Psychometric Properties of End Stage Renal Disease-adherence Questionnaire-indonesian Version Among Patients Receiving Haemodialysis

Psychometric Properties of End Stage Renal Disease-adherence Questionnaire-indonesian Version Among Patients Receiving Haemodialysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychometric Properties of End Stage Renal Disease-adherence Questionnaire-indonesian Version Among Patients Receiving Haemodialysis Yeni Yulianti, Devi Nallapan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8026418/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: This study aimed to validate the Indonesian version of the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) to assess treatment adherence among hemodialysis patients, ensuring its reliability and cultural relevance. Methods: A cross-sectional validation was conducted with 300 adult hemodialysis patients in West Java. Exploratory factor analysis (EFA) identified the scale's structure, followed by confirmatory factor analysis (CFA) for model fit. Construct validity was examined using the Morisky Medication Adherence Scale-8 (MMAS-8) and selected domains of the Kidney Disease Quality of Life Short Form (KDQOL-SF). Internal consistency was evaluated using Cronbach’s alpha, and test-retest reliability over a two-week interval was assessed via intraclass correlation coefficients (ICCs). Results: EFA revealed a five-factor model: Hemodialysis Session Adherence, Medication Adherence, Fluid Restriction, Dietary Adherence, and Understanding & Perception, explaining 67.4% of the variance. CFA indicated a good model fit (χ²/df = 2.54; CFI = 0.93; TLI = 0.91; RMSEA = 0.05). The questionnaire showed strong convergent validity with MMAS-8 scores (r = 0.57–1.00, p < 0.001) and satisfactory discriminant validity with unrelated KDQOL-SF subscales. Internal consistency was high (Cronbach’s α = 0.78–0.89), and test-retest reliability was good to excellent (ICC = 0.79–0.88). Conclusions: The Indonesian ESRD-AQ is a valid and reliable tool for assessing treatment adherence in Indonesian hemodialysis patients. Its use can enhance clinical monitoring and guide culturally sensitive interventions to improve adherence. Renal Dialysis Patient Compliance Questionnaires Psychometrics Indonesia Validation Study Figures Figure 1 Practice Highlights Validation of the ESRD-AQ instrument Indonesian version for hemodialysis patients Cultural and linguistic adaptation method using a strict five-step process Robust psychometric testing using EFA and CFA with 300 samples Results show good construct validity and internal reliability The tool can help improve clinical monitoring and interventions in Indonesia INTRODUCTION End-stage renal disease (ESRD) is a progressive and irreversible condition that results in total kidney failure, requiring patients to undergo lifelong renal replacement therapy. Among the available treatment options, hemodialysis (HD) remains the most widely used modality, providing essential life-sustaining care for individuals with ESRD (Queeley, G. L., & Campbell, 2018). However, adherence to HD regimens presents a major challenge due to the significant lifestyle changes required. Patients must adhere to strict dietary restrictions, control fluid intake, take medications consistently, and follow regular dialysis schedules (Zhianfar et al., 2020 ). Such adherence is crucial to reducing complications, minimizing hospitalizations, and improving both quality of life and survival rates (Mailani et al., 2024 ) Despite its importance, non-adherence is a persistent issue among HD patients. Research has shown that poor adherence contributes to adverse outcomes such as volume overload, uncontrolled hypertension, hospitalization, and increased mortality (Chow & Tam, 2014 ; Karamanidou et al., 2019 ). A range of interrelated factors—physical, psychological, social, and cultural—can influence patient adherence (Mechta Nielsen et al., 2023 ). Addressing these dimensions is key to improving treatment outcomes.. Several tools have been developed to assess adherence in HD populations, including the End-Stage Renal Disease-Adherence Questionnaire (ESRD-AQ), the Simplified Medication Adherence Questionnaire (SMAQ), and the Morisky Medication Adherence Scale (MMAS) ((Arafat et al., 2016 ; Guo et al., 2019 ; Tu et al., 2014 ). Among these, the ESRD-AQ is particularly comprehensive, as it evaluates multiple domains including diet, fluid restrictions, medication adherence, and dialysis attendance (Tu et al., 2014 ). It is also useful for identifying barriers and tailoring interventions to individual patient needs (Bikbov et