Indian Journal of Palliative Care
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Table of Contents 
Year : 2021  |  Volume : 27  |  Issue : 1  |  Page : 99-103

The validation of questionnaire on end-of-life care knowledge, perceptions, and preferences among end-stage renal disease patients on hemodialysis

1 Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
2 Department of Community Health, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

Date of Submission09-Jun-2020
Date of Acceptance02-Oct-2020
Date of Web Publication17-Feb-2021

Correspondence Address:
Wan Ahmad Syahril Rozli Wan Ali
Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Istana, Bandar Indera Mahkota, Kuantan 25100, Pahang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPC.IJPC_221_20

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 » Abstract 

Introduction: End-of-life care issues for end-stage renal disease (ESRD) patients are still not fully highlighted in trials and clinical practice. Due to the inadequacy, exploring patients' knowledge, perceptions, and preferences is essential to improve the delivery of care. This was performed using questionnaires which have been a widely useful tool in medical researches. Up to date, there was no published, validated questionnaire developed in Malaysia for such purposes yet. Objective: This study aimed to develop and validate the questionnaire on end-of-life care knowledge, perceptions, and preferences among hemodialysis (HD) patients. Subject and Methods: A cross-sectional study was conducted among 92 HD patients from 14 centers. It involved four phases including (i) developing the questionnaire and pretesting, (ii) improving and editing and redistribution to respondents for the pilot study, (iii) factor analysis (FA), and (iv) internal consistency reliability testing. Results: The result of FA with varimax rotation performed identified three domains for the 41 items, with 10–20 items in each domain. All the 41 analyzed items had a good factor loading of more than 0.4 with the lowest value of 0.421 and were nicely fit into three respective domains: knowledge, perceptions, and preferences. Internal consistency reliability analysis Cronbach's α values were between 0.5 and 0.7 for all domains, higher than the level set for this study (0.5). Conclusion: The questionnaire was successfully validated and considered a useful tool in describing ESRD patients' end-of-life care knowledge, perceptions, and preferences.

Keywords: End of life, end-stage renal disease, questionnaire, validation

How to cite this article:
Rozi NR, Ali WA, Draman CR, Pasi HB. The validation of questionnaire on end-of-life care knowledge, perceptions, and preferences among end-stage renal disease patients on hemodialysis. Indian J Palliat Care 2021;27:99-103

How to cite this URL:
Rozi NR, Ali WA, Draman CR, Pasi HB. The validation of questionnaire on end-of-life care knowledge, perceptions, and preferences among end-stage renal disease patients on hemodialysis. Indian J Palliat Care [serial online] 2021 [cited 2021 Jun 17];27:99-103. Available from:

 » Introduction Top

End-stage renal disease (ESRD) is defined as an irreversible decline in renal function which will be fatal in the absence of renal replacement therapy.[1] It is a life-limiting illness[2] and majority will undergo hemodialysis (HD) treatment to maintain lives.[3] However, the expected symptoms' improvement for ESRD patients was not well-documented in the literature.[4] Several studies have highlighted the high burden of physical and emotional symptoms among ESRD patients.[5],[6]

Palliative care for ESRD patients integrates education, symptoms management, advance care planning, and psychological support, leading to the terminal phase of planning for the end of life.[7] It prioritizes the comfort and quality of life aligned with patients' preferences and goals.[8] It showed great benefits regardless of either dialysis or nondialytic pathways.[9] Surprisingly, the role of renal palliative care lags far behind other terminal illnesses. The inadequacies of end-of-life care in the patient management have also been described in many studies.[9],[10] It is neither well known nor optimally implemented in the routine clinical practices in Malaysia, and research on the local practice is lacking.[11] Up to now, there was only one local, single-center study that investigated end-of-life care aspect demonstrating the low level of knowledge dissemination among patients.[11] Understanding their views including awareness, values, and preferences on the end-of-life care and its related issues is an important step to identify gaps between patients' preferences and clinical practice.

Questionnaires were widely used by researchers in understanding mass thinking. Due to its feasibility and low cost in data collection,[12] it is a readily accepted method, compared to the more invasive and long experimental study. Apart from its low cost and feasibility, its wide utilization in studies involving large number of patients was able to yield statistical analysis with bigger power compared to other methods.[13]

The development of a questionnaire that addresses end-of-life care attributable to ESRD is vital. The aim of the study is to develop and validate the questionnaire on end-of-life care knowledge, perceptions, and preferences among ESRD patients on HD.

