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R Clin Pharm 2024; 2(1): 6-17

Published online June 30, 2024 https://doi.org/10.59931/rcp.24.0002

Copyright © Asian Conference On Clinical Pharmacy.

Community Pharmacists’ Knowledge, Attitudes, Perceptions, and Practices on the Management of Common Menstrual Problems: Development and Validation of a Questionnaire Tool

Nur Diyanah Hasanah Mohammad Ashraf , Nur Aizati Athirah Daud

School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Gelugor, Pulau Pinang, Malaysia

Correspondence to:Nur Aizati Athirah Daud
E-mail aizati@usm.my
ORCID
https://orcid.org/0000-0003-4336-9468

Received: February 9, 2024; Revised: February 25, 2024; Accepted: March 9, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Menstrual health problems affect over a third of women worldwide, making them a global public health concern. However, both the public and healthcare professionals often lack knowledge about the issue, and cultural and religious beliefs can contribute to the stigmatization of menstrual health. As a result, many women do not receive appropriate treatment. Negative attitudes and perceptions from healthcare workers when handling such cases can also prevent these issues from being taken seriously, further hindering care. Because community pharmacists play a key role in managing menstrual problems in Malaysia, a questionnaire was designed to assess their knowledge, attitudes, perceptions, and practices.
Methods: Content validation and face validation were performed, enlisting expert panels to discuss the relevance, clarity, and comprehensiveness of each item. The questionnaire was designed using Google Forms and distributed online via email and WhatsApp®.
Results: The results of the reliability test using Cronbach’s alpha showed that all four domains of the questionnaire had acceptable alpha values. The highest alpha value was 0.835 (perception), while the lowest was 0.511 (practice). The alpha value for the knowledge domain was 0.670, and the attitude domain achieved an alpha of 0.621. Although the alpha values of all four domains fell into the acceptable range, improvements were suggested for the practice domain to increase its alpha value, along with the questionnaire’s overall reliability.
Conclusion: This study resulted in the development of a reliable, validated survey tool to evaluate the level of knowledge among community pharmacists in Malaysia regarding menstrual health problems, the attitudes toward and perceptions of the management of menstrual health problems within the healthcare system, and practices for handling cases related to menstrual health problems.

KeywordsCommunity pharmacists; Menstrual problems; Questionnaire; Validation; Reliability; Malaysia

Menstrual health problems, such as dysmenorrhea, premenstrual syndrome, menorrhagia, and others, are considered as a global public health concern whereby according to research, around 50% to 80% of women worldwide experienced dysmenorrhea [1]. These menstrual health problems do affect women’s social life and their ability to carry out their responsibilities in a negative manner [2]. Despite this, many women still do not receive appropriate treatment, largely because menstrual problems are not as prioritized as other health concerns like diabetes or chronic heart disease whereby for the diseases mentioned in the latter, there are updated clinical practice guidelines published by the Ministry of Health of Malaysia unlike menstrual problems. This lack of research on menstrual health makes it difficult for healthcare workers to accurately assess risk factors and diagnose menstrual-related conditions [3]. The difficulty faced by women with menstrual health problems does not end here since there are reports stating that some medical practitioners dismiss and do not take women who present symptoms associated with menstruation seriously by saying “that’s just how it is” [4]. To add on, some religious and cultural beliefs have stigmatised menstruation and conceptualised it as something that is “impure” or “dirty” and a matter deemed appropriate to be kept very private [5-7]. Due to this, any issues surrounding menstruation would often be swept under the rug instead of being addressed as needed. Lack of understanding from healthcare professionals on the patients’ religious or cultural beliefs on menstrual issues may also form prejudice against these patients [8]. Since community pharmacists play an important role in patient counselling and medication management, this study aims to create a validated and reliable questionnaire that measures community pharmacists’ knowledge, attitudes, perceptions, and practices regarding menstrual health problems in Malaysia.

Study Design and Setting

This study was a cross-sectional study using a self-completed online questionnaire via Google Forms whereby the respondents remained anonymous. This is a pilot study and was done in two phases: Phase 1 involved the development of the study instrument consists of content and face validation of the questionnaire; and Phase 2 involved the data collection for validation of the ability of the study instrument in achieving the objectives of this study whereby the knowledge, attitude, perception, and practice on the management of menstrual health problems among Malaysian community pharmacists are assessed.

In Phase 1, a total of three expert panels who were a pharmacist, a senior consultant obstetrician and gynaecologist, and a medical lecturer were involved in the content validation process while a total of 10 community pharmacists were involved in the face validation of the questionnaire. For the content validation phase, the content validity item indices used were item-level content validity index (I-CVI), scale-level content validity index based on the average method (S-CVI/Ave) and scale-level content validity index based on the universal agreement method (S-CVI/UA) [9]. Meanwhile, for the face validation phase, indices used are the item-level face validity index (I-FVI), scale-level face validity index based on the average method (S-FVI/Ave) and scale-level face validity index based on the universal agreement method (S-FVI/UA) [10]. These indices are shown in Fig. 1 and 2.

Figure 1. The definition and formula of I-CVI, S-CVI/Ave and S-CVI/UA.
Figure 2. The definition and formula of I-FVI, S-FVI/Ave and S-FVI/UA.

A scoring system ranging from 1 to 4 was used to evaluate the relevancy of each item during the content validation process. A score of 1 indicated the item was not relevant, 2 suggested the item required revision, 3 indicated the item was relevant but needed minor revision, and 4 signified the item was very relevant. Items scored as 1 or 2 were recorded with a score of 0, while items scored as 3 or 4 were recorded with a score of 1.

The same scoring system was applied during the face validation phase, with scores assessing the clarity and understandability of each item. A score of 1 indicated the item was not clear or understandable, 2 suggested it was somewhat clear, 3 indicated it was clear and understandable, and 4 signified it was very clear and understandable. Similarly, items scored as 1 or 2 were recorded with a score of 0, while scores of 3 or 4 were recorded as 1, consistent with the content validation process.

This study was conducted fully online using the Google Form whereby it was distributed via email and Whatsapp® as well as being distributed physically around the island area of Penang by the researcher. The community pharmacists were initially approached via email and Whatsapp® for recruitment in the pilot study whereby their emails and pharmacies’ phone numbers were available online. Some of the community pharmacists working in the island area of Penang were approached directly by the researcher whereby the subjects filled in the Google Form by scanning the QR code provided by the researcher.

Fig. 1 displays the definition and formula of I-CVI, S-CVI/Ave and S-CVI/UA [9] as recommended by researches done [11-13].

Fig. 2 shows the definition and formula of I-FVI, S-FVI/Ave and S-FVI/UA [10,14].

Study Population

The study population consists of community pharmacists who are currently working in Malaysia. Community pharmacists above 18 years old and are able to read and write in English as well as comprehend the language are included in this study whereas, those who have retired and do not have at least a degree in pharmacy to work as a community pharmacist in Malaysia are excluded from this study.

Sample Size

According to statistics by the Malaysian Pharmacists Society, there are a total of 12,294 pharmacists available in Malaysia as of 2016. A total of 57.89% (7,117) of the population are in the public sector while the other 42.11% (5,177) are in the private sector [15]. According to the latest statistics provided by the Ministry of Health of Malaysia (MOH), there are 1,854 community pharmacists in Malaysia as of 2011. Using the Cochran population size formula, a total of 195 community pharmacists should be recruited in a full-scale study. However, a total of 215 subjects which is an additional 10% of the calculated value is recommended to be recruited to cover for any dropouts. Since this is just a pilot study, 10% of 215 subjects were calculated instead which means that the sample size would be 20 to 30 respondents. In this study, a total of 30 respondents were successfully recruited. The calculation done using the Cochran population size formula [16], which is n=[Z2×P (1–P)]/e2. Where, n=sample size; Z=statistic for level of confidence; P=expected % population proportion; and e=level of precision. A 95% confidence level was chosen, with Z-score of 1.96, and statistical significance was set at 0.05.