al., 2020) However, instruments like the ESRD-AQ, originally developed in Western settings, may not fully capture behavioral, social, and cultural nuances in other regions. Cultural adaptation is essential—not just linguistic translation, but also ensuring contextual and conceptual equivalence (Beaton et al., 2000 ). In Indonesia, cultural factors such as religious beliefs, family-centered decision-making, and traditional healing practices significantly shape adherence behaviors (Nugroho et al., 2022 ; Pratama et al., 2020 )For example, Islamic dietary rules, fasting during Ramadan, and the use of herbal remedies can intersect with medical guidance, requiring healthcare professionals to account for cultural sensitivities when advising patients. In many Indonesian families, caregivers actively participate in managing the patient’s treatment, which can either facilitate or hinder adherence depending on their understanding and support (Bossola et al., 2020 ). Currently, no standardized, validated tool exists in Bahasa Indonesia for assessing adherence among HD patients. This study aims to adapt and validate the ESRD-AQ for use in Indonesia to enable accurate, culturally appropriate assessment and support evidence-based clinical decision-making (Setiawan, 2017 ). METHODS Study Design This study utilized a sequential mixed-methods design, consisting of two integrated phases: (1) qualitative cultural adaptation and content validation, followed by (2) quantitative psychometric evaluation of the Indonesian version of the End-Stage Renal Disease-Adherence Questionnaire (ESRD-AQ). The study adhered to the Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures (Beaton et al., 2000) and the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) checklist for evaluating health-related questionnaires (Mokkink et al., 2018). The psychometric phase followed a cross-sectional, multi-center approach to ensure generalizability across patient populations undergoing maintenance hemodialysis (HD) in Indonesia. Participants and Setting Participants were recruited from six hemodialysis (HD) centers, representing both public and private healthcare facilities across three provinces (West Java, Jakarta, and Banten), to capture geographical and sociocultural diversity. Eligible participants were adults (≥18 years) diagnosed with end-stage renal disease and undergoing maintenance hemodialysis for at least six months. Additional inclusion criteria included the ability to read and understand Bahasa Indonesia, sufficient cognitive capacity to complete a questionnaire independently or with assistance, and provision of informed consent. Patients with acute clinical instability, severe psychiatric disorders, or cognitive impairments (e.g., dementia) were excluded based on medical records and clinical assessment. Sample Size and Sampling Method Sample size determination followed COSMIN recommendations and best practices in psychometric testing, requiring a minimum of 5–10 participants per item for factor analysis (Kyriazos, 2018). Given the ESRD-AQ’s 46 items, a minimum target of 300 participants was set to allow for adequate power (0.80), model complexity in Confirmatory Factor Analysis (CFA), and attrition adjustment. Multistage purposive sampling was used to ensure representation across healthcare settings and population groups. A stratified approach ensured proportional representation by gender, age groups, and dialysis duration. Instrument The End-Stage Renal Disease-Adherence Questionnaire (ESRD-AQ) is a 46-item self-report tool designed to assess multidimensional adherence behaviors in ESRD patients (Kim et al., 2010). It comprises five sections: demographic and clinical history, adherence to hemodialysis sessions, medication adherence, fluid restriction, and dietary adherence. Items are rated using various formats, including Likert-type scales, dichotomous responses, and frequency-based indicators. Higher cumulative scores indicate better adherence. The original instrument demonstrated good internal consistency (Cronbach’s α = 0.85) and has been employed in diverse clinical settings globally (Zhianfar et al., 2020). For this study, the ESRD-AQ was culturally and linguistically adapted to Bahasa Indonesia. Cross-Cultural Adaptation Procedure The instrument was adapted via a five-step cross-cultural protocol ensuring linguistic and conceptual equivalence. Two bilingual translators created initial translations, synthesized by a third. Independent back-translation was done for accuracy. A six-member expert panel reviewed equivalence, and pre-testing with 30 patients informed revisions for cultural