Validation of Questionnaires and the Effect of Educational Videos on the Knowledge of Hyperlipidemia Patients at Banjarbaru Utara Primary Health Care

: Hyperlipidemia patients have a high risk of cardiovascular disease and stroke. Low patient knowledge causes therapy failure. Education can be provided to overcome this problem. No questionnaire instrument can measure the level of knowledge of hyperlipidemia patients. The level of knowledge of hyperlipidemia patients at Banjarbaru Utara Primary Health Care has never been studied. The research aimed to validate the questionnaire and determine the effect of educational videos on patient knowledge at the Banjarbaru Utara Primary Health Care, Banjarbaru City, South Kalimantan. The research method used to validate the questionnaire was cross-sectional, while to determine the effect of educational videos on the patient's level of knowledge using a quasi-experimental method using One Group Pre – Post Design. The research was conducted in January – March 2024 at Banjarbaru Utara Primary Health Care. The study involved eight experts, 40 patients in questionnaire validation, and 100 patients to determine the effect of educational videos. The results of questionnaire content validation show that the Content Validity Ratio (CVR) value is in the range of 0.750 – 1.000, while the Content Validity Index (CVI) value is in the range of 0.875 – 1.000. The validity test with Person Correlation shows that ten out of 20 statements on the questionnaire are considered valid (>0.312). The Cronbach's Alpha value is 0.655, indicating the questionnaire is reliable. The patient's knowledge before being given the educational video had a score of 5.96 (scale 1 – 10), while after it, it had a score of 8.73. There was an increase in the level of knowledge, reaching 46.47%. The conclusion is that the Hyperlipidemia Knowledge Questionnaire (HKQ), which consists of 10 statements, is declared valid and reliable. Educational videos significantly influence (p-value 0.000) in increasing knowledge of hyperlipidemia patients.


INTRODUCTION
Based on data from the Ministry of Health of the Republic of Indonesia, it is known that the presentation of patients visiting Primary Health Care with high cholesterol levels in Indonesia reaches 42% 1 .The proportion of hyperlipidemia in newly diagnosed type 2 diabetes mellitus patients reached 67.7% 2 .There is a strong relationship between hyperlipidemia and the incidence of cardiovascular disease and

Time and Place of Research
The research was conducted in January -March 2024.The research location was Banjarbaru Utara Primary Health Care, Banjarbaru City, South Kalimantan Province.

Population and Sample
The study population was hyperlipidemia patients seeking treatment at Banjarbaru Utara Primary Health Care.Sample selection used a purposive sampling technique according to the research objectives.Patients involved were asked to fill out informed consent.The research involved eight experts, three general practitioners, and five pharmacists to validate the questionnaire content.In the validation stage, the questionnaire involved 40 adult patients, and in the second stage, to determine the effect of providing educational videos, it involved 100 different patients.Inclusion criteria were patients aged over 18 years who were diagnosed with hyperlipidemia and visited Banjarbaru Utara Primary Health Care.

Making Questionnaires
The primary literature used by the Dyslipidemia Management Guide in Indonesia was created by the Indonesian Endocrinology Association 2 and the Dyslipidemia Management Guide was created by the Indonesian Association of Cardiovascular Specialist Doctors 16 .The questionnaire will be aimed at assessing the level of knowledge of hyperlipidemia patients so that the statements can be made to adapt to the patient's knowledge needs.Statements are made in four categories: disease, treatment, lifestyle, and complications.The total number of statements made was 20 statements.

Questionnaire Validity
Content validity was carried out by involving three general practitioners and five pharmacists to assess the suitability of the questionnaire created using the Content Validity Ratio (CVR) and Content Validity Index (CVI) parameters.Validation and reliability tests involved 40 adult hyperlipidemia patients seeking treatment at the North Banjarbaru Primary Health Care.The parameters used are difficulty level analysis, differentiating power analysis, discriminatory item test, and reliability test.A valid and reliable questionnaire is called the Hyperlipidemia Knowledge Questionnaire (HKQ)

Patient Knowledge Level
The valid questionnaire was then used to determine the effect of educational videos on the patient's level of knowledge.The stages of measuring the patient's level of knowledge are: 1. Pretest The patient will fill out the Hyperlipidemia Knowledge Questionnaire (HKQ) sheet.For patients who have difficulty reading or writing, researchers assist in filling out the questionnaire.

Educational Video Intervention
The patient then watches an educational video for hyperlipidemia patients.The hyperlipidemia educational video consists of four parts: disease, treatment, lifestyle, and complications.Educational video in animated form with a duration of 4 minutes 46 seconds.The educational video can be accessed at https://bit.ly/Video-Hiperlipidemiaor scan the barcode below.

