Measuring Cardiovascular Disease Risk Perception: Translation and Validation of the Indonesian ABCD Risk Questionnaire

Background Cardiovascular diseases (CVDs) are still increasing worldwide contributing to increasing death worldwide. To test CVDs' awareness, the Attitude and Belief about Cardiovascular Disease (ABCD) questionnaire was developed. However, this questionnaire is not available in Indonesia language. Methods The original questionnaire was translated in both directions forward and backward. The process is then continued with a content validity index created by three experts. The exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) then determine the factors that support the translated questionnaire. The splitting sample method was applied in both factor analyses. Internal consistency testing of 18 items was performed on 236 samples. Result The validity of the entire questionnaire subscale was satisfactory. Three retained factors were supported by the EFA and CFA, namely, risk perception, perceived benefit, and healthy eating intention. The internal consistency was acceptable based on Cronbach alpha and ordinal alpha. The Indonesian version of ABCD questionnaire was statistically valid and reliable to be used. Conclusion The Indonesian version of the ABCD questionnaire is a valid questionnaire to access the attitude and belief of CVDs in Indonesia.


Introduction
Globally, 17.9 million people died in 2019 due to cardiovascular diseases (CVDs) [1].Tis number rose to 19.1 million by 2020 and will continue to increase annually [2].Te number of CVDs is highest in Asia and Africa, with disabilityadjusted life years (DALYs) ranging from 6.154 to 20.998 per 100,000 people [3].A similar number of DALYs are present in Indonesia [3].Low-and middle-income countries account for about 75% of all cardiovascular disease cases worldwide [1].In 2018, 4.2 million people in Indonesia, a low-and middleincome country, were diagnosed with CVDs [4].Te rising prevalence of cardiovascular disease makes it the leading cause of death worldwide [1].
A growing number of CVDs are caused by risk factors [3].High blood pressure, dietary risk, high LDL, tobacco, high body mass index, high blood glucose, kidney dysfunction, and many other risk factors lead to CVDs [3].Reducing risk factors is essential to prevent CVDs [5].Health behaviors that minimize risk factors include increasing physical exercise, eating a healthy diet, maintaining a healthy body mass index, quitting smoking, and managing stress [5].Health beliefs afect health behavior based on someone's knowledge and perception [6].Sufcient knowledge of CVDs motivates people to seek healthy behaviors [7].
Instruments to measure the knowledge of CVDs are still lacking.A narrative review reported there were twelve instruments to measure the knowledge of cardiovascular risk; however, only four of them measure specifcally about CVDs [8].Te National Health Service of the United Kingdom previously developed the Attitude and Beliefs about Cardiovascular Disease (ABCD) Risk Questionnaire to measure attitudes and beliefs about cardiovascular disease [9].Tis questionnaire has been translated into many diferent languages around the world [10][11][12][13][14].A reliable and valid questionnaire is critical to measuring knowledge and perceptions of CVDs.Indonesia, as a major Southeast Asian country, contributes to a high incidence of CVDs [15].Terefore, it is necessary to translate the ABCD questionnaire into the Indonesian version.

Study Setting and Study
Populations.Te internet platform was utilized to recruit samples via convenience sampling.Information about this study was distributed through social media platforms such as Facebook, Instagram, and WhatsApp because these platforms are popular and commonly used in Indonesia.

2.3.
Eligibility.An inclusion criterion was being an adult (>18 years old) based on the law of Indonesia and being able to communicate well in Indonesian language.People with mental disorders are an exclusion criterion.

Sample Size Determination and the Sampling Procedure.
Te sample size's power was determined using G power post hoc analysis.Te power was 99% for an exact test with two tails and a correlation bivariate normal model (alpha error was 0.05 and sample size is 236).Tis study included a total sampling of respondents.Te splitting sample method was utilized in factor analysis [16], with 118 samples in exploratory factor analysis and 118 samples in confrmatory factor analysis.Te previous recommendation said that at least 50 samples are required to do factor analysis [17].