Study Instrument

This study instrument is a newly self-designed instrument consisting of five sections; Section A: demographic background, Section B: community pharmacists’ knowledge on definition, signs and symptoms, and management for common menstrual problems in Malaysia, Section C: community pharmacists’ attitude towards the management of common menstrual problems in Malaysia, Section D: community pharmacists’ perception on the management of common menstrual problems in Malaysia, and Section E: community pharmacists’ practice on the management of common menstrual health problems in Malaysia with the exception of the Section C of the instrument being adapted and improvised from previous research [17].

Section A consists of questions asking about the respondents’ gender, age, state that they are currently working in, ethnicity, education level, qualification (provisionally registered pharmacist or fully registered pharmacist), position (permanent pharmacist or locum pharmacist), ownership of the pharmacy they are working at, years of working experience, whether they have ever attended a course or received any training on the management of menstrual health problems, and if yes, when was it.

For Section B, a total of 11 questions were asked in relation to menstrual problems to assess the respondents’ knowledge of the definition, signs and symptoms, and management of common menstrual problems in Malaysia. The respondents were given three options and they are; ‘True’, ‘False’ or ‘I don’t know’. A mark was given if the respondents answered correctly, and none would be given if the respondents answered wrongly or decided to choose the “I don’t know” option. The questions or items are listed below:

1. Dysmenorrhea is defined as absence of menstrual periods.

2. Some of the symptoms experienced by a person with dysmenorrhea are bloating, irritability, headache, and low back pain.

3. Premenstrual syndrome refers to physical and psychological symptoms occurring prior to menstruation.

4. One of the symptoms experienced by a person with premenstrual syndrome would be change in appetite.

5. Menorrhagia is defined as heavy bleeding.

6. A symptom that a person with menorrhagia may experience would be lack of breast development.

7. Amenorrhea means painful cramps during menstruation.

8. Signs that a person has amenorrhea would be having menstrual periods lasting more than 7 days or a menstrual flow with blood clots the size of a quarter or larger.

9. Oligomenorrhea refers to people having infrequent menstrual periods.

10. In the management of menstrual problems, lifestyle changes could also help relieve the symptoms to a certain extent, aside from medical intervention.

11. The most common over-the-counter (OTC) drugs given to relieve menstrual cramps are paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs).

After calculating the total points of each respondent, the respondents’ knowledge were categorised into any of these three categories using Bloom’s cutoff point: 1) High-level knowledge (80–100%), 2) Moderate-level knowledge (60–79%), and 3) Low-level knowledge (less than 60%) [18].

Section C assessed the attitude of the respondents towards the management of common menstrual problems in Malaysia. In this section, 10 items are given in statement form and the respondents must choose on a 5-point Likert scale: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and 5=strongly agree. A scale rating of 4 or 5 indicates a positive attitude, a rating of 3 reflects a neutral attitude, and a rating of 1 or 2 represents a negative attitude. The items are as listed in which the questionnaire was adapted and improvised from the research [17] and items are as listed below:

1. Pharmacists need to know the appropriate medicine to relieve common menstrual problems.

2. Pharmacists should know non-pharmacological recommendations to manage symptoms of common menstrual problems whenever applicable.

3. Pharmacists need to assess the medication history and medical background (diagnosis, current disease’s prognosis) of a patient with a common menstrual problem in order to provide the best solution.

4. Pharmacists need to assess the lifestyle of a patient with common menstrual problem in order to provide the best solution.

5. Pharmacists need to assess the family history of a patient with a common menstrual problem in order to provide the best solution.

6. Pharmacists should provide necessary information on the medication being dispensed to treat common menstrual problems such as its indication and side effects.

7. Pharmacists need to know the suitable way to educate patients with common menstrual problems without offending their cultural beliefs.

8. Pharmacists need to know when to refer to a doctor for confirmation of diagnosis.

9. Pharmacists should not be prejudiced towards patients who lack knowledge of their menstrual cycle and common menstrual problems.

10. Pharmacists should be willing to plan out a treatment regimen to help patients with common menstrual problems.

Section D comprises nine statements. Respondents are required to rate these statements on a 5-point Likert scale, ranging from one to five, similar to the format used in Section C. A higher score suggests that respondents acknowledge the issues on the management of common menstrual problems indicating that they have good perception regarding this matter. A score of 80% to 100% shows good perception, 60% to 79% shows moderate perception, while a score of less than 60% shows poor perception according to the Bloom’s cutoff point. For the final item which is the 9th item, an open-ended statement was given for respondents to provide recommendations for enhancing the management of common menstrual issues. The items in this section are listed below:

1. Some healthcare professionals such as doctors, nurses, and pharmacists tend to dismiss patients having common menstrual problems.

2. Most patients having common menstrual problems are not taken seriously by healthcare professionals.

3. Most patients with common menstrual issues prefer to seek a second opinion from another source aside from healthcare professionals.

4. Most patients are reluctant to get any medical intervention when it comes to common menstrual problems as they find it embarrassing.

5. Insufficient information pertaining to menstrual health issues is provided for women who are experiencing common menstrual problems.

6. The media’s portrayal of menstrual symptoms as normal leads many patients to assume that their own symptoms are also normal.

7. Due to a lack of early intervention by healthcare professionals, many women suffer from serious complications of menstrual health issues, such as infertility due to untreated endometriosis.

8. There is a need for healthcare professionals to enhance their management of common menstrual problems.

For Section D, a total of six items are provided with a 5-point Likert scale: 1=never, 2=rarely, 3=sometimes, 4=often and 5=always. The final item, the 6th in the section, is an open-ended question designed as a follow-up to the 5th item. Respondents are asked to explain the reason(s) for referring patients with menstrual health issues to a physician, if applicable. The items in this section are as listed below:

1. How often do you manage a patient having menstrual health problems on a monthly basis?

2. How often do you consider patients’ complaints about their menstrual health problems to be significant?

3. Patients comply with my recommendations regarding medications or lifestyle modifications required for the management of their menstrual health problems.

4. Do you keep records of patient’s medication history for the treatment of their menstrual health issues?

5. How often do you refer patients with menstrual health problem(s) to consult a doctor?

Statistical Analysis

After the number of respondents reached to 30 for the pilot study, the data collected was analysed using SPSS version 27 as well as using Excel for the reliability test; Cronbach’s alpha test. If the value exceeds 0.6, the questionnaire is reliable [19].

Ethical Approval

This study has been reviewed and granted approval for implementation by the Jawatankuasa Etika Penyelidikan Manusia Universiti Sains Malaysia (JEPeM-USM) on the 1st of February 2023. A study protocol code was assigned for this study which is USM/JEPeM/23010112, which is valid from 1st of February 2023 until 31st January 2024.

Content Validation

In the development of the study instrument, content validation by expert panels was performed in the first phase of the pilot study. Three experts consisting of a pharmacist, a senior consultant obstetrician and gynaecologist, and a medical lecturer were involved in the content validation phase of this study.

Table 1 represents the value of the content validation index by the three expert panels. The value of I-CVI should be 1, so, any items with an I-CVI of less than 1 were revised [9,11,12].

Table 1 The value of content validation index by the three expert panels

ItemExpert 1Expert 2Expert 3Experts in agreementI-CVIUA
1111311
2111311
3111311
4111311
5111311
6111311
7111311
8111311
911020.670
10111311
11111311
12111311
13111311
14111311
15111311
1611020.670
17111311
18111311
19111311
20111311
21111311
2211020.670
23111311
24111311
25111311
26111311
27111311
28111311
29111311
30111311
31111311
32111311
33111311
3411020.670
35111311
36111311
37111311
38111311
3911020.670
4011020.670
4111020.670
42111311
43111311
44111311
45111311
46111311
47111311
Proportion in relevance110.85S-CVI/Ave0.95
S-CVI/UA0.85

I-CVI=item-level content validity index, UA=universal agreement, S-CVI/Ave=scale-level content validity index, S-CVI/UA=scale-level content validity index based on the universal agreement method.


