Adaptation and Validation of The HIV-Kq-18 HIV Knowledge Questionnaire for Healthy Indonesian Population

Background: Indonesia does not have a validated instrument to assess HIV/AIDS knowledge. The HIV-KQ-18 is one of the most extensively used instruments for assessing HIV/AIDS knowledge, and it has been translated into various languages throughout the world. This paper describes the process of adapting and validating the HIV-KQ-18, an instrument to assess the level of HIV/AIDS knowledge. Methods: In the adaptation phase, feedback for the initial Bahasa Indonesia version was gathered from two HIV activists, an obstetrician, two general practitioners, and 60 pilot participants from the physician. Additional descriptions (namely synonyms or examples) were added to the particular terms in the 6 items to make it more understandable. Results: In the validation phase 1,249 participants were recruited. The online link of HIV-KQ-18 Bahasa Indonesia was distributed to participants from six major regions in Indonesia. Internal consistency was measured using Cronbach’s alpha, while construct validity was determined using factor analysis. Based on visual observation of the scree tree in the factor analysis, one factor was preferable. The Cronbach's alpha was 0.82. Conclusion: Therefore, HIV-KQ-18 Bahasa Indonesia is a valid and reliable instrument to assess the level of HIV/AIDS knowledge in Indonesia.

. However, this report did not specify the type of instrument used to measure the level of knowledge.
Two studies have used the HIV Knowledge Questionnaire (HIV-KQ-18) instrument to assess the level of knowledge in Indonesia. These two studies focused on speci c communities, namely on 120 women living with HIV/AIDS in Lampung 7 and 396 nurses who worked in four hospitals in Jakarta 8 . However, neither of these studies performed or reported a psychometric test on HIV-KQ-18, except for the study in Lampung reporting only on the reliability test with the Cronbach's alpha 7 . No studies exist to fully adapt and validate this instrument for the Indonesian healthy adult population.
The HIV-KQ-18 instrument has been proven to be a valid (good internal consistency, Cronbach's alpha at 0.75 -0.89), stable, sensitive, and appropriate instrument for all people including low-literacy populations 9 . An instrument to assess the HIV/AIDS knowledge level is important to indicate in which speci c aspects the public needs to improve, to develop content for effective campaigns, and to assess the knowledge trend from time to time as an indicator to measure the success of an HIV campaign. Therefore, the study aimed to conduct an adaptation, validation, and psychometric test of the HIV-KQ-18 instrument on a healthy adult population in Indonesia.

Research design
The study used a cross-sectional design. Data were collected from September 2020 to January 2021. The study was approved by the Research Ethics Committee of Universitas Ahmad Dahlan, Yogyakarta, with ethical approval number 012007028 on 22 September 2020 and was divided into two main phases, adaptation and validation.

Instrument
The questionnaire consisted of sociodemographic characteristics and the HIV-KQ-18 instrument. HIV-KQ-18 is the short version of HIV-KQ-45 10,11 . Permission to translate the HIV-KQ-18 instrument was obtained from Prof. Michael P. Carey, PhD (Director, Centers for Behavioral and Preventive Medicine, The Miriam Hospital) on February 11, 2020. The HIV-KQ-18 instrument is more focused on how to prevent infection and transmission of HIV/AIDS. This instrument consists of 18 items, and each item has 3 options, namely "true", "false" or "don't know". Five items (no 1,4,11,14,17) are true statements, while other 13 items are false. The correct response is scored 1, while 0 is used for wrong or "don't know" responses.
The original HIV-KQ-18 instrument was translated to Bahasa Indonesia using a forward-backward translation and adaptation processes (Figure 1). At the end of the questionnaire, we added a question "Out of the 18 items, which statement was the most di cult or took long time to answer?". This question was used to identify additional obstacles by participants to understand the HIV-KQ-18 Bahasa Indonesia instrument.

Research sites
Participants involved in the study were sampled from six of Indonesia's main regions, namely: Sumatra, Java, Sulawesi, Kalimantan, 'Bali and Nusa Tenggara', and 'Maluku and Papua'.

Participants
Participants were Indonesians at least 17 years old, who consented to participate in the study.
Sociodemographic data such as gender, age, occupation, education level, marital status and monthly expenses were obtained from self-reports. We asked for monthly expenditure data instead of monthly income since participants indicated that they were more comfortable reporting expenses than income.
Participants were classi ed concerning having an educational background in health sciences (medicine, pharmacy, nursing, midwifery, and public health) and whether they had attended a workshop about a HIV/AIDS education. To maintain con dentiality, participants were given the right to only write their name and age. Only researchers had the right to access the dataset.

Sample size
The sample size calculation was based on a study suggesting at least 100 participants should be the minimum limit for psychometric study 12 . Two previous studies stated that the minimum number of participants should be 200 if the number of items in the instrument is not more than 40 13,14 . Another study recommends that the minimum number of participants involved in a psychometric study should be the number of items in the instrument to be validated multiplied by ten 15 . Therefore, the minimum number of participants for each region included in the study is 180 (18 items x 10). Ergo, the minimum total of participants in this study was set at 1,080 (180 x 6) participants.

