Psychometric Evaluation of the Knowledge-Attitude-Practice Questionnaire for Health Professionals in Adult Functional Constipation Care (KAP-FC)

Summary

Based on the KAP theory, this study developed and psychometrically evaluated the 28-item KAP-FC questionnaire to assess health professionals’ knowledge, attitudes, and practices regarding the care of adult functional constipation. It demonstrated good reliability (Cronbach's α = 0.914) and validity, providing a tool for nursing quality improvement.

Abstract

Functional constipation is commonly encountered in adult healthcare, yet its clinical assessment is often limited by inconsistent recognition, insufficient nurse training, and the lack of a standardized instrument to assess how healthcare professionals integrate knowledge, attitudes, and practices into routine care. To address this gap, this study developed and psychometrically evaluated the Knowledge-Attitude-Practice Questionnaire for Health Professionals in Adult Functional Constipation Care (KAP-FC). Guided by the Knowledge-Attitude-Practice (KAP) framework, an initial item pool was generated through a literature review, theoretical analysis, and qualitative interviews, followed by two rounds of Delphi consultation with an interdisciplinary expert panel. The revised questionnaire was pre-tested and subsequently administered to 466 nurses from three tertiary hospitals in Nantong using stratified convenience sampling. Item screening was performed using the critical ratio method and item-total correlation analysis, while structural validity, content validity, internal consistency, and test-retest reliability were evaluated. Following item analysis, 28 items were retained, comprising 12 knowledge, 6 attitude, and 10 practice items. Exploratory factor analysis identified six factors that explained 72.344% of the total variance, with factor loadings ranging from 0.511 to 0.894. The overall Cronbach's α was 0.914, with dimension-specific Cronbach's α values ranging from 0.881 to 0.900. The intraclass correlation coefficient for test-retest reliability was 0.936, and the scale-level content validity index (S-CVI) was 0.929. These findings demonstrate that the KAP-FC questionnaire has satisfactory preliminary reliability and validity and may serve as a useful instrument for assessing healthcare professionals' knowledge, attitudes, and practices related to adult functional constipation care.

Introduction

Functional constipation (FC) is a common functional bowel disorder in adults and is classified within disorders of gut-brain interaction¹. It is characterized by difficult, infrequent, or incomplete defecation without an identifiable structural or biochemical cause, and its diagnosis relies mainly on symptom-based clinical criteria rather than a single laboratory or imaging test^2,3. Although FC is frequently encountered in clinical practice, its assessment and management remain inconsistent, particularly in settings where constipation care is handled as part of routine nursing work^4,5.

The burden of FC is not limited to bowel symptoms. Patients with chronic constipation often experience abdominal discomfort, repeated use of laxatives, reduced quality of life, and increased healthcare use^3,6. In China, population-based evidence also shows that FC is common and is associated with demographic, dietary, lifestyle, and psychological factors⁷. These findings indicate that FC care requires more than simply recording bowel movement frequency. Clinical assessment should include symptom duration, stool characteristics, defecation habits, diet and activity patterns, medication use, psychological status, and response to treatment^3,8. However, these aspects are not always assessed consistently in daily nursing practice, especially when nurses have not received systematic training in constipation care.

Healthcare professionals, particularly nurses, play an important role in identifying FC-related symptoms, providing health education, supporting non-pharmacological interventions, observing medication response, and promoting adherence to bowel-management plans⁹. However, previous studies have shown that healthcare professionals may experience uncertainty in assessing, preventing, and managing constipation, especially in older patients and long-term care settings⁵. Recent work on constipation-related nursing quality also suggests that non-pharmacological interventions, including dietary guidance, activity support, bowel habit training, and patient education, require more standardized implementation in hospital care⁹. Therefore, the problem in clinical practice is not only whether patients understand constipation, but also whether healthcare professionals have sufficient knowledge, appropriate attitudes, and consistent practices to support FC care.