The rating score consists of scores 1, 2, 3, and 4. A score of 1 suggests that the items are not relevant, a score of 2 suggests that the items need some revision, a score of 3 suggests that the items are relevant but require minor revision, while a score of 4 suggests that the items are very relevant. If a score of 1 or 2 is given to an item, a score of 0 for the item would be recorded. If a score of 3 or 4 is given to an item, a score of 1 for the item would be recorded which was done as such in the table above. As mentioned, according to the research [9,11,12], items scoring less than 1 should be revised. Hence, items 9, 16, 22, 34, 39, 40, and 41 were revised since the I-CVI score were 0.67. According to research [9], the value of S-CVI/Ave of 0.95 and S-CVI/UA of 0.85 respectively are higher than the acceptable sample value given which is 0.80.

Face Validation

After the content validation phase, the questionnaire tool underwent a face validation phase in which the revised questionnaire was distributed to 10 community pharmacists to ensure that the items in the questionnaire were clear and comprehensive. According to the research [20] which was conducted online, the I-FVI would be the determinant as to whether the questionnaire’s face validity index has met a satisfactory level in which the I-FVI value should be at least 0.80 [20]. Table 2 shows the value of the face validation index by the 10 raters.

Table 2 The value of face validation index by the 10 raters

ItemRater 1Rater 2Rater 3Rater 4Rater 5Rater 6Rater 7Rater 8Rater 9Rater 10Raters in agreementI-FVIUA
111111111111011
211111111111011
311111111111011
411111111111011
511111111111011
611111111111011
7011111101180.80
8001111111180.80
911111111111011
1011111111111011
1111111111111011
1211111111111011
1311111111111011
1411111111111011
15111111101190.90
16111111101190.90
17111111101190.90
1811111111111011
19111111101190.90
2011111111111011
21011111101180.80
22111111101190.90
2311111111111011
2411111111111011
25111111101190.90
26111111101190.90
27111110101180.80
2811111111111011
2911111111111011
3011111111111011
31111110101180.80
3211111111111011
33111110111190.90
34011110111180.80
35111110101180.80
36111111101190.90
37011110101170.70
38011110101170.70
39111110111190.90
4011111111111011
41011111111190.90
4211111111111011
43111110111190.90
44011111111190.90
4511111111111011
4611111111111011
4711111111111011
S-FVI/Ave0.97
Proportion clarity and comprehension0.830.981110.8110.6811S-FVI/UA0.53
Average proportion of items judged clarity and comprehension by the 10 raters0.93

I-FVI=item-level face validity index, UA=universal agreement, S-FVI/Ave=scale-level face validity index, S-FVI/UA=scale-level face validity index based on the universal agreement method.


The scoring used in this face validation ranges from a score of 1 to 4. A score of 1 would mean that the item is not clear and understandable, a score of 2 would mean that the item is somewhat clear and understandable, a score of 3 would mean that the item is clear and understandable, and a score of 4 would mean that the item is very clear and understandable. If the score given for an item is 1 or 2, a score of 0 for the item would be recorded while a scoring of either 3 or 4 for an item would receive a score of 1 as such recorded in Table 2. The calculation for the Face Validation Index was done in accordance with Yusoff [10] and the value set for the I-FVI, S-FVI/Ave, and S-FVI/UA to be acceptable is 0.80 [20]. This concludes that the level of clarity and comprehension for the questionnaire is acceptable for all items except for items 37 and 38. Only the S-FVI/UA was below 0.80. With the guidance of the respondents’ comments, the items have been reviewed thoroughly.

Cronbach’s Alpha Reliability Test

Cronbach’s Alpha Reliability Test is done to ensure that the questionnaire to be used in a full-scale study is reliable. Based on the analysis done using SPSS, the coefficient of Cronbach’s Alpha for the subscales of Community Pharmacists’ Knowledge on Definition, Signs and Symptoms, and Management for Common Menstrual Problems in Malaysia as well as Community Pharmacists’ Attitude towards the Management of Common Menstrual Problems in Malaysia and Community Pharmacists’ Perception on the Management of Common Menstrual Problems in Malaysia are 0.670, 0.621 and 0.835 respectively which are considered to have acceptable reliability level [19]. Although the coefficient of Cronbach’s Alpha for the subscale of Community Pharmacists’ Practice on the Management of Common Menstrual Health Problems in Malaysia is 0.511 which is lower than 0.600, according to another research [21], a value of coefficient of Cronbach’s Alpha more than 0.5 is still acceptable. The low value for the last subscale may be due to the low number of items provided for the section. Table 3 shows the reliability analysis on four subscales of the questionnaire and Table 4 shows the Cronbach’s Alpha value if items in Section E of the questionnaire were deleted.

Table 3 Reliability analysis on four subscales of the questionnaire

Internal consistency
Total respondents (n=30)Cronbach’s alpha, αNumber of items
Section B: community pharmacists’ knowledge on definition, signs and symptoms, and management for common menstrual problems in Malaysia0.67011
Section C: community pharmacists’ attitude towards the management of common menstrual problems in Malaysia0.62110
Section D: community pharmacists’ perception on the management of common menstrual problems in Malaysia0.8358
Section E: community pharmacists’ practice on the management of common menstrual health problems in Malaysia0.5115

Table 4 Cronbach’s alpha value if item in Section E of the questionnaire was deleted

ItemCronbach’s alpha
if item deleted
10.461
20.378
30.571
40.467
50.358

The instrument developed was sent out to three expert panels for content validation. Their feedbacks were taken into account and several changes were made to the questionnaire. In terms of the relevancy of the items to the study, items 9, 16, 22, 34, 39, 40, and 41 were revised since the I-CVI score was 0.67. For item 9, which is “Have you ever attended a course or received any training on the management of menstrual health problems? (Yes or No)”, it was retained since it was deemed to be relevant to the knowledge and also how a community pharmacist practices the management of common menstrual problems in Malaysia. However, a follow-up question was added to ask when the participant received such training to increase its relevance.

Items 16 and 22, which assess pharmacists’ knowledge of menstrual health, were redesigned based on expert input. All items in this section were changed to a True/False/I don’t know format to create a more comprehensive assessment of knowledge. For instance, the original question “Dysmenorrhea is defined as?” was restructured to “Dysmenorrhea is defined as absence of menstrual periods,” with True/False/I don’t know answer options. The new items for this section now focus on the participants’ knowledge of definition, signs and symptoms, and management of common menstrual problems in Malaysia instead, as suggested by the expert panel.

For item 34, which is “Most patients having menstrual health problems are not taken seriously by healthcare professionals” having a five-Likert scale answer options of “strongly agree, agree, neutral, disagree, or strongly disagree” was retained since the lack of seriousness of healthcare professionals towards women having menstrual health problems have been acknowledged as an ongoing issue which needs to be addressed. The opinion of community pharmacists, who are also healthcare professionals, is highly relevant for gaining a broader perspective on this problem and identifying potential improvements. As for item 39 and 40, which are “Due to a lack of early intervention by healthcare professionals, many women suffer from serious complications of menstrual health issues, such as infertility due to untreated endometriosis” and “There is a need for healthcare professionals to enhance their management of menstrual health problems” respectively, both using a five-point Likert scale similar to item 34 were also retained since the majority of the expert panels agreed that these items were relevant and important for inclusion in the questionnaire. Lastly, item 41 which asks for the participants’ recommendations for enhancing the management of menstrual health issues was also retained, as input from healthcare professionals could provide valuable insights.

