
==== Front
Sci Rep
Sci Rep
Scientific Reports
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Nature Publishing Group UK London

39294411
73126
10.1038/s41598-024-73126-z
Article
The development and validation of a knowledge, attitude, and practice questionnaire of methamphetamine use
Azmi Amirul Danial 1
Wahab Suzaily suzailywhb@yahoo.com

1
Abdul Kadir Nor Ba’yah 2
Abdul Wahab Noor Alaudin 3
Razak Rogayah A 4
1 https://ror.org/00bw8d226 grid.412113.4 0000 0004 1937 1557 Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latiff, Bandar Tun Razak, Cheras, Kuala Lumpur, 56000 Malaysia
2 https://ror.org/00bw8d226 grid.412113.4 0000 0004 1937 1557 Faculty of Social Sciences and Humanities, Universiti Kebangsaan Malaysia, Bangi, 43600 Selangor Malaysia
3 https://ror.org/00bw8d226 grid.412113.4 0000 0004 1937 1557 Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur, 50300 Malaysia
4 https://ror.org/019787q29 grid.444472.5 0000 0004 1756 3061 Faculty of Social Science and Liberal Arts, UCSI University, UCSI Heights, Jalan UCSI, Cheras, Kuala Lumpur, 56000 Malaysia
18 9 2024
18 9 2024
2024
14 2183520 3 2024
13 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Methamphetamine is a synthetic psychostimulant that is showing a rising trend of usage among adolescents and youths. Its harmful side effects and high risk of developing addiction is a public health problem. Recognizing the knowledge, attitudes, and practices (KAP) on methamphetamine is critical in the planning of an intervention strategy. Currently there is a lack of KAP questionnaires on methamphetamine. The study aims to develop and validate a KAP questionnaire on methamphetamine-use for use among Malaysian adolescents. Following an extensive literature review, face and content validity were carried out among healthcare workers, the public, students, and local subject matter experts. A pilot study was conducted amongst 50 students to assess the test-retest reliability. The questionnaire was then distributed to two groups of 269 and 331 individuals for the Exploratory (EFA) and Confirmatory Factor Analysis (CFA), respectively. The internal reliability was also assessed among these groups. The content validation consisting of Item Content Validity Index (I-CVI, ranging from 0.875 to 1.00), and Scale Content Validity Index (S-CVI/Ave = 0.941) both showed good validation scores. Test-retest reliability showcased an Intraclass Correlation Coefficient (ICC) of > 0.7, indicating its reliability. The model was constructed via the EFA resulting in four constructs, and the model’s goodness of fit was confirmed with CFA. An internal reliability was calculated with Cronbach’s Alpha and showed acceptable reliability (α-values > 0.6) for all constructs. The KAP questionnaire of methamphetamine use is a valid and reliable tool that can be used among Malaysian adolescents. The model arising from this study, can also be used as a guide for future intervention models for adolescent methamphetamine-use disorder.

Keywords

Questionnaire development
Knowledge
Attitude and practice
Methamphetamine-use
Adolescents
Subject terms

Human behaviour
Population screening
Ministry of Higher Education, MalaysiaLRGS/1/2019/UKM/02/2/3 LRGS/1/2019/UKM/02/2/3 LRGS/1/2019/UKM/02/2/3 LRGS/1/2019/UKM/02/2/3 issue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

Methamphetamine, an increasingly popular psychostimulant since the early 2010s, has shown an uptrend in its use among adolescents and youths especially in Malaysia. The number of individuals arrested positive with methamphetamine rose from 9,193 in 2016 to 12,991 in 20201. Like other stimulants, methamphetamine use produces physiological and mental effects such as wakefulness, increased breathing and pulse rate, the feeling of heightened concentration, and a reduction of appetite and perceived need for sleep2,3. Within the past five years, the volume of methamphetamine seizures globally has increased almost twofold4.