Data Collection Tool.
A self-administered tool was utilized to collect information from the respondents.Te tools include demographic data, smoking habits, body weight and height, exercise activities, and an ABCD questionnaire.
2.6.Instruments 2.6.1.Te Original ABCD Questionnaire.In 2017, an ABCD questionnaire was developed to assess individuals' knowledge, perceived risks, and benefts of CVDs [9].It consists of 26 items divided into the following four dimensions: knowledge (8 items), perceived risk of heart attack/stroke (8 items), perceived benefts and intentions to change (7 items), and healthy eating intentions (3 items).Te frst dimension is on a Guttman scale, while the others are on the Likert scale (1)(2)(3)(4).Exception in scoring will be applied to the following four items: item number 8, 15, 21, and 28.Item number 8 will be scored "1" if the respondents choose "wrong;" furthermore, items number 15, 21, and 26 required unfavorable answer to get a higher score.Te minimum score was 18, and the maximum score was 80 for the overall scale.Te higher the score on the ABCD Risk Questionnaire, the greater the health belief in CVDs' perception [9].

Data Collection
Procedure.From May 2023 to June 2023, information about this study was disseminated via social media platforms such as Facebook, Instagram, and WhatsApp.Four research assistants were employed in this study to collect the data.Tey were nursing students in their four-year study and had been taught about research courses.Te explanation of the study, respondent recruitment, informed consent, and data collection were given to the research assistant.For the respondents, it took 15 minutes to fll in the questionnaire.
2.8.Data Analysis.Internal validity was analyzed using the content validity index (CVI), and a value of 0.78 or higher is considered excellent content validity [18].Statistical analysis was done with statistical software for data science (STATA) version 18. Te structural analysis of the questionnaire was assessed using factor analysis.EFA was employed to identify the latent construct underlining a set of the ABCD's variables.Te EFA assumptions were tested (sample size, distribution, collinearity, and linearity) [17,19], and the including the data were continuous variables, sample size was over than 100, and the data were in normal distribution (p > 0.05) based on Kolmogorov-Smirnov and Shapiro-Wilk tests.Te multicollinearity was checked using variance infation factor (VIF), which ranges from 1 to 6 (items 10 and 11 have VIF score 6).If the VIF is less than 10, no multicollinearity.Te linearity was observed using Q-Q plot and, the data show a linear relationship between observed variables, with no outliers.Te methods of extraction used in this study was principal axis factoring due to the data was not distributed normally using Kolmogorov-Smirnov and Shapiro-Wilk test (p < 0.05).For the rotation methods, we use orthogonal, especially varimax rotation to minimize cross loading.Te selection criteria of number of factors to be retained is based on the eigenvalue >1 rule, scree plot, variance extracted, and Barlett's chi-square test [20].CFA was done to prove the structure of ABCD Risk Questionnaire using the new data from Indonesia.Te model ft of the CFA model was assessed including X 2 /df, comparative ft index (CFI), Tucker-Lewis's index (TLI), and root mean square error of approximation (RMSEA) and standardized root mean squared error (SRMR) [21].Te reliability of the ABCD questionnaire was analyzed by test-retest reliability and internal consistency coefcient using Cronbach's alpha and Ordinal alpha.All variables were described in a univariate analysis.
2.9.Ethical Consideration.Te ethical approval was acquired from the Research Ethics Committee of Sekolah Tinggi Ilmu Kesehatan Bani Saleh under the number EC.228/KEPK/STKBS/XI/20di22. Respondents who participated in this study were willing to provide informed consent 2 Nursing Research and Practice via an online form.Respondents were asked for their initials without being asked for their email addresses to maintain anonymity and confdentiality.Furthermore, only the principal investigator accessed the link to the questionnaire.1.Furthermore, the overall result of ABCD-I revealed that the scores ranged from 34 to 76 (the maximum score is 80) with a mean of 55.24 (SD � 5.837).All domains (knowledge, perceived risks, perceived benefts, and intention to change) exhibited more than 50% of the total marks in each band (Table 1).