After incorporating these changes, the updated questionnaire was distributed to 10 community pharmacists to assess clarity and comprehensiveness. According to Andrew et al. [20], the I-FVI value of at least 0.80 is considered as acceptable. Only items 37 and 38 which are “Insufficient information pertaining to menstrual health issues is provided for women who are experiencing common menstrual problems (strongly agree, agree, neutral, disagree, strongly disagree)” and “The media’s portrayal of menstrual symptoms as normal leads many patients to assume that their own symptoms are also normal (strongly agree, agree, neutral, disagree, strongly disagree)” respectively, have a score of 0.7. Although the S-FVI/UA is lower than 0.8, the significant value to indicate that the instrument is indeed clear and comprehensive would be the S-FVI/Ave value in which the value is 0.97 [22]. Furthermore, including the item on insufficient information regarding menstrual health problems is essential, as public knowledge on these issues can empower the affected individuals to ask informed questions and explore treatment options, thereby actively participating in their own healthcare [23]. Additionally, the item addressing the media’s portrayal of all menstrual symptoms as “normal” is valuable because repeated media exposure on the same topic often leads consumers to accept said information at face value [24]. This could mislead the public into believing that their symptoms are typical, preventing them from recognizing more serious issues. Such misconceptions could lead to bigger health problems in the future.

Some respondents provided feedback for improving the questionnaire, suggesting simpler sentences for better understanding and questioning the relevance of certain items. Comments included concerns like the impact of “Ownership of pharmacy” on managing menstrual disorders and whether “Menstrual Disorder” would be more suitable than “Menstrual Problems” for a professional audience. Additionally, one respondent noted that tracking period medication falls outside a community pharmacist’s role, as severe cases are typically referred to doctors. After further discussion between the researchers, no changes were made to items 37 and 38 because the structure of the sentences was necessary for the intended message to be conveyed to the respondents of the pilot study. Furthermore, the items in question were retained, as most respondents acknowledged their relevance. For example, “Ownership of pharmacy” was seen as impactful enough to remain, and “Menstrual Problems” was considered more appropriate terminology. Additionally, keeping a record of patients’ medication for period to be relevant to the study whereby according to Community Pharmacy Benchmarking Guideline 2016 [25], the community pharmacist should maintain patient medication record in the pharmacy “to check the progress of the treatment and provide information on the medical history of the patient”.

The reliability test is a vital part of producing a sound questionnaire in which the word “reliability” is defined as “an extent to which a questionnaire, test, observation or any measurement procedure produces the same results on repeated trials” [26]. According to research [27], one of the ways that a reliability test can be done is via internal consistency reliability which is measured using the Cronbach’s Alpha coefficient as such being done in the development of this questionnaire. The acceptable values of alpha differ according to different reports. The acceptable value of Cronbach’s Alpha starts with 0.6 [19]. Another report states that the Cronbach’s Alpha value of 0.5 is also considered acceptable [21]. The suggested maximum alpha value is 0.90 since an alpha value higher than 0.9 may suggest the redundancy of certain items whereby the same question is tested but under a different guise [28,29].

The internal consistency of the knowledge, attitude and perception domains are 0.670, 0.621, and 0.835 respectively which are considered to have acceptable reliability level since they exceed the alpha value of 0.6 [19]. The last domain which is the perception domain has an alpha value of 0.511 which is still acceptable according to research [21]. However, some items in the domain should be revised or discarded so that the alpha value can increase to at least 0.6 [28]. The low value for the last subscale could either be due to the low number of questions for the section, heterogeneous constructs, or poor inter-relatedness between items. Based on the analysis done using SPSS, if item 3 of this section was deleted, which is “Patients comply with my recommendations regarding medications or lifestyle modifications required for the management of their menstrual health problems” having a five-Likert scale of ‘never’, ‘rarely’, ‘sometimes’, ‘often’ or ‘always’ as choices of option, the Cronbach’s alpha value would increase from 0.511 to 0.571 as shown in Table 4. Since the number of items for this section is already low, and an alpha value of 0.511 is considered to be acceptable, item 3 was retained. To improve the Cronbach’s alpha value of the final section of the instrument, the deletion of item 3 is suggested and two new items with high inter-relatedness to the existing ones should be added. This approach would enhance the internal consistency of the questionnaire. Adding at least two more close-ended questions is considered appropriate, as having low number of items can lower the alpha value [30]. The two newly proposed items are “How often does your patients’ religious or cultural beliefs affect the management provided to patients with menstrual health problems?” and “How often do you dispense non-pharmacological items as the sole treatment for menstrual health problems?”. These additions are expected to improve the reliability and provide deeper insights into the role of religious or cultural factors and treatment approaches in the management of menstrual health issues.

This study has several limitations. Firstly, the majority of respondents were from Penang, which may not represent the broader population of community pharmacists in Malaysia. If the aforementioned limitation were to happen in a full-scale study, the results of said study may be negatively affected. Secondly, there is potential recall bias for the questions requiring respondents to recall how often they manage a patient having menstrual health problems every month, or how often they consider patients’ complaints about their menstrual health problems to be significant, or how often do they refer patients with menstrual health problem(s) to consult a doctor. Lastly, the limited number of questions may have negatively impacted the Cronbach’s Alpha value for the last section of the instrument.

Despite these limitations, the instrument’s established validity and reliability support the feasibility of conducting a full-scale study in the future. This tool would be crucial in helping to understand issues faced by both community pharmacists and the public in managing common menstrual health problems on a deeper level which would ultimately lead to a more efficient and positive outcome in doing so for both parties involved.

In conclusion, the study successfully developed a valid and reliable questionnaire tool. With demonstrated content validity and reliability, this tool can be used in future full-scale studies to measure community pharmacists’ management of common menstrual health problems in Malaysia.

Authors would like to acknowledge expert panels who were involved in the content validation, and the participants of the pilot study.

No potential conflict of interest relevant to this article was reported.

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Article

Original Article

R Clin Pharm 2024; 2(1): 6-17

Published online June 30, 2024 https://doi.org/10.59931/rcp.24.0002

Copyright © Asian Conference On Clinical Pharmacy.

Community Pharmacists’ Knowledge, Attitudes, Perceptions, and Practices on the Management of Common Menstrual Problems: Development and Validation of a Questionnaire Tool

Nur Diyanah Hasanah Mohammad Ashraf , Nur Aizati Athirah Daud

School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Gelugor, Pulau Pinang, Malaysia

Correspondence to:Nur Aizati Athirah Daud
E-mail aizati@usm.my
ORCID
https://orcid.org/0000-0003-4336-9468

Received: February 9, 2024; Revised: February 25, 2024; Accepted: March 9, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Menstrual health problems affect over a third of women worldwide, making them a global public health concern. However, both the public and healthcare professionals often lack knowledge about the issue, and cultural and religious beliefs can contribute to the stigmatization of menstrual health. As a result, many women do not receive appropriate treatment. Negative attitudes and perceptions from healthcare workers when handling such cases can also prevent these issues from being taken seriously, further hindering care. Because community pharmacists play a key role in managing menstrual problems in Malaysia, a questionnaire was designed to assess their knowledge, attitudes, perceptions, and practices.
Methods: Content validation and face validation were performed, enlisting expert panels to discuss the relevance, clarity, and comprehensiveness of each item. The questionnaire was designed using Google Forms and distributed online via email and WhatsApp®.
Results: The results of the reliability test using Cronbach’s alpha showed that all four domains of the questionnaire had acceptable alpha values. The highest alpha value was 0.835 (perception), while the lowest was 0.511 (practice). The alpha value for the knowledge domain was 0.670, and the attitude domain achieved an alpha of 0.621. Although the alpha values of all four domains fell into the acceptable range, improvements were suggested for the practice domain to increase its alpha value, along with the questionnaire’s overall reliability.
Conclusion: This study resulted in the development of a reliable, validated survey tool to evaluate the level of knowledge among community pharmacists in Malaysia regarding menstrual health problems, the attitudes toward and perceptions of the management of menstrual health problems within the healthcare system, and practices for handling cases related to menstrual health problems.