The most used illicit substance in Malaysia as of 2020 are amphetamine-type stimulants (ATS) (including methamphetamine) followed by opiates and cannabis. ATS and cannabis were also the most commonly used illicit substances among adolescents detained in juvenile centers5. Adolescents and youths make up roughly 75% of the total substance users in Malaysia1. Currently, it is estimated that 2.0% of all Malaysian youths have used ATS at least once in their lifetime6. Worryingly, the age of initiation of substance use is showing a downwards trend in Malaysia, whereby adolescents as young as 12 years old were reported to have used substances7. A recent local study found that the prevalence of psilocybin use among ATS-users were also high at 53%8.

The dangers of methamphetamine use in adolescence are many and may predispose the affected individual to a lifetime of issues. Methamphetamine use may lead to unwanted mental and physical side effects such as the development of methamphetamine-induced psychosis9, increased likelihood of developing mood disorders, aggressive behavior10, and dangerous arrythmias11. Adolescents who first used methamphetamine at a younger age are more likely to develop a substance use disorder. This is possibly due to the neurotoxic effects of methamphetamine on an adolescent’s maturing brain, in particular the reward pathway12. Furthermore, an adolescent’s immature prefrontal cortex further hinders them from making the right choices and predicting the risks of their actions13.

Knowing the dangers that methamphetamine-use poses onto adolescents, it is thus imperative that a proper assessment tool is developed to help determine the extent of the substance use problem within the community. An important assessment tool such as a Knowledge, Attitude, and Practice (KAP) questionnaire is a widely used tool to measure the psychosocial properties of substance use in a population. Designed particularly to gauge the estimated understanding of information (i.e., knowledge), feelings and behaviors towards a topic (i.e., attitude), findings from a KAP study may prove beneficial in identifying underlying issues in methamphetamine use and in designing a targeted and well-designed intervention plan for a selected population14.

Up to date, there is a lack of validated KAP questionnaires that target adolescents’ methamphetamine use. At the time of writing this manuscript, there is only one validated KAP on methamphetamine use scale by Sharifi et al.15. The content of the scale was validated for use among Iranian youths. The scale showed good internal reliability scores with both the knowledge and attitude constructs at 0.774 and 0.784, respectively.

Therefore, this study aims to develop and validate a KAP on methamphetamine use that can be administered to adolescents in Malaysia. This validated instrument may help future intervention studies in the field of methamphetamine use among adolescents and youths.

Methods

Setting and study population

This study was done among adolescents aged 13–17 residing in high-risk for substance-use zones in central Malaysia. These zones are based on the National Anti-Drug Association’s list of 178 zones reported in a local newspaper in 201916. Only those who were able to read and write in Malay were recruited as participants. This study received ethical approval from the Ethics Committee of Universiti Kebangsaan Malaysia. This study was also performed in accordance with the Declaration of Helsinki. The enrolment of participants in the study were on a voluntary-basis and without any coercion. Informed consent was attained from all the recruited participants and their guardians. The participants assented to the study and returned a parent/guardian consent form before the commencement of the study. In the consent form, participants and their parents/guardians were ensured that all information and answers were kept confidential. The questionnaires were answered via an online survey.

The sample size was calculated based on a minimum number of respondents per item ratio of 5 respondents to every 1 item17. The questionnaire consists of 53 items thus making the minimum number of respondents to be 265.

Item development and scale validation

Item generation

Literature review was carried out to identify the potential psychosocial determinants for the misuse of methamphetamine and amphetamine-type stimulants (ATS) for youths and adolescents. Utilizing a Boolean search technique, studies stored in the Medline database was searched using “((methamphetamine) OR (amphetamine-type stimulants) OR (stimulants)) AND ((addiction) OR (misuse)) AND ((youths) OR (adolescents)) until April 2021.

Some items were also adapted from a previous KAP for methamphetamine scale by Sharifi et al.15. Other items were inspired by KAP scales for other substances, particularly cigarettes18, tranquilizers19, and substance use in general20–22.