relevance and clarity. Data Collection Procedure Data collection was integrated into routine hemodialysis sessions to optimize accessibility and minimize patient burden. Trained staff explained the study to eligible patients and obtained written informed consent. Participants completed the Indonesian ESRD-AQ in their preferred format (paper or tablet), with neutral assistance provided as needed. Completion required approximately 15–20 minutes. Subsequently, participants rated each section's clarity on a 4-point Likert scale. Data collection occurred from March to July 2025 under the principal investigator’s supervision to ensure rigorous ethical and data quality standards. Data analysis Quantitative data were analyzed using SPSS 26 for descriptive and inferential statistics and AMOS 24 for structural modeling. Descriptive statistics summarized demographics and item responses. Psychometric evaluation included Exploratory Factor Analysis with principal axis factoring and oblique rotation. Sampling adequacy was confirmed by KMO > 0.80 and Bartlett’s test (p 0.90, RMSEA < 0.08, SRMR < 0.08, and χ²/df < 3. Construct validity was examined via Pearson correlations between ESRD-AQ scores and validated instruments. Convergent validity used MMAS-8 correlations, while discriminant validity involved KDQOL-SF’s emotional well-being and physical functioning domains. Internal consistency was measured by Cronbach’s alpha (α ≥ 0.70). Test-retest reliability was evaluated in 30 participants after two weeks. Intraclass correlation coefficients (ICCs ≥ 0.75) indicated good reliability. Analyses followed a two-tailed p < 0.05 significance threshold and COSMIN guidelines for methodological quality. Ethical Considerations Ethical approval was granted by the Institutional Review Board of STIKes Sukabumi (Ref: 000724/KEP STIKES SUKABUMI/2025). The study complied with the Declaration of Helsinki, and all participants were informed of voluntary participation, confidentiality, and the right to withdraw without consequence. RESULTS A total of 300 patients undergoing hemodialysis (HD) participated in the study. The demographic characteristics are summarized in Table 1. Table 1. Demographic Characteristics of the Participants Variable n % Gender Male 181 60.4 Female 119 39.6 Age (years) ≤40 54 18.0 41–60 162 54.0 >60 84 28.0 Duration of Hemodialysis 5 years 67 22.4 Employment Status Employed 76 25.2 Unemployed 224 74.8 The exploratory factor analysis (EFA) of the Indonesian version of the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) revealed a clear five-factor structure, reflecting key domains of treatment adherence among hemodialysis patients. Table 2. EFA of the ESRD-AQ Factor Number of Items Eigenvalue Variance Explained (%) HD Session Adherence 10 6.8 14.8 Medication Adherence 8 5.4 12.1 Fluid Restriction 10 4.7 10.3 Dietary Adherence 10 4.1 9.1 Understanding & Perception 8 3.6 8.2 Table 3. CFA of the ESRD-AQ Fit Indices Values Remarks χ²/df 2.54 Acceptable (0.90) TLI 0.91 Good (>0.90) RMSEA 0.05 Acceptable (<0.08, 90% CI: 0.04–0.07) CFA supports the five-factor structure of the ESRD-AQ, with each subscale, including HD Session Adherence, Medication Adherence, Fluid Restriction, Dietary Adherence, and Understanding & Perception demonstrating acceptable standardized factor loadings ranging from 0.61 to 0.88 (Figure 1). Table 3. Construct Validity and Reliability of the Indonesian Version of the ESRD-AQ ESRD-AQ Subscale Inter-Subscale Correlations (r) MMAS-8 (Convergent Validity) KDQOL-SF Emotion (Discriminant Validity) KDQOL-SF Physical (Discriminant Validity) Cronbach’s α ICC HD Session Adherence 1.00 0.59 –0.03 0.74 0.81 0.84 Medication Adherence 0.58 with HD 0.55 with Fluid 0.50 with Perception 1.00 –0.05 0.03 0.87 0.88 Fluid Restriction 0.52 with HD 0.55 with Medication 0.48 with Perception 0.57 0.70 0.04 0.78 0.79 Dietary Adherence 0.46 with HD 0.47 with Medication 0.51 with Fluid 0.43 with Perception 0.85 –0.04 0.07 0.82 0.83 Understanding & Perception 0.49 with HD 0.50 with Medication 0.48 with Fluid 0.43 with Diet — — — — — Total Score — 0.85 –0.04 0.07 0.89 0.86 Notes: MMAS-8 = Morisky Medication Adherence Scale (for convergent validity) KDQOL-SF = Kidney Disease Quality of Life Short Form (for discriminant validity) Bolded values indicate statistically significant correlations (p < 0.001) Cronbach’s α = internal consistency reliability ICC = intraclass correlation coefficient (test–retest reliability over 2 weeks) Table 4. Internal consistency and test-retest reliability of the ESRD-AQ ESRD-AQ Domain No. of Items Cronbach’s Alpha ICC (2-week retest) Interpretation Total Score 46 0.89 