Keywords: Community pharmacists, Menstrual problems, Questionnaire, Validation, Reliability, Malaysia

Body

Menstrual health problems, such as dysmenorrhea, premenstrual syndrome, menorrhagia, and others, are considered as a global public health concern whereby according to research, around 50% to 80% of women worldwide experienced dysmenorrhea [1]. These menstrual health problems do affect women’s social life and their ability to carry out their responsibilities in a negative manner [2]. Despite this, many women still do not receive appropriate treatment, largely because menstrual problems are not as prioritized as other health concerns like diabetes or chronic heart disease whereby for the diseases mentioned in the latter, there are updated clinical practice guidelines published by the Ministry of Health of Malaysia unlike menstrual problems. This lack of research on menstrual health makes it difficult for healthcare workers to accurately assess risk factors and diagnose menstrual-related conditions [3]. The difficulty faced by women with menstrual health problems does not end here since there are reports stating that some medical practitioners dismiss and do not take women who present symptoms associated with menstruation seriously by saying “that’s just how it is” [4]. To add on, some religious and cultural beliefs have stigmatised menstruation and conceptualised it as something that is “impure” or “dirty” and a matter deemed appropriate to be kept very private [5-7]. Due to this, any issues surrounding menstruation would often be swept under the rug instead of being addressed as needed. Lack of understanding from healthcare professionals on the patients’ religious or cultural beliefs on menstrual issues may also form prejudice against these patients [8]. Since community pharmacists play an important role in patient counselling and medication management, this study aims to create a validated and reliable questionnaire that measures community pharmacists’ knowledge, attitudes, perceptions, and practices regarding menstrual health problems in Malaysia.

METHODS

Study Design and Setting

This study was a cross-sectional study using a self-completed online questionnaire via Google Forms whereby the respondents remained anonymous. This is a pilot study and was done in two phases: Phase 1 involved the development of the study instrument consists of content and face validation of the questionnaire; and Phase 2 involved the data collection for validation of the ability of the study instrument in achieving the objectives of this study whereby the knowledge, attitude, perception, and practice on the management of menstrual health problems among Malaysian community pharmacists are assessed.

In Phase 1, a total of three expert panels who were a pharmacist, a senior consultant obstetrician and gynaecologist, and a medical lecturer were involved in the content validation process while a total of 10 community pharmacists were involved in the face validation of the questionnaire. For the content validation phase, the content validity item indices used were item-level content validity index (I-CVI), scale-level content validity index based on the average method (S-CVI/Ave) and scale-level content validity index based on the universal agreement method (S-CVI/UA) [9]. Meanwhile, for the face validation phase, indices used are the item-level face validity index (I-FVI), scale-level face validity index based on the average method (S-FVI/Ave) and scale-level face validity index based on the universal agreement method (S-FVI/UA) [10]. These indices are shown in Fig. 1 and 2.

Figure 1. The definition and formula of I-CVI, S-CVI/Ave and S-CVI/UA.
Figure 2. The definition and formula of I-FVI, S-FVI/Ave and S-FVI/UA.

A scoring system ranging from 1 to 4 was used to evaluate the relevancy of each item during the content validation process. A score of 1 indicated the item was not relevant, 2 suggested the item required revision, 3 indicated the item was relevant but needed minor revision, and 4 signified the item was very relevant. Items scored as 1 or 2 were recorded with a score of 0, while items scored as 3 or 4 were recorded with a score of 1.

The same scoring system was applied during the face validation phase, with scores assessing the clarity and understandability of each item. A score of 1 indicated the item was not clear or understandable, 2 suggested it was somewhat clear, 3 indicated it was clear and understandable, and 4 signified it was very clear and understandable. Similarly, items scored as 1 or 2 were recorded with a score of 0, while scores of 3 or 4 were recorded as 1, consistent with the content validation process.

This study was conducted fully online using the Google Form whereby it was distributed via email and Whatsapp® as well as being distributed physically around the island area of Penang by the researcher. The community pharmacists were initially approached via email and Whatsapp® for recruitment in the pilot study whereby their emails and pharmacies’ phone numbers were available online. Some of the community pharmacists working in the island area of Penang were approached directly by the researcher whereby the subjects filled in the Google Form by scanning the QR code provided by the researcher.

Fig. 1 displays the definition and formula of I-CVI, S-CVI/Ave and S-CVI/UA [9] as recommended by researches done [11-13].

Fig. 2 shows the definition and formula of I-FVI, S-FVI/Ave and S-FVI/UA [10,14].

Study Population

The study population consists of community pharmacists who are currently working in Malaysia. Community pharmacists above 18 years old and are able to read and write in English as well as comprehend the language are included in this study whereas, those who have retired and do not have at least a degree in pharmacy to work as a community pharmacist in Malaysia are excluded from this study.

Sample Size

According to statistics by the Malaysian Pharmacists Society, there are a total of 12,294 pharmacists available in Malaysia as of 2016. A total of 57.89% (7,117) of the population are in the public sector while the other 42.11% (5,177) are in the private sector [15]. According to the latest statistics provided by the Ministry of Health of Malaysia (MOH), there are 1,854 community pharmacists in Malaysia as of 2011. Using the Cochran population size formula, a total of 195 community pharmacists should be recruited in a full-scale study. However, a total of 215 subjects which is an additional 10% of the calculated value is recommended to be recruited to cover for any dropouts. Since this is just a pilot study, 10% of 215 subjects were calculated instead which means that the sample size would be 20 to 30 respondents. In this study, a total of 30 respondents were successfully recruited. The calculation done using the Cochran population size formula [16], which is n=[Z2×P (1–P)]/e2. Where, n=sample size; Z=statistic for level of confidence; P=expected % population proportion; and e=level of precision. A 95% confidence level was chosen, with Z-score of 1.96, and statistical significance was set at 0.05.

Study Instrument

This study instrument is a newly self-designed instrument consisting of five sections; Section A: demographic background, Section B: community pharmacists’ knowledge on definition, signs and symptoms, and management for common menstrual problems in Malaysia, Section C: community pharmacists’ attitude towards the management of common menstrual problems in Malaysia, Section D: community pharmacists’ perception on the management of common menstrual problems in Malaysia, and Section E: community pharmacists’ practice on the management of common menstrual health problems in Malaysia with the exception of the Section C of the instrument being adapted and improvised from previous research [17].

Section A consists of questions asking about the respondents’ gender, age, state that they are currently working in, ethnicity, education level, qualification (provisionally registered pharmacist or fully registered pharmacist), position (permanent pharmacist or locum pharmacist), ownership of the pharmacy they are working at, years of working experience, whether they have ever attended a course or received any training on the management of menstrual health problems, and if yes, when was it.

For Section B, a total of 11 questions were asked in relation to menstrual problems to assess the respondents’ knowledge of the definition, signs and symptoms, and management of common menstrual problems in Malaysia. The respondents were given three options and they are; ‘True’, ‘False’ or ‘I don’t know’. A mark was given if the respondents answered correctly, and none would be given if the respondents answered wrongly or decided to choose the “I don’t know” option. The questions or items are listed below:

1. Dysmenorrhea is defined as absence of menstrual periods.

2. Some of the symptoms experienced by a person with dysmenorrhea are bloating, irritability, headache, and low back pain.