Focus group discussions were also carried out amongst adolescents from other high-risk for substance-use zones to gauge their overall knowledge and opinions regarding ATS/ methamphetamine misuse. Meetings were carried out with experts in the field of addiction to develop a set of comprehensive items for the scale.

The Knowledge construct was designed to consist of items to measure the understanding of effects of ATS/ methamphetamine, the consequences of ATS/ methamphetamine use, and the treatment modalities for ATS/ methamphetamine use disorders. The respondents were given three choices of answers for this construct which were “True”, “False”, and “Not sure”. The Attitude construct was designed to measure the acceptability of use of ATS/ methamphetamine, resilience against ATS/ methamphetamine use, curiosity to try ATS/ methamphetamine, and feelings towards people who use ATS/ methamphetamine. The Practice construct measured the behavior towards protecting oneself from using ATS/ methamphetamine, and active avoidance of ATS/ methamphetamine. Both constructs were answered on a 5-point Likert scale which were Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree for points 1,2,3,4, and 5, respectively.

The scale was developed in Malay and was validated for use in this language. Malay is widely used and understood by the Malaysian population.

Content and face validation

Content validation was done involving a panel of 8 local subject matter experts to measure the usability, understandability, and suitability of each item in their respective construct. These 8 local subject matter experts consisted of psychiatrists, psychologists, and public health specialists. Answers are given based on a 4-point Likert scale to measure the Item Content Validity Index (I-CVI) and the average Scale Content Validity Index (S-CVI/Ave). For a panel consisting of 8 experts, the suggested value for S-CVI/Ave would be > 0.8323.

Face validity was carried out amongst a group of experts, laymen, and students. Their subjective understanding of each item along with the clarity of the items were asked.

Pilot study & test-retest reliability

A pilot study was conducted among 50 participants to test the initial draft of the questionnaire in terms of the time it took to answer, the overall difficulty to answer, and the test-retest reliability. A test-retest reliability was done by administering the scale twice, four weeks apart. The Interclass Correlation Coefficient (ICC) was estimated.

Construct validity

The Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) was done to establish the validity of the construct. The EFA was done first followed by the CFA. Components extracted from the EFA was tested for goodness of model fit in the CFA. The model fit can be evaluated by measuring multiple aspects such as the Chi-square difference (CMIN/d.f.), Comparative Fit Index (CFI), Root Mean Square Error Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR)24,25.

Internal reliability

The internal reliability of the questionnaire was measured by calculating the Cronbach’s alpha coefficient. According to Hair et al. (2010), an alpha value between 0.6 and 0.7 is acceptable while greater than 0.8 is excellent. However, the items may prove redundant if the values are above 0.95.

Back-to-back translation

The Malay KAP questionnaire underwent a back-to-back translation process involving four bilingual subject matter experts. The initial translation into English was done with two psychiatrists along with the authors. Following which a finalized English draft was agreed upon. The back translation was carried out by a psychiatrist and a linguist who were kept blinded to the original Malay KAP. The authors then compared the original Malay KAP with the newly translated one to determine any discrepancies upon which a finalized English draft was decided. The back-to-back translation followed the guideline proposed by26.

A new group of school-going adolescents aged 13–17 residing in high-risk zones for substance use were recruited to test the reliability of the newly translated KAP. Only a back-to-back translation was done as both groups of adolescents were culturally similar27.

Statistical analysis

This study was analyzed by using the International Business Machines (IBM) Statistical Package for the Social Sciences (SPSS) version 25.0 and IBM SPSS Amos version 24.0.

Other than what was mentioned above, the mean age, distribution of ethnicities, and gender were also measured.