Data collection
The initial Indonesian version of HIV-KQ-18, after forward and backward translations, was evaluated by the Indonesian research team. After obtaining ethical clearance, in the adaptation phase we requested feedback for the initial version of the HIV-KQ-18 from HIV activists, an obstetrician, general practitioners and 60 pilot participants (10 participants from each region). Feedback was reviewed by the Indonesian research team to develop the nal version of HIV-KQ-18 Bahasa Indonesia.
In the validation phase, we distributed the online link of the nal version of HIV-KQ-18 Bahasa Indonesia through several social media from 29 September 2020 to 6 April 2021, namely: WhatsApp, Facebook inbox, email, Instagram, and Twitter. If participants joined through various media, we removed the duplicate participants based on the initials and date of birth. Figure 1 provides an overview of the study procedure.

Data analysis
During the adaptation phase, we discussed all of the participants' suggestions. Furthermore, the Indonesian core research team compiled and analysed the pilot data for the best item structure through consensus. Notably, whenever differences emerged in this phase, these issues were resolved by consensus.
Participants' characteristics in the adaptation phase were analysed descriptively. Item analysis was conducted by calculating the percentage of the correct answers of each item and corrected item-total correlation. Items with the percentage of correct answers being between 30-80% were considered appropriate 16 , because it avoids oor and ceiling effects and allows for additional scores to capture knowledge gains after an education program. Items with a corrected item-total correlation lower than 0.3 were considered to indicate that the items were candidates for deletion 17 ; however, an item with a corrected item-total correlation higher than 0.25 was still considered acceptable.
Validity and reliability tests were used to analyse the psychometric properties of HIV-KQ-18 Bahasa Indonesia. Factor analysis was carried out to assess the construct validity. The number of factors that could be extracted was determined by using two approaches: (i) eigenvalue of greater than 1, and (ii) visual inspection of scree tree by subtracting 1 from the number of factors in the point of in exion 15 . A factor loading of 0.4 or higher is required to indicate a good relationship between each item and underlying factor 15 . Cronbach's alpha was used to analyse the internal consistency and a Cronbach's alpha of higher than 0.7 is considered as a reliable instrument 17

Participant characteristics
In total, 1,249 participants were recruited from six regions in Indonesia during the validation phase. All participants were those in the productive age range, dominated by females, with the majority of participants' monthly expenses being <2 million rupiah (USD 137). The details of the sociodemographic characteristics of the participants are presented in Table 1. Adaptation After collecting feedback from participants during the adaptation phase, Table 2 indicates some improvements in the sentence structures or word selections. In total, there were 6 (six) items to which adjustments were made. The language patterns were adjusted by changing word selection, adding synonyms, or giving an example so that the item's context could be correctly interpreted by a broader range of participants. For example, some participants were more familiar with the term "climax", while others did not understand that word and were more familiar with the term "orgasm"; therefore, we added the Indonesian term for orgasm.

Item analysis
Item number 14 was answered correctly by nearly all the participants (97.1%) ( Table 3). On the other hand, based on our analysis, item number 12 was the most di cult item with less than 30% of participants correctly answering this item. This nding was in line with our Atlas.ti review that the fewest participants reported item number 14 as the most di cult statement to answer while the items about condoms (including item number 12) were the most di cult, according to participants. The other 16 items were acceptable since the percentage of correct answers was between 30-80%. Four items (no 4, 11, 14, and 17) had corrected item-total correlation lower than 0.3, and only two items (no 11 and 17) were lower than 0.25.  Table 4. Participants' statements about the most di cult item to answer Of the 1,249 participants, 915 participants (73% response rate) responded to the question regarding which items were the most di cult to answer. It was important to highlight that most of the participants mentioned more than 1 item. Nearly half of the participants (45%) said the questions regarding condoms (items 11, 12 and 18) were the most di cult for them to answer ( Figure 2). Furthermore, 11% of those who answered said that the questions about the HIV/AIDS incubation period (items no 6, 7, and 15) were also di cult to answer. The most common reason given was a lack of HIV/AIDS education. Other ndings in the study were 149 participants (16.3% from 915) stated that the instrument was very useful for determining a person's level of HIV/AIDS awareness because (i) to answer correctly, this instrument had to be read properly; and (ii) the sentence structure for each item was simple, clear and easy to understand.