0.86 Excellent internal and test-retest reliability Diet 10 0.82 0.84 Good reliability Medication 8 0.87 0.88 Excellent reliability Fluid 14 0.78 0.79 Acceptable reliability Dialysis 14 0.81 0.82 Good reliability DISCUSSION This study is the first to comprehensively validate the ESRD-AQ in Bahasa Indonesia, confirming factorial structure via CFA and demonstrating convergent and discriminant validity against established tools (MMAS-8 and KDQOL-SF). It reveals minimal links between emotional/physical health and adherence except fluid management, offering insights for culturally tailored interventions and advancing renal adherence research in Indonesia. The factor structure of the ESRD-AQ was rigorously examined using both exploratory and confirmatory factor analyses. The EFA yielded a five-factor solution explaining 67.4% of the total variance, and the CFA results (χ²/df = 2.54; CFI = 0.93; TLI = 0.91; RMSEA = 0.05) confirmed good model fit. These findings provide strong support for the construct validity of the instrument and are consistent with psychometric evaluations of the ESRD-AQ and similar instruments in other cultural and linguistic contexts (Lasanthika et al., 2023; Melo et al., 2024; Sharif-Nia et al., 2024). Notably, the five factors identified in this study, namely hd session adherence, medication adherence, fluid restriction, dietary adherence, and understanding & perception align with the multidimensional nature of treatment adherence in ESRD and reflect the original conceptual domains proposed by Kim et al., (2010). However, this study diverges from earlier validations in Turkish and Chinese populations, where slightly different factor solutions were reported, such as a combined 'fluid-diet' factor or lower explained variance (Antony et al., 2020; Seng et al., 2020). The higher total variance explained in the current study (67.4%) underscores the cultural relevance and item clarity achieved through adaptation in the Indonesian setting. The CFA standardized loadings (ranging from 0.61 to 0.88) further affirm that individual items meaningfully contribute to their respective constructs. This validation is particularly notable as it is among the first studies to comprehensively evaluate the ESRD-AQ using both EFA and CFA in an Indonesian population. Previous validations have largely focused on internal consistency alone or employed EFA without subsequent model confirmation (Karami et al., 2024; Zhianfar et al., 2020). The inclusion of CFA in this study fills a significant methodological gap in renal adherence research in Southeast Asia and supports the questionnaire’s structural soundness. Importantly, inter-subscale correlations provide additional support for internal construct validity. All subscales were moderately to strongly correlated (r = 0.43–0.58), suggesting that while conceptually distinct, the domains are functionally interrelated. For example, HD Session Adherence demonstrated strong associations with both Medication Adherence and Fluid Restriction, reinforcing the interconnected nature of adherence behaviors in ESRD treatment. These findings mirror patterns seen in a Brazilian study by Karami et al., (2024), yet this study extends that work by offering a full correlation matrix and clearly defined theoretical boundaries for each subscale. Convergent validity was demonstrated by strong and statistically significant correlations between the ESRD-AQ and the MMAS-8, a gold standard for medication adherence measurement. The strongest associations were observed with the Medication (r = 1.00), Diet (r = 0.85), and Dialysis (r = 0.59) subscales. These findings support the ESRD-AQ’s capacity to measure key dimensions of adherence in line with established instruments, similar to results observed in validation studies conducted in Korea (Kim et al., 2010) and Portugal Karami et al., (2024). However, the present study is unique in concurrently validating multiple subdomains beyond medication against an external criterion, thereby offering a more comprehensive view of adherence behaviors. Discriminant validity was largely supported by weak and non-significant correlations with unrelated constructs from the KDQOL-SF Emotional and Physical Functioning subscales. This suggests that the ESRD-AQ measures specific behavioral domains rather than general well-being or quality of life. These results are congruent with prior research indicating that behavioral adherence tools should be functionally distinct from HRQoL instruments (Antony et al., 2020; Feijão & de Freitas Melo, 2020). Nonetheless, two exceptions emerged: moderate to strong correlations between the Fluid