A total of 389 participants from three different hospitals in equal numbers were recruited. The mean age of the participants was 33.5 (SD= 13.2), with primary females (56.6%). Most [57.7%] of the participants opted to respond to the tool in English, and the remaining participants filled in the Urdu version. A cumulative of (22.1%) were estimated with low education, (and 88.9%) of the participants had no health insurance and no health coverage from employers (20.1%). The following demographic characteristics of participants are shown [Appendix, table 1].
Internal Consistency Reliability of Knowledge of Sociodemographic Domains on Advance Directives
There were a total of 19 items described in sociodemographic sub-domains of knowledge on advance directives; family helps support/ decisions (The FHSD), Socio-cultural/ religion (SR), and physical health awareness experiences (PH). The overall six items in the family help support/ decision component showed an overall mean of 2.37 (SD = 0.19), five items in sociocultural/ religion (SR) with a standard of 2.53 (SD= 0.54), and eight items in physical health experience awareness (PH) with individual item frequency and proportions were reported as it had a dispersion of non-directional things from which we found that 84.83% were physically healthy, with only 22.37% notified to have any health issues, about 76.61% reported that they didn't have any extensive treatments in the present or past. Most participants [89.46%] stated that no terminally ill patients were in their families. Therefore 89.46% said that they have not yet experienced a situation where someone has asked their choices about how to get treated. More than half of the participants [55.78%] reported that they didn't experience the death of a close family member or friend in the last two years. 59.90% of participants didn't experience any significant impact on life in terms of care at the End of life. As a result, 67.35% of the participants didn't feel it necessary to discuss end-of-life decisions [Appendix, table 2].
Based on [Appendix, table 3], it is identified that the reliability of FHSD's items has values around 0.7, which means that the variable is reliable. Moreover, the composite reliability of SR is also steadfast because the matter is 0.72, which is higher than 0.7. PH also has high composite reliability because the value is 0.92, which is more than 0.7. This means that the actual values are closer to representing individual item values. This was after looking for possibilities that were capable of improving reliability was found that those items that showed an increase in the variances of item test correlation were the items that were displaying a direction based on assigned coding. Therefore, first, all those items were looked into each directional domain. In that way, we could also calculate the average mean and standard deviation for all sociodemographic three fields (FHSD, SR, PH) on advance directives along with the improved particular domain consistency reliability. For family, and health support decisions (FHSD), the internal consistency reliability Cronbach's alpha (α = 0.68), followed by sociocultural / religion (SR), showed reliability (Cronbach's alpha α =0.72). Last is physical health (PH) awareness experiences found a mean of 0.38 (SD = 0.06) with the reliability of (Cronbach's alpha α = 0.92). The overall standard of all the retained eleven items was 1.77 (SD = 0.93), along with consistency reliability (Cronbach's alpha α = 0.58) which was found to be not much affected but improved the particular three domains.
Internal Consistency Reliability of Knowledge, Attitude, and Perceptions on Advance Directives
Further distribution of three main components of the tool on which the entire study depends that knowledge of advance directives (KAD), Attitude towards advance directives (AAD), and perceptions on advance directives (PAD) were assessed [Appendix, table 4]. There was a total of 28 items including seven items in the knowledge component with an overall mean of 0.13 (SD =0.01), for perceptions there were ten questions with a general standard of 3.37 (SD =0.26), and the last component attitude had eleven items with the overall mean 3.57 (SD = 0.24). Although mean and standard deviation was calculated for the perceptions component but when looking at the tool carefully, we found that some questions were non-directional including PAD4 and PAD9. We calculated the proportions separately for these two items and found that 48.59% were the participants who mostly agreed that patients should have the power to decide when to avoid futile treatment /life support only when they are sick. The majority, 38.30% of the participants, disagreed with the statement that doctors should not offer expensive treatments to patients if they cannot afford them, especially if they are futile, while 30.85% agreed. The knowledge component's consistency reliability showed good overall reliability (Cronbach's α = 0.99). When overall Cronbach's alpha was checked for the perception component, it found reasonably acceptable reliability (Cronbach's α =0.60). Certain items showed a massive variance in item test correlation which we checked step by step and found that if only those items were retained, dropping the rest would increase the reliability. The exact process for the component attitude towards advance directives showed moderately acceptable reliability (Cronbach's α = 0.72) with similar situation-like perceptions, as some items showed a considerable difference in test correlation. The overall reliability without dropping off any items showed (Cronbach's α =0.66), which is moderately acceptable.
