropriate |
| 4.3 | 5 | 1 | 5 | 1 | Appropriate |
| 4.4 | 5 | 1 | 5 | 1 | Appropriate |
| 5.1 | 5 | 1 | 5 | 1 | Appropriate |
| 5.2 | 5 | 1 | 5 | 1 | Appropriate |
| 5.3 | 5 | 1 | 5 | 1 | Appropriate |
| 5.4 | 5 | 1 | 5 | 1 | Appropriate |
| 5.5 | 5 | 1 | 5 | 1 | Appropriate |
| 41 Items | S-CVI/Ave = 0.99 | ||||
Nr = Number of experts rating 3 or 4, ICVI = item-level content validity index, S-CVI/Ave = average of the item-level CVIs
Test-retest reliability
Two hundred thirty-three patients answered the questionnaire for the second time after two weeks. The sample size meets the requirements for test-retest reliability testing. The ICC value of three weeks interval test-retest reliability was in the range of 0.801 to 0.959, indicating that the questionnaire has acceptable test-retest reliability. The results of the test-retest reliability are shown in Table 5.
Table 5.
The results of the test-retest reliability
| Items | ICC | P |
|---|---|---|
| 2.1 | 0.952 | < 0.001 |
| 2.2 | 0.875 | < 0.001 |
| 2.3 | 0.828 | < 0.001 |
| 2.4 | 0.954 | < 0.001 |
| 2.5 | 0.861 | < 0.001 |
| 2.6 | 0.837 | < 0.001 |
| 2.7 | 0.866 | < 0.001 |
| 2.8 | 0.808 | < 0.001 |
| 2.9 | 0.890 | < 0.001 |
| 2.10 | 0.821 | < 0.001 |
| 2.11 | 0.940 | < 0.001 |
| 2.12 | 0.937 | < 0.001 |
| 2.13 | 0.955 | < 0.001 |
| 2.14 | 0.969 | < 0.001 |
| 2.15 | 0.944 | < 0.001 |
| 2.16 | 0.866 | < 0.001 |
| 3.1 | 0.843 | < 0.001 |
| 3.2 | 0.821 | < 0.001 |
| 3.3 | 0.846 | < 0.001 |
| 3.4 | 0.834 | < 0.001 |
| 3.5 | 0.857 | < 0.001 |
| 3.6 | 0.904 | < 0.001 |
| 3.7 | 0.900 | < 0.001 |
| 3.8 | 0.882 | < 0.001 |
| 3.9 | 0.849 | < 0.001 |
| 4.1 | 0.959 | < 0.001 |
| 4.2 | 0.958 | < 0.001 |
| 4.3 | 0.922 | < 0.001 |
| 4.4_1 | 0.879 | < 0.001 |
| 4.4_2 | 0.887 | < 0.001 |
| 4.4_3 | 0.911 | < 0.001 |
| 4.4_4 | 0.921 | < 0.001 |
| 4.4_5 | 0.922 | < 0.001 |
| 4.4_6 | 0.913 | < 0.001 |
| 4.4_7 | 0.885 | < 0.001 |
| 5.1 | 0.875 | < 0.001 |
| 5.2 | 0.880 | < 0.001 |
| 5.3 | 0.870 | < 0.001 |
| 5.4 | 0.804 | < 0.001 |
| 5.5 | 0.801 | < 0.001 |
ICC = intraclass correlation coefficient, P = P-values (P < 0.05 is considered statistically significant)
Structure validity using factor analysis
According to our results, the KMO value of the questionnaire is 0.911, and the P value of Bartlett’s sphericity test is less than 0.001, indicating that the test sampling of each variable in the model is adequate and the data is suitable for conducting factor analysis. Table 6 shows the result of the KMO test and Bartlett’s sphericity test.
Table 6.
Result of the KMO test and Bartlett’s sphericity test
| Test | Results | |
|---|---|---|
| KMO | 0.911 | |
| Bartlett’s sphericity test | Chi-square | 4207.607 |
| Degree of freedom | 435 | |
| Significance | < 0.001 | |
KMO = Kaiser–Meyer–Olkin
The factors were rotated by varimax rotation to clarify the correspondence between elements and research items. Table 7 shows that 3 factors were extracted, and the eigenvalues were more significant than 1. The Variance contribution rate (%) of these three factors after rotation was 23.000%, 17.224%, and 13.036%, respectively, and the total variance explanation rate after rotation was 53.259%. The number of factors extracted follows expectations. There is no cross-over between items in the factor loadings; the factor loadings are all greater than 4, ranging between 0.525 ~ 0.893. However, there are 5 items with commonalities less than 0.4 (2.2, 2.10, 2.11, 2.12 and 2.13). These low commonalities items cannot effectively contribute to each factor. Therefore, these five items were deleted. Table 8 shows the results of factor loading and commonalities.
Table 7.