Data Analysis
Content validity includes validity testing using Lawshe's Content Validity Ratio (CVR) and Content Validity Index (CVI) analysis.Testing involved three general practitioners and five pharmacists.The CVR value is considered valid if it gets a minimum score of 0.750 17 , while the acceptable CVI value is at least 0.830.
The difficulty level and differentiating power of the questionnaire was calculated based on research by Damayanti et al. 18 .Validity with Person Correlation was measured using SPSS 26.If the correlation coefficient value is more than 0.3, it is considered to have high discriminatory power.The reliability of the questionnaire was assessed using the Cronbach's Alpha coefficient parameter.This coefficient was obtained through a test using SPSS 26.The results are reliable if the Cronbach's Alpha coefficient is > 0.6.The influence of knowledge level was analyzed statistically using SPSS by comparing the pretest and posttest results.The homogeneity test used Levene's Test, while the normality test used the Shapiro-Wilk Test.Next, the Mann-Whitney test was carried out on both data.

RESULTS AND DISCUSSION Content Validity Test
The questionnaire, consisting of 20 statements, was then subjected to content validation.Content validation was carried out by eight experts composed of three general practitioners and five pharmacists to assess the questionnaire that had been created.The characteristics of experts are presented in the table below.The characteristics of experts are presented in the Table 1.
Experts assess the suitability of the content in each statement.Appropriate statements receive a score of 1, while inappropriate statements receive a score of 0. The results of content validation are presented in the form of CVR and CVI values according to the Table 2.
Based on content validation by eight experts, the CVR value was 0.750 -1.000, while the CVI value was in the range of 0.875 -1.000.Content validation provides an overview of the extent to which questions or statements are considered relevant to assess a target or objective 19 .The parameters used to assess content validation in this research are the CVR and CVI values.The CVR value shows the ability of an item to be accepted as part of a questionnaire.In contrast, the CVI value is the average number of items that can be part of a questionnaire instrument 20 .If the CVR and CVI values from the questionnaire are below the required limits, then the statements in the questionnaire must be removed.The results of this study show that all statement items are above the CVR Critical Value of 0.750 17 and the CVI Critical Value of 0.830 21 .Content validation shows that all questionnaire statements are valid.

Validity and Reliability
The questionnaire that has been validated for content is then tested on respondents.Patients were selected randomly and according to the patient's consent to fill out the questionnaire.The characteristics of the respondents are presented in the Table 3.
Table 3 Respondents were dominated by patients aged 31-40 years (30%) and 41-50 years (25%), female gender (77.5%), undergraduate education level (37.5%), working (70%), and distance home to Primary Health Care less than 5 kilometers (75%).The research data is supported by references stating that the incidence of hyperlipidemia begins at the age of over 30 years, and the peak occurs at 50 years 22 .In other research, it states that females are the patients who experience the most hyperlipidemia compared to males 23 .

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Difficulty Level Analysis and Differentiating Power Analysis.
The level of difficulty of the questions is measured using the Difficulty Index.The results obtained are then categorized based on the level of difficulty.The analysis results are presented in the Table 4 Based on the Difficulty Index results, are 15 items in the easy category, three in the medium category, and two in the difficult category.Questions in the easy category dominate the 20 statement items.This is influenced by the characteristics of the respondents involved in this research, who were dominated by respondents with undergraduate education levels (37.%%).A high level of education correlates with the patient's knowledge level, making it easy for patients to answer statements correctly.Items on the questionnaire that have a difficulty index that is too low (<0.15) or too high (>0.85)are excluded from the questionnaire 24 .
The differentiating power shows eight statements in the poor category, 7 in the fair category, 2 in the good category, and 1 in the bad category.Statements that fall into the poor category for differentiating power should not be included in the questionnaire.Fair and good category statements are highly recommended for use because they have differentiating power, which is considered to meet the requirements (18).Statements with a discrimination index value of less than 0.2 should be excluded from the questionnaire.One of the factors that influence the discrimination index is the respondent's knowledge 25 .

Validity with Person Correlation
A total of 20 Statement items were tested using SPSS to determine the Person Correlation value.The Person Correlation results are compared with the r table to determine the validity of the Statement.The test results obtained ten valid statements with a Person Correlation value above 0.312 at Table 5 18 .The Person Correlation value shows that there are 10 statement items that have a value of more than 0.312.Person Correlation value with r table for 40 respondents.A total of 10 statements are valid for use in the questionnaire.Invalid statements have a correlation with the difficulty index and differentiating index of the item.

Reliability Test
Statements that have been tested on respondents are analyzed to determine reliability.The results show a Cronbach's Alpha value of 0.655.Reliability testing is a description of the consistency of measurements carried out on several subjects in the same population.The minimum acceptable Cronbach's Alpha value is in the range of at least 0.5 -0.7 13 .The higher the Cronbach's Alpha value, the more reliable the questionnaire.The results of validity and reliability testing eliminated several statement items, finally there were 10 valid and reliable statements.Valid statements on the questionnaire are presented in the Table 6.