At present, most constipation-related instruments are designed to assess patient symptoms, bowel function, disease severity, treatment response, or quality of life. These tools are valuable for patient evaluation, but they do not measure healthcare professionals’ FC-related knowledge, attitude, and practice. General nursing competency instruments can evaluate broad professional ability, but they are not specific to FC and cannot identify deficits in Rome IV-related knowledge, risk-factor assessment, laxative-related observation, defecation guidance, psychological support, or adherence management^10,11. Existing constipation-related KAP studies have also mainly focused on patients or special populations, such as pregnant women and parents of children with FC^12,13. This leaves a clear gap for a focused questionnaire to evaluate how health professionals understand FC, view their role in care, and implement FC-related nursing practices.

The KAP framework was selected because FC care depends on the interplay among what healthcare professionals know, how they perceive their role, and how they act in clinical practice. Knowledge of the diagnostic criteria, risk factors, treatment principles, and medication-related issues is necessary, but knowledge alone may not lead to standardized practice. Attitudes toward the nurse’s role, willingness to provide education, and recognition of FC as a care problem may influence whether this knowledge is translated into assessment, guidance, and follow-up. Therefore, a KAP-based questionnaire can provide a more complete assessment than a knowledge-only test or a general competency scale. It may also help identify training needs and support nursing quality evaluation, although its clinical predictive value still requires further study.

In light of this gap, this study aimed to develop and psychometrically evaluate the Knowledge-Attitude-Practice Questionnaire for Health Professionals in Adult Functional Constipation Care (KAP-FC). The questionnaire was designed for health professionals involved in adult FC care and was developed through a literature review, qualitative interviews, a Delphi consultation, pretesting, item analysis, and psychometric evaluation. By assessing FC-related knowledge, attitudes, and practices collectively, the KAP-FC questionnaire is intended to serve as a focused tool for identifying care-related weaknesses and supporting targeted training in adult FC nursing care.

Protocol

This study was based on the Knowledge-Attitude-Practice (KAP) framework and used a three-phase process to develop and psychometrically evaluate the Knowledge-Attitude-Practice Questionnaire for Health Professionals in Adult Functional Constipation Care (KAP-FC). The study was approved by the Ethics Committee of Nantong City Hospital (Approval No. NTLYLL2022087), and written informed consent was obtained from all participants before enrollment. Participants were informed that they could withdraw from the study at any time without consequence. All participants were assured that the questionnaire data would be used solely for research purposes and would be kept confidential.

Construction and development of the initial questionnaire

In the first phase, an initial item pool was developed through literature review, theoretical analysis, and qualitative interviews. The literature review focused on functional constipation, constipation-related nursing care, health education, patient assessment, treatment adherence, and the development of KAP-based questionnaires. On this basis, the research team drafted preliminary items covering three theoretical domains: knowledge, attitude, and practice. Semi-structured interviews were then conducted after appointments were arranged with the participants. Each interview lasted approximately 15–30 min and was conducted in a separate doctor’s or nurse’s office to ensure privacy and minimize interruptions.

Purposive sampling was then used to recruit eight healthcare experts from the gastroenterology and geriatrics departments at a tertiary hospital in Nantong for semi-structured interviews. The inclusion criteria were as follows: (1) at least 15 years of clinical experience in gastroenterology or geriatrics in a tertiary hospital; (2) a bachelor’s degree or above; (3) a senior professional title, or an intermediate professional title together with at least five years of provincial-level gastroenterology specialist nurse qualification; and (4) informed consent and voluntary participation in the study. Before the interview, the research team explained the study purpose, interview content, confidentiality requirements, and the participants’ right to withdraw.

The semi-structured interview guide included the following questions: (1) Are you familiar with the diagnostic criteria for FC? (2) Is FC common in your department? (3) How do you evaluate the ability of clinical nurses to provide FC care, and can this ability meet routine clinical needs? (4) What constipation-related knowledge should qualified nurses possess in clinical practice? (5) Do you have any further comments on the issues discussed above? (6) What role should clinical nurses play in the care of patients with FC, and what care measures should they implement?

