The understanding, attitude, practice, and health literacy questionnaire on COVID-19 in Malay language (MUAPHQ C-19): development, validation and application / Izzaty Dalawi

COVID-19 has remained a global human health threat since its existence. Inadequate knowledge, attitude, practice, and health literacy (KAPH) greatly influenced the public's attitude and adoption of protective and preventive behaviours. Unfortunately, most of the existing tools to assess the KAP on COVID-19 were developed by foreign country researchers, scarce Malay language tools, and needed more validation reporting. This study aimed to develop and validate a KAPH questionnaire in the Malay language that measures the understanding, attitude, practice and health literacy towards COVID-19 among the public in Malaysia; and to determine the associated factors. The study was conducted in three phases: Phase 1 - A methodological study for questionnaire development; Phase 2 - Two cross-sectional studies for questionnaire validation. Phase 3 – A cross-sectional study questionnaire application. Malaysian adults who literate in the Malay language were included. Microsoft Excel, IBM SPSS Ver. 27, and IBM AMOS Ver. 26 were used for data analysis. Six expert panels and 655 Malaysian public participated in the validation and application phase of the study. A 54-item MUAPHQ C-19 (Ver. 1.0) containing four domains, i.e., understanding, attitude, practice, and health literacy, was developed based on the literature review result and focus group discussion. Content validity analysis based on six expert panel's judgements on the item relevancy and essentiality (SCVI/Ave: 0.97 to 1; CVR: 0.3 to 1) made the 52-item MUAPHQ C-19 (Ver. 2.0). Face validity analysis yielded a 50-item MUAPHQ C-19 (Ver. 3.0) with better clarity and comprehensiveness (S-FVI/Ave: 0.87 to 0.98). The EFA has generated a 42-item MUAPHQ C-19 (Ver. 4.0). The internal and test-retest reliability was acceptable. The CFA generated six models before achieving best-fit indices with an RMSEA of 0.072, CFI was 0.883, TLI was 0.867, and ꭓ2/df of 2.218. The multicollinearity issue was managed; thus, only three domains except the understanding domain remained and yielded a 25-item MAPHQ C-19 (Ver. 5.0). The Composite Reliability, Convergent Validity and Discriminant Validity for all three domains were achieved. In phase 3, the mean scores of public attitudes, health literacy and practice towards COVID-19 were 7.64 (SD=1.26), 8.26 (SD=1.28) and 7.24 (SD=1.20), respectively. The predictor for good attitude was COVID-19 health literacy (p<0.001) and self-employed worker (p=0.028). Indian race was a predictor for a poor attitude (p=0.013). The predictor for sufficient COVID-19 health literacy was non-smoker (p=0.022), while non-health sector worker and Indian race was the predictor for inadequate COVID-19 health literacy (p=0.005 and p=0.049, respectively). The predictors for good practice towards COVID-19 were age (p<0.001), female gender (p<0.001), ex-smoker (p=0.028), attitude (p=0.001) and COVID-19 health literacy (p<0.001); while the T20 group was the predictor for poor practice towards COVID-19 (p=0.017). In conclusion, the study produced a valid and reliable new 25-item MAPHQ C-19 that can be used to measure the attitude, practice, and health literacy on COVID-19 among the general public in Malaysia. The attitude and practice of the public towards COVID-19 are generally moderate, while COVID-19 health literacy is sufficient. Consistent health education on COVID-19 prevention and control with more focus on minority races group of the public as well as smokers is needed to ensure good attitude and practice related to COVID-19 is optimised. Future studies with a broader population using MAPHQ C-19 should be conducted from time to time. Questionnaire revalidation with the acquisition of understanding domain is welcomed in future studies.