 » Subjects and Methods Top

Questionnaire development

The questionnaire was adapted and modified from a study conducted in 2008 involving chronic kidney disease stage 4–5 peritoneal and HD patients at the University of Alberta, Canada. It was developed from an extensive review of the literature on vital factors, including treatment of symptoms, place of death, and advance care planning.[14]

Some modifications were made in consideration to our local settings. The decision was made after an expert panel meeting for content validity. Content validity is to show whether items in a questionnaire covered the intended topics clearly.[12] The questionnaires were translated into the Malay language by two health-care professionals who were fluent in both the languages.

The questionnaire consisted of the following four main domains:

  1. Background and sociodemographic data
  2. Self-reported knowledge
  3. End-of-life care perceptions
  4. End-of-life care preferences.

Section A consisted of patients' sociodemography. In Section B, patients' knowledge of the disease and its trajectory was assessed. The responses were put into 3-point Likert scale whereby responses 1, 2, and 3 were marked as 0, 1 and 2, respectively. The higher the marks indicated better knowledge and vice versa. Section C addressed patients' end-of-life care perceptions. This section also applied marking from 0 to 2, in which higher marks demonstrated better perception. A 3-point scale from “1 = very/somewhat important,” “2 = unsure,” and “3 = extremely/somewhat unimportant” was applied. Both Sections B and C had “unsure” answer option to avoid bias from guessing. Section D involved questions on preferences in relation to end-of-life care issues. Patients chose the preferred options outlined.

An initial pretesting among unintended population for face validity was conducted to ensure its feasibility, readability, and comprehensibility. The questionnaire was then revised, according to the inquiries and suggestions given by the respondents. The questionnaires were redistributed via convenient sampling and delivered in a structured interview-based survey. Inclusion criteria included age more than 18 years old with ESRD on HD. Patients who were unable to understand English or Malay language were excluded from the study.

Construct validity

Factor analysis (FA) was performed on the data collected to test for construct validity.[15] It was performed by dividing into three factors because during the questionnaire development phase, three domains for FA have been identified, namely knowledge, perception, and preference.

Internal consistency reliability analysis

Internal consistency reliability analysis was tested using Cronbach's alpha (α). The Cronbach α was set at 0.5 for this current study.

 » Results Top

A total of 92 patients completed the questionnaire. The validation process of the questionnaire included internal consistency and construct validity assessment. There were three domains, namely knowledge (B), perception (C), and preferences (D) with 41 items altogether.

Construct validity

[Table 1] shows the result of FA with varimax rotation that identified three domains for the 41 items, with 10–20 items in each domain. All the analyzed items had a factor loading of more than 0.4, the cutoff point for a good factor loading,[16] with the lowest value of 0.421, and were nicely fit into three respective domains.
Table 1: Factor loading of each item based on factor analysis

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Internal consistency reliability analysis

[Table 2] shows Cronbach's α reliability analysis for the 11 items in domain knowledge, 10 items in domain perceptions, and 20 items in domain preferences. The results of the analysis indicated that Cronbach's α was between 0.5 and 0.7 for all factors, which was moderately consistent and acceptable. All the Cronbach's α values obtained were higher than the level set for this study which was 0.5.
Table 2: Reliability analysis with Cronbach's alpha for each domain

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 » Discussion Top

Although the concept of end-of-life care for ESRD patients has been around for many years, it is lagging behind other terminal illnesses and was not thoroughly discussed in routine clinical practice.[10],[11] Thus, there is an urgent need to create a validated questionnaire. The questionnaire comprised four domains which were (i) patients' background and sociodemographic data, (ii) end-of-life care knowledge, (iii) end-of-life care perceptions, and (iv) end-of-life care preferences. These were adapted from a similar study conducted in Alberta, Canada, which had been validated. However, modifications were made in terms of items arrangements for each domain, wordings with Malay translation to fit the local population. Its purpose was to gain understanding in the local context and identify gaps in the current practice. Both clinicians and patients unusually have distinctive priorities and preference in viewing this subject. Therefore, establishing mutual understanding will yield a better outcome.

The three domains which undergone validation analysis were knowledge, perceptions, and preferences, containing 41 items. The items per domain ranged from 10 to 20 items. It underwent content validity by the respective experts on subject matters and face validity in which only a few reported little difficulties. No early termination or adverse effect was recorded. Focusing on the construct validity of the developed questionnaire, FA performed on the data collected shows that the number of factor solution was three. These findings supported the convergence and discriminant validity of the questionnaire as it fulfilled two out of three criteria on a number of factors which needed to be obtained, namely all factors obtained have eigenvalue of >1 (not shown) and number of factors were following the number of domain identified in the development of the questionnaire. In addition, all factors' loading values were more than 0.4 and items in each domain were inter-correlated within but not with items in other domain.