Interviews were conducted by trained research team members. With participant consent, interviews were audio-recorded and transcribed verbatim. The research team reviewed the transcripts after each interview and continued recruitment until no new themes or item-relevant information emerged, indicating data saturation. The Colaizzi seven-step analysis method was used to extract themes and core items¹⁴. An initial questionnaire containing 30 items across the knowledge, attitude, and practice dimensions was then developed.

Scoring criteria were defined before the formal survey. In the knowledge dimension, single-choice items were scored from 1 to 3 points based on the response option, with higher scores indicating greater knowledge. For multiple-choice items, scores were calculated according to the proportion of correctly selected correct options using the following formula: Item score = 1 + 2 × (number of correctly selected correct options/total number of correct options). The calculated score was then converted according to the predefined questionnaire scoring table. The score was then assigned according to the predefined scoring table for the questionnaire. The total knowledge score was calculated by summing the scores of all knowledge items, with higher scores indicating a higher level of FC-related knowledge. For the attitude dimension, a 5-point Likert scale was used, ranging from 1 = strongly disagree to 5 = strongly agree, with total scores ranging from 6 to 30. For the practice dimension, a 5-point Likert scale was used, with responses ranging from 1 = never to 5 = always, and total scores from 10 to 50. Higher scores indicated more positive attitudes or more standardized practice.

Validation and evaluation of the questionnaire content

Sixteen interdisciplinary experts, including gastroenterologists, gastroenterology specialist nurses, and geriatric nursing experts, participated in two rounds of Delphi consultation. The inclusion criteria were as follows: (1) gastroenterology medical experts with more than 15 years of professional experience and either a senior professional title or a master’s degree or higher; gastroenterology nursing experts with a bachelor’s degree or higher and either a senior professional title or provincial-level specialist nurse qualification for at least five years; or geriatric medical or nursing experts with a bachelor’s degree or higher and a senior professional title; (2) familiarity with the Delphi technique; and (3) voluntary participation and willingness to complete the consultation process. In both rounds, the Delphi questionnaires were distributed separately, and all experts completed them independently and anonymously. The feedback and comments obtained from the first round were summarized by the research team and incorporated into the second-round questionnaire to guide further item revision and expert evaluation.

Before each consultation round, the research team screened experts according to the predefined eligibility criteria and confirmed their professional background, years of experience, title, specialty, and willingness to participate. The consultation questionnaire asked experts to rate the importance of each item and provide qualitative comments on wording, clinical relevance, item clarity, and dimensional attribution. The expert participation rate, expert authority coefficient (Cr), coefficient of variation (CV), full-score rate, and Kendall’s coefficient of concordance were used to evaluate expert authority and consensus.

Items were retained when they met the following criteria: mean importance score ≥ 3.5, CV ≤ 0.25, and full-score rate ≥ 20%. Items that did not meet these criteria were revised or deleted after discussion by the research team, taking into account the experts’ qualitative comments and the item's theoretical relevance to FC nursing care. Items with unclear wording but adequate theoretical relevance were modified, whereas items with poor expert agreement, low importance, or conceptual overlap with other items were deleted or merged. After the two Delphi rounds, the questionnaire contained 30 items across the knowledge, attitude, and practice dimensions.

The revised questionnaire was then pre-tested. Stratified convenience sampling was used to recruit 30 registered clinical nurses from a tertiary hospital in Nantong, including 40% from gastroenterology, 40% from geriatrics, and 20% from other departments. The inclusion criteria were that participants be registered clinical nurses working in a tertiary hospital, provide informed consent, and be willing to participate. The exclusion criteria were nurses with 12 months or less of work experience, trainee nurses, pediatric nurses, and nurses with past or current mental health disorders. The survey was coordinated by the nursing department and conducted by trained research team members in each department. Participants completed the questionnaire 30 min after the departmental shift handover, and the research team provided standardized instructions for its completion. Thirty questionnaires were distributed and returned, yielding a 100% response rate. Participants reported no difficulty understanding the items, and the mean completion time was 8.5 ± 2.3 min. The pre-test showed good internal consistency, with a Cronbach’s α of 0.926, supporting the feasibility of the questionnaire for the formal survey.