3. Premenstrual syndrome refers to physical and psychological symptoms occurring prior to menstruation.

4. One of the symptoms experienced by a person with premenstrual syndrome would be change in appetite.

5. Menorrhagia is defined as heavy bleeding.

6. A symptom that a person with menorrhagia may experience would be lack of breast development.

7. Amenorrhea means painful cramps during menstruation.

8. Signs that a person has amenorrhea would be having menstrual periods lasting more than 7 days or a menstrual flow with blood clots the size of a quarter or larger.

9. Oligomenorrhea refers to people having infrequent menstrual periods.

10. In the management of menstrual problems, lifestyle changes could also help relieve the symptoms to a certain extent, aside from medical intervention.

11. The most common over-the-counter (OTC) drugs given to relieve menstrual cramps are paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs).

After calculating the total points of each respondent, the respondents’ knowledge were categorised into any of these three categories using Bloom’s cutoff point: 1) High-level knowledge (80–100%), 2) Moderate-level knowledge (60–79%), and 3) Low-level knowledge (less than 60%) [18].

Section C assessed the attitude of the respondents towards the management of common menstrual problems in Malaysia. In this section, 10 items are given in statement form and the respondents must choose on a 5-point Likert scale: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and 5=strongly agree. A scale rating of 4 or 5 indicates a positive attitude, a rating of 3 reflects a neutral attitude, and a rating of 1 or 2 represents a negative attitude. The items are as listed in which the questionnaire was adapted and improvised from the research [17] and items are as listed below:

1. Pharmacists need to know the appropriate medicine to relieve common menstrual problems.

2. Pharmacists should know non-pharmacological recommendations to manage symptoms of common menstrual problems whenever applicable.

3. Pharmacists need to assess the medication history and medical background (diagnosis, current disease’s prognosis) of a patient with a common menstrual problem in order to provide the best solution.

4. Pharmacists need to assess the lifestyle of a patient with common menstrual problem in order to provide the best solution.

5. Pharmacists need to assess the family history of a patient with a common menstrual problem in order to provide the best solution.

6. Pharmacists should provide necessary information on the medication being dispensed to treat common menstrual problems such as its indication and side effects.

7. Pharmacists need to know the suitable way to educate patients with common menstrual problems without offending their cultural beliefs.

8. Pharmacists need to know when to refer to a doctor for confirmation of diagnosis.

9. Pharmacists should not be prejudiced towards patients who lack knowledge of their menstrual cycle and common menstrual problems.

10. Pharmacists should be willing to plan out a treatment regimen to help patients with common menstrual problems.

Section D comprises nine statements. Respondents are required to rate these statements on a 5-point Likert scale, ranging from one to five, similar to the format used in Section C. A higher score suggests that respondents acknowledge the issues on the management of common menstrual problems indicating that they have good perception regarding this matter. A score of 80% to 100% shows good perception, 60% to 79% shows moderate perception, while a score of less than 60% shows poor perception according to the Bloom’s cutoff point. For the final item which is the 9th item, an open-ended statement was given for respondents to provide recommendations for enhancing the management of common menstrual issues. The items in this section are listed below:

1. Some healthcare professionals such as doctors, nurses, and pharmacists tend to dismiss patients having common menstrual problems.

2. Most patients having common menstrual problems are not taken seriously by healthcare professionals.

3. Most patients with common menstrual issues prefer to seek a second opinion from another source aside from healthcare professionals.

4. Most patients are reluctant to get any medical intervention when it comes to common menstrual problems as they find it embarrassing.

5. Insufficient information pertaining to menstrual health issues is provided for women who are experiencing common menstrual problems.

6. The media’s portrayal of menstrual symptoms as normal leads many patients to assume that their own symptoms are also normal.

7. Due to a lack of early intervention by healthcare professionals, many women suffer from serious complications of menstrual health issues, such as infertility due to untreated endometriosis.

8. There is a need for healthcare professionals to enhance their management of common menstrual problems.

For Section D, a total of six items are provided with a 5-point Likert scale: 1=never, 2=rarely, 3=sometimes, 4=often and 5=always. The final item, the 6th in the section, is an open-ended question designed as a follow-up to the 5th item. Respondents are asked to explain the reason(s) for referring patients with menstrual health issues to a physician, if applicable. The items in this section are as listed below:

1. How often do you manage a patient having menstrual health problems on a monthly basis?

2. How often do you consider patients’ complaints about their menstrual health problems to be significant?

3. Patients comply with my recommendations regarding medications or lifestyle modifications required for the management of their menstrual health problems.

4. Do you keep records of patient’s medication history for the treatment of their menstrual health issues?

5. How often do you refer patients with menstrual health problem(s) to consult a doctor?

Statistical Analysis

After the number of respondents reached to 30 for the pilot study, the data collected was analysed using SPSS version 27 as well as using Excel for the reliability test; Cronbach’s alpha test. If the value exceeds 0.6, the questionnaire is reliable [19].

Ethical Approval

This study has been reviewed and granted approval for implementation by the Jawatankuasa Etika Penyelidikan Manusia Universiti Sains Malaysia (JEPeM-USM) on the 1st of February 2023. A study protocol code was assigned for this study which is USM/JEPeM/23010112, which is valid from 1st of February 2023 until 31st January 2024.

RESULTS

Content Validation

In the development of the study instrument, content validation by expert panels was performed in the first phase of the pilot study. Three experts consisting of a pharmacist, a senior consultant obstetrician and gynaecologist, and a medical lecturer were involved in the content validation phase of this study.

Table 1 represents the value of the content validation index by the three expert panels. The value of I-CVI should be 1, so, any items with an I-CVI of less than 1 were revised [9,11,12].

Table 1 . The value of content validation index by the three expert panels.

ItemExpert 1Expert 2Expert 3Experts in agreementI-CVIUA
1111311
2111311
3111311
4111311
5111311
6111311
7111311
8111311
911020.670
10111311
11111311
12111311
13111311
14111311
15111311
1611020.670
17111311
18111311
19111311
20111311
21111311
2211020.670
23111311
24111311
25111311
26111311
27111311
28111311
29111311
30111311
31111311
32111311
33111311
3411020.670
35111311
36111311
37111311
38111311
3911020.670
4011020.670
4111020.670
42111311
43111311
44111311
45111311
46111311
47111311
Proportion in relevance110.85S-CVI/Ave0.95
S-CVI/UA0.85

I-CVI=item-level content validity index, UA=universal agreement, S-CVI/Ave=scale-level content validity index, S-CVI/UA=scale-level content validity index based on the universal agreement method..



The rating score consists of scores 1, 2, 3, and 4. A score of 1 suggests that the items are not relevant, a score of 2 suggests that the items need some revision, a score of 3 suggests that the items are relevant but require minor revision, while a score of 4 suggests that the items are very relevant. If a score of 1 or 2 is given to an item, a score of 0 for the item would be recorded. If a score of 3 or 4 is given to an item, a score of 1 for the item would be recorded which was done as such in the table above. As mentioned, according to the research [9,11,12], items scoring less than 1 should be revised. Hence, items 9, 16, 22, 34, 39, 40, and 41 were revised since the I-CVI score were 0.67. According to research [9], the value of S-CVI/Ave of 0.95 and S-CVI/UA of 0.85 respectively are higher than the acceptable sample value given which is 0.80.

Face Validation

After the content validation phase, the questionnaire tool underwent a face validation phase in which the revised questionnaire was distributed to 10 community pharmacists to ensure that the items in the questionnaire were clear and comprehensive. According to the research [20] which was conducted online, the I-FVI would be the determinant as to whether the questionnaire’s face validity index has met a satisfactory level in which the I-FVI value should be at least 0.80 [20]. Table 2 shows the value of the face validation index by the 10 raters.

Table 2 . The value of face validation index by the 10 raters.