Content Validity.
As the World Health Organization suggested, the forward-backward translation was conducted before translating the ABCD Risk Questionnaire into the Indonesian language-translated version (hereafter ABCD-I) without compromising reliability and validity.Te items were distributed into the following four domains: knowledge (8 items), perceived risk (8 items), perceived benefts (7 items), and intention to change (3 items).After getting the questionnaire translated, the expert panel process was conducted.Moreover, the expert panelists analyzed item by item and suggested revisions to make the item concise and understandable.Te expert and team made revisions by considering several slight changes, such as adding prefxes and sufxes, to create sense-making sentences in the Indonesian language version.Tree experts were invited to evaluate the CVI of the ABCD-I Risk Questionnaire.Te CVI was evaluated with the item content validity index (I-CVI), Scale CVI (S-CVI)/ Ave, and S-CVI/UA.Te I-CVI score was between 0.67 and 1.00, whereas the SCI/Ave and S-CVI/UA were 0.94 and 0.81, respectively.A CVI of ≥0.80 is recommended to prove that the determined item and questionnaire are clear, homogenous, and relevant.Te expert agreed that all the items translated from the original questionnaire were preserved because they were considered essential, appropriate, and interlinked.

Structural Validity.
Te structural validity of the ABCD Risk Questionnaire was evaluated to refect the dimensionality of the items [23].In the present study, EFA was utilized to investigate the underlying factors, whereas CFA was employed to verify the variable's factor structure.Both EFA and CFA were efective statistical procedures for ensuring the validity of the ABCD Risk Questionnaire.Before undertaking EFA and CFA, we evaluated the monotonicity and scalability of items using a Mokken scaling analysis (MSA).Te result of both data showed H ≥ 0.4 refects a moderate coefcient of scalability (H).All items in the ABCD-I questionnaire in EFA data were considered to be scalable (ranged between 0.485 and 0.872), and in CFA data, they also refected to be scalable (ranged between 0.409 and 0.910).
Te EFA is needed to explore the factorial structure of the ABCD Risk Questionnaire (Indonesia language version).Te EFA was conducted using the principal axis factoring method of extraction with the varimax rotation method.Collected data deemed suitable to proceed into factor analysis based on the (1) Kaiser-Meyer-Olkin (KMO) measure, which indicated the compactness of correlation patterns to build distinct and reliable factors, and (2) Bartlett's test of sphericity, which represented whether the correlation matrix is signifcantly diferent from an identity matrix.Te result of KMO (0.794) and Bartlett's χ 2 value (2620.061,p < 0.001) in this study met the conditions for continuing the exploratory factor analysis (EFA).Te diagonal of the antiimage correlation matrix is over 0.5.

Nursing Research and Practice
Tere were three factors retained based on the eigenvalue >1 rule, and the same numbers of factors are also shown based on scree plot.Te principal axis factoring was used, and the initial eigenvalues showed 86.72% of the total cumulative variance.Te frst factor is 38.68%, the second is 32.16%, and the third is 15.88%.Te factor-loading matrix for the fnal is presented in Table 2. Most items corresponded with the original subscale, except for perceived beneft 5. Based on the factor analysis calculation, three factors emerged from the data set and had eigenvalues over Kaiser's criterion of 1.
Te confrmation of sufcient factors was determined from the Scree plot and a parallel analysis (PA) (see Figure 1).PA was based on the calculation of randomly generated multiple data matrices, which have the same number of variables and cases as the original raw data set.Subsequently, diferences between randomly and empirically generated eigenvalues are tested, and a signifcantly higher random dataset eigenvalue indicates the cutof point for true factor numbers.After conducting PA (principal axis/common factor analysis, 95%), we retained three factors emerging through EFA, as shown in Nursing Research and Practice the PA result (Figure 1).However, item 5 of perceived beneft dimension was not in the same factor as the originals.
Te difculty index of the overall knowledge subscale was 0.856.Most of the items were easy for respondents to answer.Te most difcult items were Knowledge 8, and the easiest was Knowledge 2 (Table 3).
Te CFA was done to prove the structure using the new data from Indonesia.We tested two models of CFA; the frst model included 18 items of ABCD Risk Questionnaire (Figure 2), whereas the second model included only 16 items (item numbers 21 and 26 were taken out) (Figure 3).Te internal loading of the frst model showed reliability ranging from 0.05 to 0.96.Te goodness of ft result indicated from frst CFA was not good (χ 2 � 424.74, df � 132, p < 0.001, SRMR � 0.102, RMSEA � 0.138, CFI � 0.792, and TLI � 0.759).On the other hand, the internal loading of the second model showed reliability ranging 0.11-0.96,whereas the goodness model of ft was acceptable good (χ 2 � 333.81, df � 101, p < 0.001, SRMR � 0.081, RMSEA � 0.140, CFI � 0.827, and TLI � 0.795).