Reliability and validity testing of the questionnaire

In October 2022, three tertiary hospitals in Nantong were randomly selected for the formal questionnaire survey. Stratified convenience sampling was used to recruit nurses from departments with a high frequency of FC-related care needs, including gastroenterology, neurology, cardiology, and geriatrics, as well as other clinical departments when eligible nurses were available. Within each selected department, eligible nurses were invited by trained research team members after coordination with the nursing department. The inclusion and exclusion criteria were the same as those used in the pre-test.

A total of 491 questionnaires were collected. After excluding 25 invalid questionnaires, 466 valid questionnaires were included in the final analysis, giving an effective response rate of 94.9%. The final sample included 71 nurses from gastroenterology or gastrointestinal disease-related departments and 395 nurses from other departments.

Questionnaires were administered through both online and paper-based routes. For the online survey, the questionnaire link was distributed through the hospital OA system using a Chinese online questionnaire survey platform. Each IP address was allowed to submit the questionnaire only once to reduce duplicate responses, and the acceptable response time was set at 3 to 15 min based on the pre-test completion time. Responses outside the predefined time range or with obvious invalid response patterns were automatically flagged. For the paper-based survey, questionnaires were distributed after morning departmental meetings and collected on-site. Research team members checked the completeness of paper questionnaires immediately after collection. Questionnaires with missing key information, incomplete item responses that prevented score calculation, duplicate submissions, or invalid response patterns were excluded from analysis. For analyzable questionnaires with minor missing information in non-key demographic variables, the available valid item responses were retained for analysis.

Standardized expert and participant selection

Eligibility criteria were established before the semi-structured interviews, Delphi expert consultations, pre-test, and formal survey. For the interview and Delphi phases, experts were screened according to specialty, years of professional experience, educational background, professional title, specialist qualification, familiarity with the Delphi method, and willingness to participate. For the nurse pre-test and formal survey, participants were screened according to registration status, clinical work experience, department, informed consent, and exclusion criteria. This process was used to ensure the professional relevance of expert input and the eligibility of survey participants.

Standardized data collection

Before formal data collection, standardized training was provided for all research personnel. A 10-minute instructional video on questionnaire completion was prepared, and five postgraduate nursing students were trained as quality-control personnel. They used unified instructions to explain the survey's purpose, completion requirements, and precautions, thereby reducing interpretation bias.

Two data collection routes were used to improve response coverage and data quality. Online questionnaires were distributed through the hospital OA system using a link to the questionnaire platform (n = 379). To reduce duplicate submissions, each IP address was permitted to submit the questionnaire only once. During data collection, duplicate questionnaires were identified based on repeated IP addresses, repeated submission records, or obvious overlap in participant information and were excluded from the analysis. Based on the pre-survey completion time, the acceptable response-time range was set to 3–15 min, and questionnaires outside this range or with obvious invalid response patterns were automatically flagged by the system. Paper questionnaires were distributed after departmental morning meetings (n = 112), collected onsite immediately upon completion, and checked by the research team for completeness. Incomplete responses were identified by missing key demographic information, unanswered questionnaire items that prevented score calculation, or incomplete item responses across the knowledge, attitude, or practice dimensions. Questionnaires with duplicate submissions, incomplete key information, invalid response patterns, or responses that did not meet the predefined quality-control criteria were excluded from the final analysis.

Sample size calculation

The sample size was determined based on the principle that it should be at least 10 times the number of questionnaire items. The initial questionnaire contained 30 items across three dimensions; therefore, at least 300 participants were required. In the formal survey, 466 valid questionnaires were collected, exceeding the minimum required sample size by 55.33% and meeting the requirements for psychometric analysis.

Statistical methods

Statistical analysis was performed using SPSS version 23.0. Expert consultation reliability was evaluated using the expert participation rate, expert authority coefficient (Cr), coefficient of variation, and Kendall’s coefficient of concordance. Categorical variables were presented as frequencies and percentages, and continuous variables were presented as mean ± standard deviation.