subscale and Emotional well-being (r = 0.70), and between the Dialysis subscale and Physical Functioning (r = 0.74). These findings may reflect the bidirectional influence between physical/emotional burden and specific adherence behaviors, particularly in fluid restriction and missed dialysis sessions. Although not anticipated, these results open new lines of inquiry into psychosomatic influences on adherence in ESRD—an area underexplored in current literature. The ESRD-AQ also demonstrated excellent reliability. The total Cronbach’s alpha (0.89) and subscale alphas (ranging from 0.78 to 0.87) exceeded the accepted threshold for internal consistency and were comparable to or higher than those reported in prior studies from China (Meng et al., 2022) and Greece (Zhianfar et al., 2020). Test-retest reliability, assessed over a two-week interval, yielded strong intraclass correlation coefficients (ICC range = 0.79–0.88), supporting the tool’s temporal stability. Previous validations often lacked longitudinal follow-up or used smaller subsamples; the current study’s structured two-week retest with 30 participants offers more robust evidence of score stability. Clinically, the Indonesian ESRD-AQ offers a reliable, culturally tailored instrument for evaluating adherence in routine care, aiding providers in identifying at-risk patients and developing personalized interventions. In research, it allows for standardized measurement of adherence behaviors, improving the quality and comparability of studies. As adherence is a key determinant of clinical outcomes in ESRD, including survival, hospitalization, and quality of life (Fisher et al., 2019; Mirzaei-Alavijeh et al., 2023; Wang et al., 2020), thus this tool can contribute to more effective chronic disease management frameworks. However, this study is not without limitations. First, the validation process was conducted in a single geographic region, which may limit the generalizability of the findings to other parts of Indonesia. Future studies should replicate the validation process in diverse settings to confirm the questionnaire's applicability across different regions. Second, the study focused on psychometric properties without examining the longitudinal predictive validity of the questionnaire. Future research could explore the ability of the ESRD-AQ to predict clinical outcomes such as hospitalization rates and survival among hemodialysis patients. CONCLUSION In summary, this study advances the literature by providing the first full psychometric validation of the ESRD-AQ in Bahasa Indonesia, incorporating both factor structure analysis and construct validity. The higher variance explained, strong model fit, and domain-specific validation distinguish this work from earlier studies. By contextualizing the ESRD-AQ for the Indonesian setting and empirically validating its theoretical structure, this research addresses a crucial gap in global adherence measurement tools and enhances the capacity for both clinical monitoring and research on treatment behaviors in ESRD populations. References Antony, E., James, M., Roy, A., & George, S. (2020). Assessment of treatment adherence and its predictors in maintenance hemodialysis patients. Asian J Res Nephr , 3 (3), 22–29. Arafat, S. 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Effectiveness of a multifaceted educational intervention to enhance therapeutic regimen adherence and quality of life amongst iranian hemodialysis patients: A randomized controlled trial (MEITRA study). Journal of Multidisciplinary Healthcare , 361–372. Yulianti, Y. (2025). informed consent. Zenodo. https://doi.org/10.5281/zenodo.17254380 Yulianti, Y. (2025). Research Ethics Approval. Zenodo. https://doi.org/10.5281/zenodo.17238613 Yulianti, Y. (2025). Master Data Excel Table for Validity Testing. Zenodo. https://doi.org/10.5281/zenodo.17231628 Yulianti, Y. (2025). Email for permission to use a questionnaire. Zenodo. https://doi.org/10.5281/zenodo.17231574 Yulianti, Y. (2025). Psychometric Properties Of End Stage Renal Disease-Adherence Questionnaire-Indonesian Version Among Patients Receiving Haemodialysis. Zenodo. https://doi.org/10.5281/zenodo.17254462 Additional Declarations The authors declare no competing interests. Supplementary Files rawdataESRDAQ46Items1.xlsx Raw Data ESRD Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Yulianti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYJCCAwwMFjxgxgcDGzkw4wFhLRJALcwMB2cUpBmDRRIIWyTBANLCzPHhUGIDiI9Pi8Hx3oOHedskZPhn9x88zGBwIH1+2OGHQFvs5HQbcGg5cy4BpIVH4s5hhsMFBndyN95OMwBqSTY2O4BDy40cA7AWhhvJDIdnGDzL3Tg7AaTlQOI2XFruv4FokQdp4TE4nG44O/0Dfi03eCBaDKBaEuSlc/DbInkmx+DgnHMSPIY3kg0OzjBIM9wgnVNwIMEAt1/4jp8x/vCmzMZe7kbi4w8f/tjIy89O3/zhQ4WdHC4tCkBxJh4Up4JVGmBXDgLyDQwMjD/QRUbBKBgFo2AUIAMAQsJqY3+s+uIAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-3987-2554","institution":"Lincoln