Factor characteristic value and variance contribution rate
| Factors | Characteristics | Variance contribution rate (%) | Cumulative contribution rate (%) |
|---|---|---|---|
| Factor 1 | 6.670 | 23.000 | 23.000 |
| Factor 2 | 4.995 | 17.224 | 40.224 |
| Factor 3 | 3.780 | 13.036 | 53.259 |
Table 8.
Results of factor loading and commonalities
| Items | Factor | Communalities | ||
|---|---|---|---|---|
| 1 | 2 | 3 | ||
| 2.1 | 0.654 | 0.429 | ||
| 2.2 | 0.540 | 0.296 | ||
| 2.3 | 0.660 | 0.441 | ||
| 2.4 | 0.697 | 0.489 | ||
| 2.5 | 0.692 | 0.487 | ||
| 2.6 | 0.646 | 0.425 | ||
| 2.7 | 0.668 | 0.448 | ||
| 2.8 | 0.661 | 0.437 | ||
| 2.9 | 0.636 | 0.408 | ||
| 2.10 | 0.613 | 0.379 | ||
| 2.11 | 0.741 | 0.551 | ||
| 2.12 | 0.753 | 0.572 | ||
| 2.13 | 0.525 | 0.276 | ||
| 2.14 | 0.538 | 0.293 | ||
| 2.15 | 0.587 | 0.351 | ||
| 2.16 | 0.656 | 0.436 | ||
| 3.1 | 0.724 | 0.527 | ||
| 3.2 | 0.769 | 0.593 | ||
| 3.3 | 0.863 | 0.746 | ||
| 3.4 | 0.794 | 0.635 | ||
| 3.5 | 0.826 | 0.688 | ||
| 3.6 | 0.824 | 0.679 | ||
| 3.7 | 0.738 | 0.547 | ||
| 3.8 | 0.718 | 0.518 | ||
| 3.9 | 0.686 | 0.472 | ||
| 5.1 | 0.843 | 0.717 | ||
| 5.2 | 0.893 | 0.805 | ||
| 5.3 | 0.885 | 0.783 | ||
| 5.4 | 0.885 | 0.749 | ||
| 5.5 | 0.828 | 0.687 | ||
Internal consistency reliability
The results of the internal reliability analysis showed that the Cronbach’s α value (Table 9) of the knowledge, attitude and Exergames dimensions were 0.886, 0.915, and 0.915, respectively. Cronbach’s α values after deleting items are all smaller than those without deletion, as shown in Table 10, indicating that no items need to be deleted.
Table 9.
The results of ‘Cronbach’s α value
| Dimensions | Number of items | Cronbach’ α |
|---|---|---|
| General knowledge about exercise | 11 | 0.886 |
| Attitude towards exercise | 9 | 0.915 |
| Perception of Exergames | 5 | 0.915 |
Table 10.
Results of ‘Cronbach’s α value after deleting items
| Items | ‘Cronbach’s α value after deleting items |
|---|---|
| General knowledge about exercise | |
| 2.1 | 0.878 |
| 2.3 | 0.877 |
| 2.4 | 0.877 |
| 2.5 | 0.874 |
| 2.6 | 0.877 |
| 2.7 | 0.877 |
| 2.8 | 0.878 |
| 2.9 | 0.879 |
| 2.14 | 0.872 |
| 2.15 | 0.872 |
| 2.16 | 0.878 |
| Attitude towards exercise | |
| 3.1 | 0.909 |
| 3.2 | 0.906 |
| 3.3 | 0.898 |
| 3.4 | 0.904 |
| 3.5 | 0.901 |
| 3.6 | 0.902 |
| 3.7 | 0.909 |
| 3.8 | 0.910 |
| 3.9 | 0.912 |
| Perception of exergames | |
| 5.1 | 0.901 |
| 5.2 | 0.887 |
| 5.3 | 0.891 |
| 5.4 | 0.896 |
| 5.5 | 0.906 |
Discussion
The knowledge-attitude-practice (KAP) model proposes that health knowledge is essential to set up healthy beliefs that could influence attitude and behaviour change [32]. Previous research has demonstrated obesity leads to an increased risk of gout [33]. Weight loss and low-to-moderate-intensity exercise significantly reduced inflammation levels, gout attack frequency, pain scores, and SUA [34, 35]. Patients’ education, philosophy and motivation are of great significance to whether they will adopt appropriate exercise methods and successful weight loss, which largely depends on whether the patient has sufficient KAP [36].
However, to our knowledge, there have been no KAP questionnaires to assess awareness levels on exercise and perception of exergames in patients with gout. Moreover, it is unclear whether patients with gout are aware of the potential risk of obesity, the importance of exercise, how to exercise reasonably, and whether patients with gout have adequate exercise. Therefore, this study developed and validated an instrument to examine the KAP of patients with gout to exercise.