For item analysis, the critical ratio method and the item-total correlation method were used¹⁵. In the critical ratio method, the total questionnaire scores were ranked from high to low, with the top 27% classified as the high-score group and the bottom 27% as the low-score group. Independent-sample t-tests were then used to compare item scores between the two groups. Items with non-significant between-group differences (P > 0.05) or a critical ratio < 3.0 were considered for deletion. In the item-total correlation method, Pearson product-moment correlation coefficients were calculated between each item and the total questionnaire score, and items with correlation coefficients < 0.30 were considered for deletion.

Validity was evaluated using structural validity and content validity. For structural validity, exploratory factor analysis (EFA) was performed. The suitability of the data for factor analysis was assessed using the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test of sphericity. In this study, Bartlett’s test of sphericity was significant (P < 0.001), and the KMO value was 0.881, indicating that the data were suitable for factor analysis¹⁶. Principal component analysis with Kaiser-normalized varimax rotation was then used to extract factors. Common factors were retained based on eigenvalues > 1 and visual inspection of the scree plot. A cumulative variance contribution rate > 40%, item factor loadings > 0.40, and absence of cross-loadings were considered acceptable¹⁷. For content validity, six experts with experience in gastroenterology or gastrointestinal disease care and familiarity with questionnaire development were invited to evaluate the questionnaire. Each item was assessed using a four-point Likert-scale relevance, and the content validity index (CVI) was calculated. An item-level CVI > 0.780 and a scale-level CVI > 0.600 were considered to indicate acceptable content validity¹⁸.

Reliability was evaluated using Cronbach’s α, split-half reliability, and test-retest reliability. Cronbach’s α > 0.700 was considered acceptable, and values between 0.800 and 0.900 indicated good internal consistency. Split-half reliability > 0.700 was considered acceptable¹⁹. For test-retest reliability, 47 nurses were randomly selected from the 466 participants and completed the questionnaire again after a two-week interval. Stability over time was assessed using the intraclass correlation coefficient based on a two-way mixed-effects model with absolute agreement.

Results

Expert consensus and initial questionnaire refinement

Two rounds of Delphi expert consultation were conducted during questionnaire refinement. In the first and second rounds, 17 and 16 consultation questionnaires were distributed, respectively, and 16 valid questionnaires were returned in each round, giving effective response rates of 94.12% and 100.00%. Sixteen experts from six tertiary hospitals in three cities in China participated in the Delphi consultation. The mean age of the experts was 39.63 ± 7.90 years, and their mean professional experience was 17.88 ± 9.51 years; 50.00% held senior professional titles. The expert authority coefficient (Cr) was 0.91 in both rounds, indicating a high level of expert authority. The importance scores of the items ranged from 4.06 to 4.94 in the first round and from 4.31 to 4.81 in the second round, while the coefficients of variation ranged from 0.05 to 0.29 and from 0.08 to 0.22, respectively, consistent with the values reported in Table 1. The Kendall’s W coefficients were 0.359 and 0.543 in the two rounds, respectively, and both were statistically significant (P < 0.05), indicating acceptable and improved agreement among the experts, as shown in Table 2.

Based on the literature review, theoretical analysis, qualitative interviews, and Delphi consultation, the initial item pool was revised and refined. After two rounds of expert consultation, the KAP-FC questionnaire comprised 30 items across three dimensions: knowledge, attitude, and practice. The retained items covered key content on pathogenic factors, diagnostic criteria, and treatment interventions, indicating substantive relevance and expert consensus prior to formal psychometric testing.

Participant characteristics and survey completion

A total of 491 questionnaires were collected in the formal survey. After excluding 25 invalid questionnaires, 466 valid questionnaires were included in the final analysis, yielding an effective response rate of 94.9%, as shown in Table 3. The final sample included six male nurses (1.29%) and 460 female nurses (98.71%). Regarding age, 229 participants (49.15%) were aged ≤ 30 years, 192 (41.20%) were aged 31–40 years, and 45 (9.66%) were aged > 40 years. In terms of work experience, 297 participants (63.73%) had 1–10 years of work experience, 125 (26.82%) had 11–20 years, and 44 (9.44%) had more than 20 years of work experience. Most participants held a bachelor's degree (87.55%) and a junior professional title (66.31%). Seventy-one nurses (15.24%) worked in gastroenterology departments, while 395 (84.76%) worked in other departments. In addition, 159 nurses (34.12%) had previous experience working in gastroenterology, and 144 (30.90%) had received constipation-related training.