It can be concluded that this questionnaire has a satisfactory internal validity whereby all the items for knowledge, perception, and preference have Cronbach's α value of more than 0.5, the value set in this study. A higher value of Cronbach's α can be achieved by increasing the number of items in each domain as described by the previous researcher that items of <10 in a section are likely to yield α value of <0.7.[12],[17] The similar trend is observed in this study whereby preference domain has the highest of the value of 0.797, followed by perception and knowledge with the α values of 0.601 and 0.573, respectively. The latter two both have 10 and 11 items and produce about a relatively similar α value. As opposed to the preference domain which consists of 20 items, the α value obtained was comparably high.

 » Conclusion Top

This questionnaire was successfully validated and considered as a useful tool. This is the first successfully validated questionnaire for such purpose in Malaysia. Improvement will still be necessary from time to time to ensure its relevance in relation to the evolving disease patterns.

Financial support and sponsorship

This study was funded by International Islamic University Malaysia Research Initiative Grant Scheme.

Conflicts of interest

There are no conflicts of interest.

 » References Top

Abbasi MA, Chertow GM, Hall YN. End stage renal disease. BMJ Clin Evid 2010;2010:2002.  Back to cited text no. 1
Kane PM, Vinen K, Murtagh FE. Palliative care for advanced renal disease: A summary of the evidence and future direction. Palliat Med 2013;27:817-21.  Back to cited text no. 2
Hs W, Sunita B, Rosnawati Y, Yeap L, Dg L. Malaysian Society of Nephrology. 24th Report of the Malaysian Dialysis and Transplant Registry 2016. Available at: [Last accessed on 2019 Aug 02].  Back to cited text no. 3
Wu YL, Cheung DS, Takemura N, Lin CC. Effects of hemodialysis on the symptom burden of terminally Ill and nonterminally Ill end-stage renal disease patients. J Palliat Med 2019;22:282-9.  Back to cited text no. 4
Bujang MA, Musa R, Liu WJ, Chew TF, Lim CT, Morad Z. Depression, anxiety and stress among patients with dialysis and the association with quality of life. Asian J Psychiatr 2015;18:49-52.  Back to cited text no. 5
Beng TS, Yun LA, Yi LX, Yan LH, Peng NK, Kun LS, et al. The experiences of suffering of end-stage renal failure patients in Malaysia: A thematic analysis. Ann Palliat Med 2019;8:401-10.  Back to cited text no. 6
Bristowe K, Horsley HL, Shepherd K, Brown H, Carey I, Matthews B, et al. Thinking ahead-the need for early advance care planning for people on haemodialysis: A qualitative interview study. Palliat Med 2015;29:443-50.  Back to cited text no. 7
Grubbs V, Moss AH, Cohen LM, Fischer MJ, Germain MJ, Jassal SV, et al. A palliative approach to dialysis care: A patient-centered transition to the end of life. Clin J Am Soc Nephrol 2014;9:2203-9.  Back to cited text no. 8
Morton RL, Webster AC, McGeechan K, Howard K, Murtagh FE, Gray NA, et al. Conservative management and end-of-life care in an Australian cohort with ESRD. Clin J Am Soc Nephrol 2016;11:2195-203.  Back to cited text no. 9
Fassett R, Robertson I, Mace R, Youl L, Challenor S, Bull R. Palliative care in end stage renal disease. Nephrology 2011;16:4-12.  Back to cited text no. 10
Hing Wong A, Chin LE, Ping TL, Peng NK, Kun LS. Clinical impact of education provision on determining advance care planning decisions among end stage renal disease patients receiving regular Hemodialysis in University Malaya Medical Centre. Indian J Palliat Care 2016;22:437-45.  Back to cited text no. 11
Pasi H, Isa Z, Shamsul AS. The Validation of questionnaire on risk perception of developing five most common non-communicable diseases in Malaysia. IOSR J Nurs Heal Sci 2013;1:29-35.  Back to cited text no. 12
Nieuwenhuijsen MJ. Design of exposure questionnaires for epidemiological studies. Occup Environ Med 2005;62:272-80, 212-4.  Back to cited text no. 13
Davison SN. End-of-life care preferences and needs: Perceptions of patients with chronic kidney disease. Clin J Am Soc Nephrol 2010;5:195-204.  Back to cited text no. 14
Dawson J, Fitzpatrick R, Carr A. Questionnaire on the perceptions of patients about shoulder surgery. J Bone Joint Surg Br. 1996;78:593–600.  Back to cited text no. 15
Y. H. Chan.Biostatistics 302: Principal component and factor analysis. Singapore Med J 2004;45:558.  Back to cited text no. 16
Turconi G, Celsa M, Rezzani C, Biino G, Sartirana MA, Roggi C. Reliability of a dietary questionnaire on food habits, eating behaviour and nutritional knowledge of adolescents. Eur J Clin Nutr 2003;57:753-63.  Back to cited text no. 17


  [Table 1], [Table 2]


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