ItemRater 1Rater 2Rater 3Rater 4Rater 5Rater 6Rater 7Rater 8Rater 9Rater 10Raters in agreementI-FVIUA
111111111111011
211111111111011
311111111111011
411111111111011
511111111111011
611111111111011
7011111101180.80
8001111111180.80
911111111111011
1011111111111011
1111111111111011
1211111111111011
1311111111111011
1411111111111011
15111111101190.90
16111111101190.90
17111111101190.90
1811111111111011
19111111101190.90
2011111111111011
21011111101180.80
22111111101190.90
2311111111111011
2411111111111011
25111111101190.90
26111111101190.90
27111110101180.80
2811111111111011
2911111111111011
3011111111111011
31111110101180.80
3211111111111011
33111110111190.90
34011110111180.80
35111110101180.80
36111111101190.90
37011110101170.70
38011110101170.70
39111110111190.90
4011111111111011
41011111111190.90
4211111111111011
43111110111190.90
44011111111190.90
4511111111111011
4611111111111011
4711111111111011
S-FVI/Ave0.97
Proportion clarity and comprehension0.830.981110.8110.6811S-FVI/UA0.53
Average proportion of items judged clarity and comprehension by the 10 raters0.93

I-FVI=item-level face validity index, UA=universal agreement, S-FVI/Ave=scale-level face validity index, S-FVI/UA=scale-level face validity index based on the universal agreement method..



The scoring used in this face validation ranges from a score of 1 to 4. A score of 1 would mean that the item is not clear and understandable, a score of 2 would mean that the item is somewhat clear and understandable, a score of 3 would mean that the item is clear and understandable, and a score of 4 would mean that the item is very clear and understandable. If the score given for an item is 1 or 2, a score of 0 for the item would be recorded while a scoring of either 3 or 4 for an item would receive a score of 1 as such recorded in Table 2. The calculation for the Face Validation Index was done in accordance with Yusoff [10] and the value set for the I-FVI, S-FVI/Ave, and S-FVI/UA to be acceptable is 0.80 [20]. This concludes that the level of clarity and comprehension for the questionnaire is acceptable for all items except for items 37 and 38. Only the S-FVI/UA was below 0.80. With the guidance of the respondents’ comments, the items have been reviewed thoroughly.

Cronbach’s Alpha Reliability Test

Cronbach’s Alpha Reliability Test is done to ensure that the questionnaire to be used in a full-scale study is reliable. Based on the analysis done using SPSS, the coefficient of Cronbach’s Alpha for the subscales of Community Pharmacists’ Knowledge on Definition, Signs and Symptoms, and Management for Common Menstrual Problems in Malaysia as well as Community Pharmacists’ Attitude towards the Management of Common Menstrual Problems in Malaysia and Community Pharmacists’ Perception on the Management of Common Menstrual Problems in Malaysia are 0.670, 0.621 and 0.835 respectively which are considered to have acceptable reliability level [19]. Although the coefficient of Cronbach’s Alpha for the subscale of Community Pharmacists’ Practice on the Management of Common Menstrual Health Problems in Malaysia is 0.511 which is lower than 0.600, according to another research [21], a value of coefficient of Cronbach’s Alpha more than 0.5 is still acceptable. The low value for the last subscale may be due to the low number of items provided for the section. Table 3 shows the reliability analysis on four subscales of the questionnaire and Table 4 shows the Cronbach’s Alpha value if items in Section E of the questionnaire were deleted.

Table 3 . Reliability analysis on four subscales of the questionnaire.

Internal consistency
Total respondents (n=30)Cronbach’s alpha, αNumber of items
Section B: community pharmacists’ knowledge on definition, signs and symptoms, and management for common menstrual problems in Malaysia0.67011
Section C: community pharmacists’ attitude towards the management of common menstrual problems in Malaysia0.62110
Section D: community pharmacists’ perception on the management of common menstrual problems in Malaysia0.8358
Section E: community pharmacists’ practice on the management of common menstrual health problems in Malaysia0.5115

Table 4 . Cronbach’s alpha value if item in Section E of the questionnaire was deleted.

ItemCronbach’s alpha
if item deleted
10.461
20.378
30.571
40.467
50.358

DISCUSSION

The instrument developed was sent out to three expert panels for content validation. Their feedbacks were taken into account and several changes were made to the questionnaire. In terms of the relevancy of the items to the study, items 9, 16, 22, 34, 39, 40, and 41 were revised since the I-CVI score was 0.67. For item 9, which is “Have you ever attended a course or received any training on the management of menstrual health problems? (Yes or No)”, it was retained since it was deemed to be relevant to the knowledge and also how a community pharmacist practices the management of common menstrual problems in Malaysia. However, a follow-up question was added to ask when the participant received such training to increase its relevance.

Items 16 and 22, which assess pharmacists’ knowledge of menstrual health, were redesigned based on expert input. All items in this section were changed to a True/False/I don’t know format to create a more comprehensive assessment of knowledge. For instance, the original question “Dysmenorrhea is defined as?” was restructured to “Dysmenorrhea is defined as absence of menstrual periods,” with True/False/I don’t know answer options. The new items for this section now focus on the participants’ knowledge of definition, signs and symptoms, and management of common menstrual problems in Malaysia instead, as suggested by the expert panel.

For item 34, which is “Most patients having menstrual health problems are not taken seriously by healthcare professionals” having a five-Likert scale answer options of “strongly agree, agree, neutral, disagree, or strongly disagree” was retained since the lack of seriousness of healthcare professionals towards women having menstrual health problems have been acknowledged as an ongoing issue which needs to be addressed. The opinion of community pharmacists, who are also healthcare professionals, is highly relevant for gaining a broader perspective on this problem and identifying potential improvements. As for item 39 and 40, which are “Due to a lack of early intervention by healthcare professionals, many women suffer from serious complications of menstrual health issues, such as infertility due to untreated endometriosis” and “There is a need for healthcare professionals to enhance their management of menstrual health problems” respectively, both using a five-point Likert scale similar to item 34 were also retained since the majority of the expert panels agreed that these items were relevant and important for inclusion in the questionnaire. Lastly, item 41 which asks for the participants’ recommendations for enhancing the management of menstrual health issues was also retained, as input from healthcare professionals could provide valuable insights.

After incorporating these changes, the updated questionnaire was distributed to 10 community pharmacists to assess clarity and comprehensiveness. According to Andrew et al. [20], the I-FVI value of at least 0.80 is considered as acceptable. Only items 37 and 38 which are “Insufficient information pertaining to menstrual health issues is provided for women who are experiencing common menstrual problems (strongly agree, agree, neutral, disagree, strongly disagree)” and “The media’s portrayal of menstrual symptoms as normal leads many patients to assume that their own symptoms are also normal (strongly agree, agree, neutral, disagree, strongly disagree)” respectively, have a score of 0.7. Although the S-FVI/UA is lower than 0.8, the significant value to indicate that the instrument is indeed clear and comprehensive would be the S-FVI/Ave value in which the value is 0.97 [22]. Furthermore, including the item on insufficient information regarding menstrual health problems is essential, as public knowledge on these issues can empower the affected individuals to ask informed questions and explore treatment options, thereby actively participating in their own healthcare [23]. Additionally, the item addressing the media’s portrayal of all menstrual symptoms as “normal” is valuable because repeated media exposure on the same topic often leads consumers to accept said information at face value [24]. This could mislead the public into believing that their symptoms are typical, preventing them from recognizing more serious issues. Such misconceptions could lead to bigger health problems in the future.