Results

The literature review along with the focus group discussions conducted uncovered several potential psychosocial determinants that plays a role in the use of ATS/ methamphetamine among adolescents which were gender, age, past psychiatric diagnoses, family adversity, family involvement in substance, involvement in risky behaviors, affiliation with deviant peers, social acceptability, and accessibility to substances28–36. This has resulted in an initial draft of the questionnaire consisting of 67 items. Discussions with experts in the field revealed several redundant items consisting of double-barreled items, items which were difficult to understand, and culturally irrelevant items which were then removed. An example of this would be substituting the word “berada dengan” (being around) to “bergaul dengan” (mixing with) in an item asking on the acceptance to befriend a person who uses methamphetamine and not simply the act of being in the presence of one. An item removed was one that asked on the knowledge of the use of stimulants to lose weight. This was in view of the possibility of sparking an interest in seeking out stimulants to lose weight amongst those who answered the questionnaire.

This has resulted in a finalized first draft consisting of 53 items. A flow diagram of the process of the validation study is shown in Fig. 1.

The pilot study was conducted among a group of 50 adolescents with a mean age of 15.2 years old. A majority were female, 68.6%, and Malay, 99.0%.

A total of 269 and 331 respondents were recruited for the EFA and CFA study, respectively. The mean age of the respondents were 14.8 years old with 53.8% being female. Most of the respondents, 98.4%, were Malay.

Fig. 1 Flow diagram of the validation process.

Face and content validity

The face and content validity found that the items of the finalized first draft to be relevant. Double barreled items were split into separate items and redundant items were removed. The S-CVI/Ave value for the Knowledge, Attitude, and Practice constructs were 0.975, 0.934, and 0.914, respectively. The questionnaire remained at 53 items.

Pilot study and test-retest reliability

The pilot study conducted was answered completely in two occasions by 50 participants. In this study, the items were reported to be easily understood and participants answered all items within 15–20 min. The ICC estimates and their 95% confidence intervals for the Knowledge (0.76, 0.65–0.84), Attitude (0.82, 0.73–0.87), and Practice (0.82, 0.74–0.88) were all > 0.75, indicating an excellent value for the test-retest reliability and reproducibility (Fleiss, 1986).

Construct validity and model goodness of fit

A principal component analysis was carried out on 269 adolescents using the varimax rotation resulting in a Kaiser-Meyer-Olkin (KMO) value of 0.89 and a significant Bartlett’s test of sphericity (p < 0.001) indicating that the factor analysis was appropriate in this study (Leech et al., 2013). This has resulted in four components when compared against parallel analysis which explains 42.48% of the variance. The four constructs were Knowledge with 19 items, Protective Behaviors towards Methamphetamine use Avoidance with 11 Items, Feelings towards Methamphetamine users with 10 items, and Acceptance towards Methamphetamine use with 6 items. The last three constructs make up both the Attitude (feelings and acceptance towards methamphetamine use) and Practice (methamphetamine use avoidance) part of the KAP questionnaire. This new draft based off the EFA resulted in a 46-item questionnaire.

This new draft was then given to 331 respondents for the CFA to test out the goodness of fit. Items that didn’t have a high factor loading were discarded, and inter-item error correlations were added. Table 1 describes the indicators for the tested model.

Table 1 Fit indicators for the tested model.

	χ2	CMIN/d.f	CFI	TLI	RMSEA	SRMR	
Model	p < 0.001	1.74	0.91	0.90	0.05	0.06	
χ2 = Chi-Square; CMIN/d.f = Chi-Square Mean/ degree of freedom; CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; RMSEA = Root Mean Square Error Approximation; SRMR = Standardized Root Mean Square Residual.

The finalized questionnaire showing the best fit for the model consists of 30 items with 4 similar constructs. Knowledge, Protective Behaviors towards Methamphetamine use Avoidance, Feelings towards Methamphetamine users, and Acceptance towards Methamphetamine use with 13, 7, 7, and 3 items, respectively. Figure 2 shows the finalized model. The finalized items with their descriptions and item loading are shown in Table 2.Fig. 2 The finalized knowledge-attitude-practice model.

Table 2 Finalized items with their item loadings in each construct.