Te Reliability of the ABCD-Indonesian Version.
Cronbach's alpha (α) is commonly used to evaluate a questionnaire's internal consistency/reliability. Tis study showed that the Cronbach's (α) of the entire questionnaire was 0.737; for each domain sequentially, it was 0.462, 0.873, 0.787, and 0.431.In consideration of the ordinal scales used in the instrument (question 9 to question 26), we also calculated the ordinal alpha [24,25].Te result showed that the ordinal alpha of the entire questionnaire was 0.638, whereas each factor sequentially showed the ordinal alpha of 0.859, 0.828, and 0.676 (Table 4).

Discussion
In this study, we adopted the Indonesian ABCD Risk Questionnaire with an online survey of adult respondents.Te original questionnaire consists of the following four domains: CVDs knowledge, perceived risk of heart attack/ stroke, perceived benefts, and intentions to change, and healthy eating intentions [9].Te content validity of our fndings shows the overall I-CVI and S-CVI above the expected (0.78 and 0.70), which means the Indonesian version of ABCD risk is valid [26].Te two items with an I-CVI under 0.70 are modifed to be more understandable in Indonesian.Item number 8, "a family history of heart disease is not a risk factor for high blood pressure," is a negative statement, and it is a common statement in the Indonesian population.Te respondents may misunderstand whether the answer is true or false since this statement might confuse the reader.It is also shown in the difculty index that item number 8 has the lowest grade.Te difculty index of 0.7 is considered easy to answer by respondents [27].Tis item was changed into a positive statement: "a family history of heart disease is a risk factor for high blood pressure".Item number 9, "I feel I will sufer from a heart attack or stroke sometime during my life" is too forthright, and the respondents are confused about how to respond.Asian people, including Indonesians, are more likely to choose fewer .extreme responses [28].We changed item number 9 to "there is a possibility that I will have a heart attack or stroke" as the initial development by Woringer et al. [9].Te unidimensional test using the Mokken analysis showed that a coefcient of scalability (H) refected the result of H ≥ 0.5 [29].All 18 items constructed in the questionnaire showed that H ranged between 0.910 and 0.409 (all are above 0.4) [30].Tis result implies that the scalability of the questionnaire is good and then all the questions were retained as a set of questionnaires.Furthermore, this study showed the KMO result of 0.79 with a signifcant p value of Bartlett's Test of Sphericity (0.0001), indicating the sample size was adequate for EFA analysis.A KMO level of 0.5 is suitable for analysis, whereas 0.8 is best for analysis [31].On the other hand, the p value signifcance of Bartlett's test of sphericity refects that the analysis could proceed [17].Te goodness of ft of the frst CFA model of CFA was not satisfactory.However, the second model showed a better and more acceptable model compared to the frst model (refected through higher TLI and CFI values and SRMR value of 0.08 considered as high).Te SRMR provides the accuracy test of ft better than RMSEA [32].
Te EFA and CFA showed that Indonesia ABCD questionnaire has three latent variables.In our fndings, three factors emerged based on eigenvalues (>1) of factor analysis.Following this, we conducted parallel analysis (PA) to determine the appropriate number of factors (see Figure 1).PA calculates the eigenvalues of randomly generated multiple data matrices with the same number of variables and cases as the original raw dataset.Te diferences between randomly generated and empirical eigenvalues were then tested.Te cutof point of this comparison will extract the retained factors.Terefore, three factors were retained through the EFA and PA analysis.Tis fnding shows a similar result to the original questionnaire, as well as other versions from several diferent countries (China: 3 factors, Hungary: 3 factors, United Kingdom: 3 factors, and Netherlands: 3 factors [12][13][14]33]).However, based on EFA result in this study, item 5 of perceived beneft factor will be allocated into diferent factors from the original instrument.
Based on CFA, practically all ABCD items had a threefactor structure, which was similar to the original instruments.However, as items 21 and 26 had low factor loading scores, these were removed from the model to improve the model's goodness of ft.Tese two questions were negative remarks on the ABCD Risk Questionnaire.Tere is a lack of research on negative statements in Likert scales in Indonesia; nonetheless, previous research suggests that both positive and negative statements should not be included in a scale [34].Te presence of these two types of statements caused confusion for the respondent [34].Terefore, we recommend changing the negative statements into positive ones.
Te internal consistency of the overall scale was lower than the original scale (0.85, 0.82, and 0.56 for perception risk, beneft, and healthy eating intentions) [9].Even though Cronbach's α for two domains (knowledge and intention to change) were below the minimum threshold of 0.70, we found that the entire questionnaire's reliability was strong as a set.Furthermore, considering the Likert scale used in the instrument (from question 9 to 26), we also calculated the ordinal α for the entire instrument (0.638) that showing a lower α score than the Cronbach α (0.737).However, almost all the ordinal α for each factor (assessing with ordinal scale) were greater than the Cronbach α.Terefore, considering the factor analysis study using the Likert-style scale, we are more confdent on the reliability result calculated with ordinal coefcient alpha [25].Our fndings were similar to the Malay version that internal consistency of that version was over 0.70 [14].Furthermore, the low Cronbach's α was acceptable as the original questionnaire for domain intention to change because this domain only has a threeitem scale.