The KAP instrument developed by this study ultimately consists of 41 items in five sections with the 7 items in Sect. 1 surveying patients’ sociodemographic information and anthropometric parameters. The knowledge section of the instrument consists of 7 items, mainly to measure whether patients with gout have enough knowledge about exercise. The attitude section includes 9 questions to understand whether gout patients perceive exercise negatively or positively. The 4 items in the practice section focus on the frequency and intensity of daily exercise for patients with gout. The last part of the instrument is appended with 5 items about the perception of exergames in patients with gout. The last section investigates whether patients with gout can accept Exergames as an innovative weight loss strategy.
Furthermore, this study tested the reliability and validity of the instrument through scientific validation procedures. Reliability and validity are among the most common and fundamental strategies to evaluate tools used for data collection. These can be used to assess the authenticity of the data obtained and the instrument’s measurement effect, respectively [37]. The verification process is lengthy. The first is to quantify the instrument’s content validity by calculating the values of CVR, I-CVI and S-CVI. In the first round of validity testing, 11 items with a CVR lower than 0.99 were eliminated, 3 items were rephrased, and 15 items were added based on the recommendations of the panel group. In the second round of validity testing, the finalized 41 items met the standard of I-CVI greater than 0.8 and obtained a high S-CVI/Ave (0.99). This proves that this instrument sufficiently represents the construct variables and can well reflect the KPA of exercise and the perception of exergames in patients with gout. Although content validity assessment is subjective, the panel of local experts helped us better understand whether the instrument is appropriate for the local population’s cultural context and whether adjustments are necessary.
The study next examined the instrument’s test-retest reliability, construct validity and internal consistency test-retest reliability of the instrument after ICC measured at two-week intervals. The ICC value of knowledge dimensions is 0.88, indicating the questionnaire has good test-retest reliability. The ICC value of the attitude and exergames dimensions exceeds 0.9, which is considered to have excellent test-retest reliability. Factor analysis is recommended as the most commonly used golden method to test the structural validity of instruments [38]. Five items in the knowledge domain were below 0.4. A communality measures the degree to which an item correlates with all the other items. Items must possess a commonality exceeding 0.4 to demonstrate a satisfactory level of correlation [39]. Therefore, these five low-relevance items were removed. The Cronbach’s α value of the instrument’s knowledge, attitude, and exergames domains is more significant than 0.7, indicating that the instrument has acceptable internal inconsistency [31].
This study did have two main limitations. The first limitation was language bias. Since the questionnaire is compiled in English, there may be a possibility of ignoring the gout population who do not understand English. Additionally, since the verification of the content validity of the questionnaire is based on the expert panel’s subjective opinions, the experts’ personal bias may inevitably be introduced in this process.
Conclusion
The instrument developed and verified by this study is currently the only KAP questionnaire to examine exercise and exergames for patients with gout. This questionnaire showed acceptable content validity, test-retest reliability, internal consistency, and construct validity. Therefore, it is an effective and reliable instrument that can assist researchers or public health experts in identifying the KAP related to exercise and perception of Exergames among the gout population. This can aid in the development of targeted exercise intervention strategies or educational programs to improve the health outcomes of individuals with gout. Since this study included only gout patients from Pulau Pinang, Malaysia, its applicability is limited to this specific population. Future studies should test in different patient populations to verify the generalizability of this instrument.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Abbreviations
- MSU
Monosodium urate crystals
- SUA
Serum uric acid
- KAP
Knowledge-Attitude- Practice
- CVR
Content validity ratio
- S-CVI/Ave
Scale-level content validity index
- I-CVI
Item-level content validity index
- ICC
Intraclass correlation coefficient
- EFA
Exploratory factor analysis
- KMO
Kaiser–Meyer–Olkin
Author contributions
M.C. and H.A.Y. contributed to the conception and design of the study, collected data, performed analysis and wrote the manuscript. J.C. provided funding and professional guidance for the study. L.Z. contributed to interpreting the analyses. All authors contributed to the manuscript revision and approved the submission.
Funding
This Study is supported by: the project of the third affiliated Hospital of Zhejiang Chinese Medical University (No. ZS22YA01), the Key Scientific Research and Development Program of Zhejiang Province, China (No. 2021C03050), Hangzhou Science and Technology Development Plan Project, China (2020ZDSJ0881).
Data availability
Data is provided within the manuscript or supplementary information files.
Declarations
Ethics approval and consent to participate
This study has been approved by Human Research Ethic Committee USM (USM/JEPeM/22090586). Each participant was provided with informed consent before completing the questionnaire.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Conflict of interest
The authors declare no conflict of interest in this study.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Hazwani Ahmad Yusof, Email: hazwanihanafi@usm.my.
Jianer Chen, Email: chenje@zcmu.edu.cn.
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Data Availability Statement
Data is provided within the manuscript or supplementary information files.