Reliability of Knowledge on Advance Directives
The results were precisely reported the way they were done for the subdomains of sociodemographic variables. For knowledge on Advance Directive scale there were total of 7 items and all were retained (AAD1) do you know what Advance Directives or Living Will is, (AAD 2) an advance directive is a legal document that allows people to exercise their rights to accept or refuse medical care, when they can no longer make their own decisions, (AAD 3) a living-will enables individuals to describe in writing the type of healthcare they do or do not wish to receive when they are terminally ill, (AAD 4) a durable power of attorney for healthcare gives a person (surrogate decision-maker) the authority to make healthcare decisions for the patient, when they are no longer able to make those decisions, (AAD5) people may appoint anyone they wish as their surrogate decision-maker (proxy), (AAD 6) living wills and durable powers of attorney for healthcare must always be notarized, (AAD 7) an advance directive becomes effective when people are not able to make and/ or communicate their medical treatment decisions. These items did not affect the reliability of dropping any of its objects, showed (Cronbach's α = 0.99) with skipped responses that were considered zero (assumed not to know).
Reliability of Perceptions on Advance Directives
For Perceptions on Advance Directives out of eight directional items that were PAD 1, PAD 2, PAD3, PAD5, PAD6, PAD7, PAD8, and PAD10, it was found that only three things were (PAD6 ) even if the patient has expressed their End of life care choices when the time comes, the family decides what is right or wrong and act accordingly, (PAD 7) even if the patient has expressed their End of life care choices when the time comes, the person who is paying the bill decides what is right or wrong and act accordingly, and (PAD 8) patient's choices are only honored when they pay for themselves were retained. The rest were dropped, as in doing so, the overall reliability of the particular component did improve.
Reliability of Attitude on Advance Directives
Moreover, for analysis of the scale of attitudes on advance directives, the reliability test is conducted, and according to the results of composite reliability, KAD has a value of 0.99. The variable is highly reliable as the matter is more than 0.7 for composite reliability. AAD, PAD, and KAP on advanced directives have composite reliability values above 0.7, which means that these variables are also reliable. Moreover, the importance of SD is less than 1 for all the variables, meaning there is less deviation in the dataset. For evaluation of each of the items, [Appendix, table 4] can be analyzed.
Exploratory Factor Analysis
The factor loadings were found based on reliability results mentioned in [Appendix, table 5]. With all the retained items in table two (FH1, FH2, FH3, FH4, FH5, FH6, SR1, SR2, PH6, PH7, PH8, PAD6, PAD7, PAD8, AAD1, AAD3, AAD5, AAD6, AAD7, AAD8, AAD9, AAD10, AAD11) except the knowledge component (7 items), factor analysis was performed with pairwise correlation to assess any multicollinearity (high inter-correlations between two or more independent variables). If exceeding the criteria of 0.8 may undermine the statistical significance of independent variables found between none of the components. The Eigenvalues greater than one or equal to one were obtained in five factors. Most items of each element had variances greater than 0.4, but some of the things dispersed in every five factors when not rotated. Further, rotation (varimax) was observed, and the variances of each item were improved considerably along with particular components in certain factors. We named factor 1 as physical health awareness experience (PH) with (Cronbach's α = 0.93), factor 2 the Attitude on Advance directives (AAD) (Cronbach's α = 0.75), factor 3 family help support/ decisions (FH) with (Cronbach's α= 0.68), factor 4 perceptions on advance directives (PAD) (Cronbach's α= 0.64), and factor 5 was named as sociocultural and religion (SR) (Cronbach's α = 0.72). We performed confirmatory factor analysis (CFA) for the knowledge component as it was adopted by the western study (KAESAD). The research was done on the sample with skipped responses that were considered zero but ended in non-convergence due to the small sample size as only 51 out of 389 respondents completed this tool (Refer to the descriptive table 2 of this tool in which we found that most of the responses were similar) but the overall consistency reliability was good (Cronbach's α = 0.75). The second method, when performing factor analysis, particularly for those who responded to the survey, didn't show many differences in results and factor loadings. Still, the overall reliability got little affected (Cronbach's α = 0.71).