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The questionnaire contains ten statements that the patient answers true or false.Each statement answered according to the answer key gets a score of 1; if it is inappropriate, it gets a 0. The total score is in the range 0 -10.The results are classified based on the level of knowledge, namely 8 -10 (very good), 6-7.99 (good), 4 -5.99 (less), 2 -3.99 (very poor), and 0 -1.99 (very poor).

The Effect of Educational Videos on Patient Knowledge
A valid questionnaire was then used to determine the effect of educational videos on the knowledge of hyperlipidemia patients at the North Banjarbaru Primary Health Care.The characteristics of the respondents involved are presented in the Table 7.The characteristics of the patients involved in assessing the influence of educational videos on knowledge mainly were aged 31-40 years (38%), female (74%), undergraduate education level (38%), working (65%), and distance from home to Primary Health Care.Less than 5 km (78%).North Banjarbaru Primary Health Care is P a g e | 37 an urban Primary Health Care located in the capital of South Kalimantan Province.This causes the patients who visit dominated by patients of productive age with undergraduate education and work.Other research shows that the age of hyperlipidemia patients is in the final age range of 39 -65 years, with the highest incidence in married women 26 .
Patients were asked to answer questionnaires before the intervention (pretest) and after the intervention (posttest).A valid questionnaire consisting of 10 statements is used; each correct answer will receive a score of 1 point, while incorrect answers will receive 0 points.The intervention provided is an animated educational video equipped with information related to hyperlipidemia.The questionnaire results before and after the intervention based on the average score for each statement item are presented in the Table 8.Based on the Table 8, the average score before intervention was 5.96, which is classified as poor (4 -5.99).Regarding the score for each statement, statements 5 and 6 relating to knowledge of lifestyle have the lowest scores of 0.47 and 0.54 (scale 0 -1), followed by statement number 1 relating to knowledge about disease with a score of 0.55 ( scale 0-1).Low knowledge about lifestyle is correlated with awareness of healthy living.Bad lifestyles, such as low exercise activity and a lack of understanding about healthy lifestyles, influence high cholesterol levels 27 .Cardiovascular patients, such as hyperlipidemia, hypertension, and diabetes mellitus, are known to have a lifestyle as the worst aspect to control 28 .
The intervention in the form of an educational video about hyperlipidemia is essential if it is seen from the patient's level of knowledge before the intervention.The results in the Table 8 show that the intervention impacts increasing patient knowledge.The average score on all statement items increased.The highest level of knowledge in the disease category with statement number 1 and the treatment category with statement number 3 have the same score, namely 0.93.Patients understand that the diagnosis of hyperlipidemia is assessed based on several parameters, not only based on total cholesterol levels.Patients also understand that simvastatin should be taken at night.9 show the average questionnaire score before the intervention showed a value of 5.96, while after the intervention, the questionnaire score was 8.73 (scale 1 -10).There was an increase in the level of knowledge after the intervention of 46.47%.The results of statistical tests using SPSS 26 with the Mann-Whitney Test showed that the P-value was 0.000, which indicated that there was a significant difference between the scores from the questionnaire results before and after the intervention.The research data is supported by references that state that there is a correlation between education and patient knowledge about drug use 29 .Other research states that patient education has a significant effect on increasing knowledge 30 .Research in Singapore involving 1000 respondents showed that public knowledge and awareness of hyperlipidemia and its treatment was very low.Efforts to increase knowledge by implementing health promotion through patient education 14 .Based on the results of this research, education via video has been proven to increase the knowledge of hyperlipidemia patients.
This study has limitations, namely that the population used was hyperlipidemia patients from an urban Primary Health Care background.This research was conducted in Indonesia, so the literature used as a reference for creating the questionnaire came from treatment guidelines in Indonesia.There may be slight differences with other countries.The questionnaire used is an Indonesian language questionnaire, so if it is applied in other countries, adjustments need to be made to the sentence structure.This research implies that the questionnaire in this study can be applied to determine the level of knowledge of hyperlipidemia patients in Primary Health Care.Patients with a low level of knowledge should receive education before undergoing treatment.Screening the patient's level of knowledge can also be carried out and is helpful in increasing medication adherence and the success of therapy.The educational videos used in this research can be used as material to educate patients.

P a g e | 30 Figure 1 .
Figure 1.Educational Video Display and Educational Video Access Barcode

Table 1 .
Characteristics of Experts . Characteristics of Respondents in the Questionnaire Validity Test

Table 4 .
. Difficulty Index and Differentiating Power Analysis

Table 5 .
. Validity Test Results with Person Correlation Parameters

Table 7 .
Characteristics of Respondents

Table 8 .
Average Score for Each Statement

Table 9 .
Questionnaire Analysis Results Before -After Intervention