Discussion
Our ndings suggest that the HIV-KQ-18 Bahasa Indonesia is a reliable and valid instrument for use in a healthy Indonesian population. The instrument's adaptation phase indicates that adding a few words or examples to explain the context of each item is extremely bene cial to participants' understanding. This approach has also been applied in other adaptation and validation studies in Indonesia 18, 19 .
Furthermore, based on factor analysis, we decided to prefer only one factor based on visual inspection of the scree tree.
This study is the rst HIV-KQ-18 Bahasa Indonesia psychometric test study in Indonesia. Our results show that our adaptation test has expanded the use of the instrument in a broader general population compared to previous studies that used the instrument only for nurses 8 or people living with HIV 20 . In addition, participants were given an opportunity to report which statements were the most di cult for them. The majority of participants reported di culty in responding to items regarding condoms, while others confessed to knowing little about HIV/AIDS. Other than sexual intercourse, some participants have ambiguity on how HIV/AIDS is transmitted and how to reduce the risk of getting HIV/AIDS. In the study, 97% of participants correctly answered item number 14, indicating that the majority of participants believed that HIV/AIDS is closely linked to sexual activity with more than one partner. However, more than half of the participants still believe that deep kissing with a partner with HIV did not transmit HIV, and using Vaseline or baby oil with condoms can be used to lower the risk of getting HIV.
In Indonesia, the use of condoms as an effort to prevent HIV/AIDS transmission poses a challenge. So far, health professionals and HIV/AIDS campaigners have struggled to balance the "pros and cons" of condom use from a public point of view. Most Indonesians hold strong religious beliefs. According to a previous survey, they were opposed to the advertising of condoms or any other kind of safe sex outside of marriage, which they saw as encouraging promiscuity and violating divine rules 21 . A previous study conducted in Uganda found that a campaign to encourage safe sex through the use of condoms has also provoked passionate debate in Uganda, with powerful religious leaders opposing activities they believe will lead to sexual promiscuity 22 . Moreover, premarital sex is uncommon and taboo in Indonesia. This has an impact on people's understanding of condom use for health reasons. According to a study of 913 unmarried Indonesian men (15-24 years), from 33 provinces in 2007-2012, 15% of them were unaware that condoms are used not only to prevent conception, but also to reduce the chance of developing sexually transmitted diseases 22 .
The study revealed that education about condoms is important for the public. Just 25% of the participants in the study correctly answered item number 12 regarding natural skin condoms. This is in contrast to the original study of HIV-KQ-18 in the US, in which approximately 60% of participants correctly answered this item 11 . Promoting condoms remains a challenge for Indonesians because condoms have not become a common topic to discuss. Anyone found carrying condoms will be judged for his/her negative behaviours. Therefore, in Indonesia, a limited number of people have understanding about natural skin condoms as a special material for condoms.
For construct validity, although four factors could be extracted based on eigenvalues, we decided to prefer only one factor based on visual inspection of the scree tree. In the four factors based on eigenvalues, two items have cross loadings, and the di culty to interpret each factor as a unique factor.
This nding is similar with the development of the original version HIV-KQ-45 10 . Four items (number 4, 11, 14, and 17) had loading factors lower than 0.4, and these items also had corrected item-total correlations lower than 0.3. Therefore, these items are candidates for deletion. However, other considerations are needed, since the development of HIV-KQ-18 also mandates that the instrument should also include items regarding misconceptions about HIV risks, sexual risk behaviours, and the ability to assess knowledge gained from educational programs 10 .
Our study has both strengths and limitations. The strengths of the study are that it is the rst adaptation and validation study of HIV-KQ-18 with over 1,000 participants from all main islands in Indonesia, and data collection was obtained from six main regions in Indonesia. The study provides evidence of validity and reliability in the range of participants' educational backgrounds from low to high educational background. The limitation of the study is that since the instrument was distributed through an online link, there is a potential participant bias that people with lower education and poor literacy levels would not participate in it. This is indicated by most participants coming from people with a bachelor degree, while only 25.2% of participants have an educational background of up to senior high school. Since people with poor literacy levels may have lower knowledge about HIV/AIDS, our ndings may be slightly higher than the real public knowledge of HIV/AIDS. However, the study covered the two age groups with the largest number of people infected with HIV in the last ten years, i.e. 25-49 years (roughly 70%) and 20-24 years (roughly 15%) 23 . Further studies are proposed to use the instrument in paper form to target participants with low literacy levels, especially those who are not connected to the internet or have low educational levels.

Conclusion
Based on psychometric analysis, HIV-KQ-18 Bahasa Indonesia is a valid and reliable instrument to assess the level of HIV/AIDS knowledge in the Indonesian population. We encourage the use of this standard instrument in future research and its use as a reference for measuring HIV knowledge.

Consent to participate
All participants have read the material about the research, including knowing that the research has been authorized by the Ethics Committee. Willingness to participate was expressed by giving a tick of approval and completing the instrument.

Consent for publication
All the authors have reviewed and approved the nal version of the manuscript being submitted. The manuscript is not currently being considered elsewhere.
Availability of data and material (data transparency) The rst and the corresponding author can be contacted for data for research purposes.
Con icts of interest MJP reports grants and honoraria from various pharmaceutical companies, including those developing, producing and marketing diabetes drugs. However, all grants and honoraria were completely unrelated to this speci c study. The other authors declare that they have no con icting interests related to this speci c study and topic. All authors also contributed to the funding.
Authors' contributions BA was the initiator of the research idea. All Indonesian authors carried out the data collection. MRR carried out the data analysis. MRR and BA drafted the manuscript. BA, MRR, JvdS, and MJP contributed to data interpretation. All authors were involved in the study's conceptualization and design, provided input, read and approved the manuscript. Questions which were the most di cult for participants to answer according to Atlas.Ti analysis