Limitation
Tis study was distributed through an online platform.Consequently, the demographic data do not vary, especially on religion and background education.However, the number of respondents was signifcant to achieve the data variation.Moreover, there are several Indonesian terminologies which could not be as precise as the meaning of English terminologies.Terefore, we considered the panelist' difculties in selecting the most representative Indonesian terminologies during the forward translation.Tis issue may lead to ambiguity among the respondents in interpreting the questions and statements in the questionnaire.

Conclusion
Based on psychometric investigation, this study concluded that the Indonesian version of ABCD questionnaire is a valid and accurate to be used for assessing the knowledge, perceived risk, perceived beneft, and intention to change.A few items on the ABCD questionnaire have been modifed to be ftted into Indonesian cultural norms and make the questionnaire easier to respond.Because CVDs are common in low-income countries, this conclusion can be extended to the original study to assess Indonesian attitudes and beliefs.the translation and content validity indexing processes.We would also like to thank everyone who agreed to participate in this study.Tis research received funding from Universitas Pelita Harapan and Tarumanagara Institute.

2. 1 .
Study Design and Period of the Study.Tis study was an instrumental questionnaire validation study which conducted in Indonesia from May 2023 to June 2023.

Figure 1 :
Figure 1: Te comparison of scree plot and simulated parallel analysis within 95%.
[22]nesian ABCD Questionnaire.Mrs.Woringer, the original author, granted permission to use the ABCD Risk Questionnaire.Te World Health Organization (WHO) translation process was used, which included forward translation, reverse translation, an expert panel, pretesting, and the fnal version[22].Forward translation was accomplished by a medical professional with over 15 years of experience pursuing a doctoral degree at the University of Auckland.A medical specialist translator did the backward translation with a doctoral degree from the University of North Texas and is currently working as a postdoctoral scholar at the Carol Nese College of Nursing at Pennsylvania State University.Te expert panel had three experts, namely, a cardiologist from a government hospital, a nursing professor with a doctoral degree and an interest in cardiovascular research, and a nurse with nine years of hospital experience and three years of experience in the intensive coronary care unit.Following the discussion, a comprehensive ABCD questionnaire in Indonesia was developed.A pretest was carried out on 40 respondents to assess validity and reliability.Te fnal step was analyzed and changed before the Indonesian version was obtained.3.2.Sociodemographic Characteristics.Te analysis was conducted with data from 236 samples who responded to the adapted and translated questionnaire.Te respondents ranged from 18 to 44 years old, with a mean of 26.41 (SD 5.252).Te respondents were predominantly female (n � 145, 61.4%).More than half of the respondents attended university (n � 160, 67.8%), followed by high school and secondary education (31.8% and 0.4%).Te highest number of respondents are Christian protestants (n � 137, 58.1%), followed by Muslims (n � 75, 31.8%),Catholics (n � 17, 7.2%), Buddhas (n � 5, 2.1%), and Confucians (n � 2, 0.8%).
Note.Te "minimum residual" extraction method was used in combination with "Varimax" rotation; the hidden loadings were below 0.3.

Table 3 :
Item statistics of knowledge subscale of ABCD.

Table 4 :
Figure CFA model for original ABCD Risk Questionnaire.Reliability estimated with Cronbach α and ordinal α.