Construct	Cronbach α	Variable	Item Description	Item Loading*	
Knowledge	0.886	K2	Meth can be taken …	0.542	
K3	Those who use …	0.642	
K4	Meth can cause …	0.598	
K5	Meth may cause …	0.627	
K6	Meth use can …	0.619	
K7	Meth can be in …	0.629	
K9	Using meth can …	0.587	
K13	Those using meth …	0.617	
K14	Taking meth in …	0.712	
K15	Meth is one …	0.615	
K18	The effect of using …	0.575	
K19	One may experience symptoms …	0.702	
K20	A person who uses meth …	0.639	
Protective Behaviors towards Methamphetamine use avoidance	0.838	A2	I will try my best …	0.437	
A7	I have the …	0.438	
A12	I will advise …	0.648	
A13	I am ready to …	0.710	
A14	I am ready to …	0.738	
A16	I will make sure that …	0.568	
P12	Support from family and friends …	0.649	
Feelings towards Methamphetamine users	0.818	A3	I will not accept …	0.527	
A4	I feel anxious …	0.732	
A5	I will feel …	0.759	
A6	I will get …	0.547	
A10	I am afraid …	0.633	
P3	Meth users are …	0.439	
P11	The use of meth …	0.527	
Acceptance towards Methamphetamine use	0.690	P1	Using meth for …	0.701	
P2	Using meth can …	0.674	
P6	Occasionally using meth …	0.656	
*Item loading is for the Malay version of the KAP Questionnaire.

Questionnaire item and overall reliability

The finalized 30-item questionnaire showed good internal reliability as all the constructs, Knowledge (Cronbach’s α = 0.886), Protective Behaviors towards Methamphetamine use Avoidance (Cronbach’s α = 0.838), Feelings towards Methamphetamine users (Cronbach’s α = 0.818), and Acceptance towards Methamphetamine use (Cronbach’s α = 0.690) achieved an acceptable reliability score for use in this population37.

The English translated questionnaire scored good internal reliability as well with the Knowledge, Protective Behaviors towards Methamphetamine use Avoidance, Feelings towards Methamphetamine users, and Acceptance towards Methamphetamine use constructs scored an alpha value of 0.763, 0.749, 0.778, and 0.729, respectively.

Discussion

In this study, the validation of the KAP questionnaire of methamphetamine-use was assessed among Malaysian adolescents. The results indicated that the questionnaire showed good validity in terms of face, content, and construct validity. The questionnaire also demonstrated acceptable reproducibility and reliability. The content validity scored more than the recommended 0.83, thus making the items relevant for its initial construct23.

Several steps were taken to ensure the reliability and validity of this questionnaire. Suggestions by Song et al. (2015) were closely followed to ensure that the questionnaire measures what it is supposed to measure appropriately38. The suggested steps were dictating a concept and format of questionnaire that will be used, subjectively and objectively validating the questionnaire, running a pilot study, and to run a reliability and validation test onto the questionnaire. Furthermore, it was also suggested that simple and straightforward language were used for the items. Similarly suggested by Stehr-Green et al. (2015), short sentences with easily understood language is important in the formulation of items for a questionnaire39.

The knowledge section comprises of items testing the general knowledge, different types, addictive properties, possible intervention plans, bodily effects, and legal repercussions of methamphetamine use. Other KAP questionnaires on substance use also tested the knowledge of their participants with similar components such as knowledge on the unwanted side effects of methamphetamine use on physical health, the misconceptions of methamphetamine15, social effects of substance use, types and availability of treatment centers for substance use40, and the different types of substances41.

The CFA shows that there is positive correlation between the four constructs, where an increment of each construct will lead to an increase in value of another. This is particularly so for the constructs protective behaviors towards methamphetamine use avoidance, feelings towards methamphetamine users, and acceptance towards methamphetamine use. A strong correlation could be seen between both attitude constructs (feelings and acceptance towards methamphetamine use) and practice (methamphetamine use avoidance). In the attitude constructs, perceptions to harmfulness of methamphetamine along with the general acceptability of methamphetamine use were measured. A past study found that social acceptability along with perception of harm play a significant role in predicting substance use42. It is not surprising then to see a strong positive correlation between the attitude constructs and the methamphetamine use avoidance construct.