Item screening and retention

Item analysis was performed using the critical ratio and item-total correlation methods. In the critical ratio analysis, K12 in the knowledge dimension had a critical ratio of 2.182, which was < 3.0, indicating insufficient item discrimination. The critical ratios of the remaining items ranged from 5.950 to 28.632, with statistically significant differences between the high-score and low-score groups (P < 0.001). In the item-total correlation analysis, K10 and K12 had Pearson correlation coefficients of 0.287 and 0.161 with the total questionnaire score, respectively, both < 0.30. Therefore, K10 and K12 were deleted. The remaining 28 items had item-total correlation coefficients > 0.30 and were retained for subsequent validity and reliability testing, as shown in Table 4.

Structural validity based on exploratory factor analysis

The 28 retained items were included in the exploratory factor analysis. The KMO value was 0.881, and Bartlett's test of sphericity was significant (χ² = 9532.378, P < 0.001), indicating that the data were suitable for factor analysis. Using principal component analysis with varimax rotation, six factors with eigenvalues > 1 were extracted, explaining 72.344% of the total variance (Figure 1). The factor loadings of the 28 items ranged from 0.511 to 0.894. All factor loadings were > 0.40, and no cross-loadings were observed, supporting the structural validity of the questionnaire. The final questionnaire consisted of 28 items organized into three dimensions, including 12 knowledge items, 6 attitude items, and 10 practice items (Table 5 and Table 6).

The six extracted factors were named according to their item content. Factor 1 was named Attitude toward FC care; Factor 2, FC-related risk and population knowledge; Factor 3, Proactive nursing practice; Factor 4, Treatment-related nursing practice; Factor 5, Diagnostic knowledge; and Factor 6, Treatment-related knowledge. Factor 1 corresponded to the attitude domain, Factors 2, 5, and 6 corresponded to the knowledge domain, and Factors 3 and 4 corresponded to the practice domain. Therefore, the six factors were retained as sub-factors within the three theoretical KAP dimensions of knowledge, attitude, and practice. This factor structure supports the planned theoretical framework of the KAP-FC questionnaire.

Content validity

Six nursing experts participated in the content validity evaluation of the questionnaire. The scale-level content validity index (S-CVI) was 0.929, and the item-level content validity indices (I-CVI) ranged from 0.833 to 1.000, as shown in Table 7. These results indicated that the retained items had acceptable content relevance and were consistent with the intended assessment domains of adult FC nursing care.

Internal consistency and test-retest reliability

The final 28-item KAP-FC questionnaire showed good reliability. The Cronbach’s α values of the three dimensions ranged from 0.881 to 0.900, and the overall Cronbach’s α was 0.914. The split-half reliability coefficients of the three dimensions ranged from 0.705 to 0.906, and the overall split-half reliability coefficient was 0.791 (P < 0.001). The test-retest reliability coefficients of the three dimensions ranged from 0.813 to 0.914, and the overall test-retest reliability ICC was 0.936; all were statistically significant (P < 0.001), as shown in Table 8. These findings indicated good internal consistency, acceptable split-half reliability, and temporal stability of the questionnaire. Overall, the results indicate that the development and validation protocol was completed as planned, and the resulting questionnaire had acceptable preliminary reliability and validity.

DATA AVAILABILITY:

The de-identified dataset supporting the findings of this study is publicly available on Zenodo at https://doi.org/10.5281/zenodo.21298839.

Figure 1: Scree plot of exploratory factor analysis. Scree plot showing the eigenvalues of the extracted components from the exploratory factor analysis of the KAP-FC questionnaire. Six factors with eigenvalues > 1 were retained based on the Kaiser criterion and visual inspection of the scree plot. Please click here to view a larger version of this figure.