Some respondents provided feedback for improving the questionnaire, suggesting simpler sentences for better understanding and questioning the relevance of certain items. Comments included concerns like the impact of “Ownership of pharmacy” on managing menstrual disorders and whether “Menstrual Disorder” would be more suitable than “Menstrual Problems” for a professional audience. Additionally, one respondent noted that tracking period medication falls outside a community pharmacist’s role, as severe cases are typically referred to doctors. After further discussion between the researchers, no changes were made to items 37 and 38 because the structure of the sentences was necessary for the intended message to be conveyed to the respondents of the pilot study. Furthermore, the items in question were retained, as most respondents acknowledged their relevance. For example, “Ownership of pharmacy” was seen as impactful enough to remain, and “Menstrual Problems” was considered more appropriate terminology. Additionally, keeping a record of patients’ medication for period to be relevant to the study whereby according to Community Pharmacy Benchmarking Guideline 2016 [25], the community pharmacist should maintain patient medication record in the pharmacy “to check the progress of the treatment and provide information on the medical history of the patient”.

The reliability test is a vital part of producing a sound questionnaire in which the word “reliability” is defined as “an extent to which a questionnaire, test, observation or any measurement procedure produces the same results on repeated trials” [26]. According to research [27], one of the ways that a reliability test can be done is via internal consistency reliability which is measured using the Cronbach’s Alpha coefficient as such being done in the development of this questionnaire. The acceptable values of alpha differ according to different reports. The acceptable value of Cronbach’s Alpha starts with 0.6 [19]. Another report states that the Cronbach’s Alpha value of 0.5 is also considered acceptable [21]. The suggested maximum alpha value is 0.90 since an alpha value higher than 0.9 may suggest the redundancy of certain items whereby the same question is tested but under a different guise [28,29].

The internal consistency of the knowledge, attitude and perception domains are 0.670, 0.621, and 0.835 respectively which are considered to have acceptable reliability level since they exceed the alpha value of 0.6 [19]. The last domain which is the perception domain has an alpha value of 0.511 which is still acceptable according to research [21]. However, some items in the domain should be revised or discarded so that the alpha value can increase to at least 0.6 [28]. The low value for the last subscale could either be due to the low number of questions for the section, heterogeneous constructs, or poor inter-relatedness between items. Based on the analysis done using SPSS, if item 3 of this section was deleted, which is “Patients comply with my recommendations regarding medications or lifestyle modifications required for the management of their menstrual health problems” having a five-Likert scale of ‘never’, ‘rarely’, ‘sometimes’, ‘often’ or ‘always’ as choices of option, the Cronbach’s alpha value would increase from 0.511 to 0.571 as shown in Table 4. Since the number of items for this section is already low, and an alpha value of 0.511 is considered to be acceptable, item 3 was retained. To improve the Cronbach’s alpha value of the final section of the instrument, the deletion of item 3 is suggested and two new items with high inter-relatedness to the existing ones should be added. This approach would enhance the internal consistency of the questionnaire. Adding at least two more close-ended questions is considered appropriate, as having low number of items can lower the alpha value [30]. The two newly proposed items are “How often does your patients’ religious or cultural beliefs affect the management provided to patients with menstrual health problems?” and “How often do you dispense non-pharmacological items as the sole treatment for menstrual health problems?”. These additions are expected to improve the reliability and provide deeper insights into the role of religious or cultural factors and treatment approaches in the management of menstrual health issues.

This study has several limitations. Firstly, the majority of respondents were from Penang, which may not represent the broader population of community pharmacists in Malaysia. If the aforementioned limitation were to happen in a full-scale study, the results of said study may be negatively affected. Secondly, there is potential recall bias for the questions requiring respondents to recall how often they manage a patient having menstrual health problems every month, or how often they consider patients’ complaints about their menstrual health problems to be significant, or how often do they refer patients with menstrual health problem(s) to consult a doctor. Lastly, the limited number of questions may have negatively impacted the Cronbach’s Alpha value for the last section of the instrument.

Despite these limitations, the instrument’s established validity and reliability support the feasibility of conducting a full-scale study in the future. This tool would be crucial in helping to understand issues faced by both community pharmacists and the public in managing common menstrual health problems on a deeper level which would ultimately lead to a more efficient and positive outcome in doing so for both parties involved.

CONCLUSION

In conclusion, the study successfully developed a valid and reliable questionnaire tool. With demonstrated content validity and reliability, this tool can be used in future full-scale studies to measure community pharmacists’ management of common menstrual health problems in Malaysia.

FUNDING

None.

ACKNOWLEDGMENTS

Authors would like to acknowledge expert panels who were involved in the content validation, and the participants of the pilot study.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Fig 1.

Figure 1.The definition and formula of I-CVI, S-CVI/Ave and S-CVI/UA.
Research in Clinical Pharmacy 2024; 2: 6-17https://doi.org/10.59931/rcp.24.0002

Fig 2.

Figure 2.The definition and formula of I-FVI, S-FVI/Ave and S-FVI/UA.
Research in Clinical Pharmacy 2024; 2: 6-17https://doi.org/10.59931/rcp.24.0002

Table 1 The value of content validation index by the three expert panels

ItemExpert 1Expert 2Expert 3Experts in agreementI-CVIUA
1111311
2111311
3111311
4111311
5111311
6111311
7111311
8111311
911020.670
10111311
11111311
12111311
13111311
14111311
15111311
1611020.670
17111311
18111311
19111311
20111311
21111311
2211020.670
23111311
24111311
25111311
26111311
27111311
28111311
29111311
30111311
31111311
32111311
33111311
3411020.670
35111311
36111311
37111311
38111311
3911020.670
4011020.670
4111020.670
42111311
43111311
44111311
45111311
46111311
47111311
Proportion in relevance110.85S-CVI/Ave0.95
S-CVI/UA0.85

I-CVI=item-level content validity index, UA=universal agreement, S-CVI/Ave=scale-level content validity index, S-CVI/UA=scale-level content validity index based on the universal agreement method.


Table 2 The value of face validation index by the 10 raters

ItemRater 1Rater 2Rater 3Rater 4Rater 5Rater 6Rater 7Rater 8Rater 9Rater 10Raters in agreementI-FVIUA
111111111111011
211111111111011
311111111111011
411111111111011
511111111111011
611111111111011
7011111101180.80
8001111111180.80
911111111111011
1011111111111011
1111111111111011
1211111111111011
1311111111111011
1411111111111011
15111111101190.90
16111111101190.90
17111111101190.90
1811111111111011
19111111101190.90
2011111111111011
21011111101180.80
22111111101190.90
2311111111111011
2411111111111011
25111111101190.90
26111111101190.90
27111110101180.80
2811111111111011
2911111111111011
3011111111111011
31111110101180.80
3211111111111011
33111110111190.90
34011110111180.80
35111110101180.80
36111111101190.90
37011110101170.70
38011110101170.70
39111110111190.90
4011111111111011
41011111111190.90
4211111111111011
43111110111190.90
44011111111190.90
4511111111111011
4611111111111011
4711111111111011
S-FVI/Ave0.97
Proportion clarity and comprehension0.830.981110.8110.6811S-FVI/UA0.53
Average proportion of items judged clarity and comprehension by the 10 raters0.93

I-FVI=item-level face validity index, UA=universal agreement, S-FVI/Ave=scale-level face validity index, S-FVI/UA=scale-level face validity index based on the universal agreement method.


Table 3 Reliability analysis on four subscales of the questionnaire

Internal consistency
Total respondents (n=30)Cronbach’s alpha, αNumber of items
Section B: community pharmacists’ knowledge on definition, signs and symptoms, and management for common menstrual problems in Malaysia0.67011
Section C: community pharmacists’ attitude towards the management of common menstrual problems in Malaysia0.62110
Section D: community pharmacists’ perception on the management of common menstrual problems in Malaysia0.8358
Section E: community pharmacists’ practice on the management of common menstrual health problems in Malaysia0.5115

Table 4 Cronbach’s alpha value if item in Section E of the questionnaire was deleted

ItemCronbach’s alpha
if item deleted
10.461
20.378
30.571
40.467
50.358

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December 2024

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