The knowledge construct showed the least correlation with the other constructs. Among these participants, the knowledge of methamphetamine does not correlate strongly with the attitude and practice constructs of methamphetamine use. These findings are similar to a study done by Mallah et al. (2021) in their KAP on tranquilizers questionnaire where the knowledge construct correlates not as strongly to the attitude constructs19. This may be attributed to the strong stigmatization against people who use substance which may play a role in developing protective attitudes and behaviors against methamphetamine despite the level of knowledge43. This is in line with Malaysia’s strong stance against illicit substances which may influence the attitudes towards substance use44.

Since this KAP model is representative of the adolescent population in Malaysia, it can serve as a guide for developing future intervention modules for methamphetamine use in this population. It is then recommended that the development of intervention modules should include the following four factors Knowledge, Protective Behavior towards Methamphetamine use Avoidance, Feelings towards Methamphetamine users, and Acceptance towards Methamphetamine use behavior as obtained from the KAP model. The KAP model emphasizes the improvement of knowledge on methamphetamine to facilitate some changes in attitudes and behavior where it is hypothesized that with greater knowledge comes more protective attitudes. A local study has shown similarly whereby an education program done among school-going children showed significant improvements in their knowledge, attitudes towards harm reduction, and perception on substance-related problems after the program45.

This study is not without limitations. Although it is expected that a certain percentage of adolescents are using methamphetamine in high-risk for substance use areas, the authors did not specifically asked regarding their history of substance use. We would like to recommend a future study regarding the KAP of methamphetamine-use among adolescents particularly looking at the differences between those who use and those who do not use methamphetamine as past studies have shown a difference between these two populations in terms of understanding the risk factors to using substances, acceptance of substance use, and hindering behavior towards substance use46. Furthermore, it would be beneficial to also test the validity and reliability of this questionnaire in older age groups as there may be distinct differences in not just the levels of knowledge but also the acceptance and ultimately, attitude towards substances. Lastly, we were unable to proceed with concurrent validity due to the absence of a validated questionnaire on methamphetamine in the local population.

Conclusion

Adolescent methamphetamine use is an uprising public health and mental health issue in Malaysia that should not be overlooked. The lack of a validated assessment tool to measure the general public’s understanding and perception of methamphetamine in Malaysia is worrying. This study has produced a valid and reliable bilingual KAP on methamphetamine questionnaire that can be administered to Malaysian adolescents and youths. Furthermore, the model that was generated in this study could be beneficial in the development of intervention modules for adolescents using methamphetamine.

Abbreviations

KAP Knowledge-attitude-practice

ATS Amphetamine-type stimulants

Acknowledgements

We would like to thank the Ministry of Higher Education (MoHE) for financially supporting this study under the grant LRGS/1/2019/UKM/02/2/3. We would also like to express our gratitude to the Faculty of Medicine, Universiti Kebangsaan Malaysia for supporting this study. We are grateful to the local subject matter experts that have contributed their knowledge and expertise in the development phase of this questionnaire. Not forgetting our utmost gratitude to the teachers and students who participated in this study.

Author contributions

AA and SW contributed to conception and design of the study. AA performed the statistical analysis and wrote the first draft of the manuscript. SW, NAK and NAW wrote sections of the manuscript. RA facilitated in the conception and design of the questionnaire used in this study. All authors contributed to manuscript revision, read, and approved the submitted version.

Funding

The study was funded by the Ministry of Higher Education (MoHE) under the grant LRGS/1/2019/UKM/02/2/3.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study received ethics approval from the National University of Malaysia’s Ethics Committee. Since the study samples were below 18, assent and parental or guardian consent was taken prior to the commencement of this study.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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