Table 1: Degree of consensus in expert opinions. Mean importance ratings, coefficients of variation, and full-score rates for questionnaire items during the two rounds of Delphi consultation. These indicators were used to evaluate expert consensus and guide questionnaire refinement. Please click here to download this Table.

Table 2: Degree of coordination in expert opinions. Kendall's coefficient of concordance (W) for the knowledge, attitude, and practice dimensions, and for the overall questionnaire across the two Delphi consultation rounds. Higher W values indicate greater agreement among the experts. Please click here to download this Table.

Table 3: Demographic characteristics of survey participants. Demographic and professional characteristics of the 466 nurses who participated in the formal questionnaire survey. Participant characteristics include age, sex, education level, professional title, department, clinical experience, and constipation-related training. Please click here to download this Table.

Table 4: Item analysis of the KAP-FC questionnaire. Results of the item analysis using the critical ratio method and item-total correlation analysis. Items were retained or removed based on predefined criteria for discrimination and correlation. Please click here to download this Table.

Table 5: Factor matrix of the KAP-FC questionnaire. Rotated factor matrix of the 28 retained questionnaire items obtained by principal component analysis with varimax rotation. Factor loadings demonstrate the association of each item with the extracted factors. Please click here to download this Table.

Table 6: Factor loadings and interpretation of the final questionnaire. Factor loadings and corresponding item descriptions for the six retained factors of the final KAP-FC questionnaire. The factors are organized according to the theoretical domains of knowledge, attitude, and practice. Please click here to download this Table.

Table 7: Content validity evaluation of the KAP-FC questionnaire. Item-level content validity indices (I-CVI) and scale-level content validity index (S-CVI) based on expert ratings. These indices were used to evaluate the relevance and representativeness of the questionnaire items. Please click here to download this Table.

Table 8: Reliability Analysis of the KAP-FC questionnaire. Internal consistency, split-half reliability, and test-retest reliability of the KAP-FC questionnaire and its three dimensions. Reliability was assessed using Cronbach's α coefficients, split-half coefficients, and intraclass correlation coefficients (ICC). Please click here to download this Table.

Discussion

This study developed and psychometrically evaluated the KAP-FC questionnaire for health professionals involved in adult FC care. The main value of the work lies not only in the final 28-item questionnaire but also in the stepwise protocol used to build the instrument. The process combined a literature review, qualitative interviews, a Delphi consultation, pretesting, item analysis, and psychometric evaluation. This sequence helped ensure that the items were first grounded in clinical content and expert experience, and were then tested statistically before being retained in the final questionnaire. This approach is important in questionnaire development because item generation, content review, pre-testing, and psychometric testing each address different sources of measurement error^18,20,21.

Compared with existing constipation-related instruments, the KAP-FC questionnaire has a different assessment purpose. Most constipation tools focus on patient symptoms, bowel function, severity, treatment response, or quality of life^22,23, whereas this questionnaire is intended to assess health professionals’ knowledge, attitudes, and practices in adult FC care. General nursing competency tools can evaluate broader professional ability, but they are not designed to identify FC-specific gaps, such as knowledge of diagnostic criteria, risk-factor assessment, non-pharmacological guidance, laxative-related observation, medication adherence, and psychological support^24,25. These FC-related care elements are clinically relevant, as current constipation management includes pharmacological treatment decisions as well as nursing-led or non-pharmacological interventions such as dietary guidance, activity support, bowel habit training, and patient education^8,9. Therefore, the KAP-FC questionnaire may be used as a focused assessment tool for identifying FC-related training needs among nurses and other health professionals, rather than as a direct measure of patient outcomes or clinical effectiveness.

The use of the KAP framework was appropriate for this work because adult FC care depends on more than knowledge alone. Health professionals need to understand diagnostic criteria, risk factors, treatment principles, and medication-related issues, but they also need to recognize their role in FC care and apply this knowledge in routine assessment, patient education, bowel habit guidance, medication observation, and follow-up^26,27. Recent constipation-related guidelines also emphasize that treatment should be based on symptom evaluation, lifestyle and dietary measures, and appropriate pharmacological management, further supporting the need to assess both knowledge and clinical practice²⁵. A recent KAP-based nursing assessment study used the knowledge-attitude-practice structure to evaluate nurses’ assessment ability across delirium subtypes, supporting the use of this framework when both professional cognition and clinical behavior need to be assessed²⁷. In the present study, the three KAP domains provided the theoretical structure, while EFA further separated the retained items into more specific content areas within these domains²⁸.

Several protocol steps may also improve reproducibility. First, the semi-structured interviews helped identify clinically relevant item content before expert consultation. Second, the Delphi process provided a structured method for item revision based on expert ratings and comments. Third, the pre-test allowed the research team to check item comprehensibility, completion time, and administration feasibility before the formal survey. Fourth, quality-control procedures, including standardized instructions, online response-time limits, IP restriction, and on-site checking of paper questionnaires, reduced avoidable problems during data collection. These details are important for future users who wish to repeat or adapt the protocol, because questionnaire development often fails not because of the final statistical analysis but because the early item generation and data collection steps are insufficiently controlled.

The protocol can be modified for different clinical settings. In hospitals with fewer gastroenterology resources, local expert interviews may need to include nurses from geriatrics, neurology, cardiology, surgery, rehabilitation, and long-term care, because FC care is not limited to gastrointestinal units. In primary care or community settings, some items may require wording adjustments to align with the local scope of practice, especially those related to medication observation, patient follow-up, and referral. For digital surveys, duplicate-response control and completion-time review should be retained, while paper surveys require immediate completeness checking. If the questionnaire is used in other regions or among other health professional groups, further content review, pre-testing, and confirmatory factor analysis should be performed before routine use.

Several limitations should be acknowledged. First, this study provides preliminary evidence of the KAP-FC questionnaire's reliability and validity. However, the present validation focused on questionnaire development and psychometric evaluation, and the effect of applying this tool in routine FC management has not yet been examined. Future studies may further assess whether KAP-FC-guided training or quality-improvement programs can improve FC-related care processes and patient outcomes. Second, the Cronbach’s α values showed good internal consistency. Nevertheless, high internal consistency may also indicate partial similarity between some items. Future studies may examine item performance in larger, more diverse samples to determine whether the questionnaire can be refined while maintaining its content coverage. Third, the sample was mainly drawn from tertiary hospitals in Jiangsu Province. Although this sample was adequate for preliminary psychometric testing, further validation in primary healthcare institutions, hospitals from different regions, and other health professional groups would help confirm the broader applicability of the KAP-FC questionnaire. Fourth, the factor structure was evaluated using exploratory factor analysis, content validity, and reliability testing. Confirmatory factor analysis was not performed in the present study. Future studies using independent samples may further verify the stability of the factor structure. Fifth, this study did not examine the association between nurses’ KAP-FC scores and patient-level outcomes. Further longitudinal studies may explore whether KAP-FC scores are associated with patient quality of life, treatment adherence, healthcare costs, or the effectiveness of FC-related nursing interventions.

The KAP-FC questionnaire was developed based on the KAP framework and demonstrated promising preliminary reliability and validity for assessing health professionals’ knowledge, attitudes, and practices regarding adult FC care. It may provide a useful assessment tool for identifying FC-related training needs and supporting nursing quality evaluation. However, further studies are needed to confirm its factor structure, predictive validity, and value in improving FC management and patient outcomes.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Delphi expert consultation forms	N/A	N/A	Used for two-round expert scoring and iterative revision.
Initial 30-item draft questionnaire	N/A	N/A	Used as the initial instrument for item generation and expert review.
Online questionnaire	N/A	N/A	Used for large-scale data collection.
Paper questionnaire	N/A	N/A	Used for paper-based data collection.
Pretest questionnaire	N/A	N/A	Completed by 30 nurses to assess item clarity.
Revised questionnaire (post-Delphi)	N/A	N/A	Used for pilot testing.
SPSS Statistical Software	IBM Corp., Armonk, NY, USA	Version 23.0	Used for statistical analyses including EFA and reliability testing.