University College, Selangor, Malaysia","correspondingAuthor":true,"prefix":"","firstName":"Yeni","middleName":"","lastName":"Yulianti","suffix":""},{"id":539657915,"identity":"2e0a55b2-e77c-49cb-aba5-742e82d011c6","order_by":1,"name":"Devi Nallapan","email":"","orcid":"https://orcid.org/0000-0003-2673-5614","institution":"Lincoln University College, Selangor, 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06:43:27","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":90663,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8026418/v1/b1f52d07f0f9a1048e9b5152.html"},{"id":95173426,"identity":"e622611b-ea1e-4179-b662-96b10dec06ab","added_by":"auto","created_at":"2025-11-05 06:43:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":356396,"visible":true,"origin":"","legend":"\u003cp\u003eCFA diagram with standardized loadings\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8026418/v1/c7416b54e16137fc8b268cfe.png"},{"id":95230525,"identity":"eaf23d92-6b54-4bdc-94cf-b224c4da2c24","added_by":"auto","created_at":"2025-11-05 16:37:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":935028,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8026418/v1/969240b7-ea65-4ddb-b58d-32fd61cc27b0.pdf"},{"id":95173421,"identity":"fcc78a1c-8ea0-4682-bd86-bed536d76c2f","added_by":"auto","created_at":"2025-11-05 06:43:27","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":70857,"visible":true,"origin":"","legend":"\u003cp\u003eRaw Data ESRD\u003c/p\u003e","description":"","filename":"rawdataESRDAQ46Items1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8026418/v1/90b80a3180a66de8fdace5ae.xlsx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003ePsychometric Properties of End Stage Renal Disease-adherence Questionnaire-indonesian Version Among Patients Receiving Haemodialysis\u003c/p\u003e","fulltext":[{"header":"Practice Highlights","content":"\u003cul\u003e\n \u003cli\u003eValidation of the ESRD-AQ instrument Indonesian version for hemodialysis patients\u003c/li\u003e\n \u003cli\u003eCultural and linguistic adaptation method using a strict five-step process\u003c/li\u003e\n \u003cli\u003eRobust psychometric testing using EFA and CFA with 300 samples\u003c/li\u003e\n \u003cli\u003eResults show good construct validity and internal reliability\u003c/li\u003e\n \u003cli\u003eThe tool can help improve clinical monitoring and interventions in Indonesia\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eEnd-stage renal disease (ESRD) is a progressive and irreversible condition that results in total kidney failure, requiring patients to undergo lifelong renal replacement therapy. Among the available treatment options, hemodialysis (HD) remains the most widely used modality, providing essential life-sustaining care for individuals with ESRD (Queeley, G. L., \u0026amp; Campbell, 2018). However, adherence to HD regimens presents a major challenge due to the significant lifestyle changes required. Patients must adhere to strict dietary restrictions, control fluid intake, take medications consistently, and follow regular dialysis schedules (Zhianfar et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Such adherence is crucial to reducing complications, minimizing hospitalizations, and improving both quality of life and survival rates (Mailani et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eDespite its importance, non-adherence is a persistent issue among HD patients. Research has shown that poor adherence contributes to adverse outcomes such as volume overload, uncontrolled hypertension, hospitalization, and increased mortality (Chow \u0026amp; Tam, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Karamanidou et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). A range of interrelated factors\u0026mdash;physical, psychological, social, and cultural\u0026mdash;can influence patient adherence (Mechta Nielsen et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Addressing these dimensions is key to improving treatment outcomes..\u003c/p\u003e\u003cp\u003eSeveral tools have been developed to assess adherence in HD populations, including the End-Stage Renal Disease-Adherence Questionnaire (ESRD-AQ), the Simplified Medication Adherence Questionnaire (SMAQ), and the Morisky Medication Adherence Scale (MMAS) ((Arafat et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Guo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Tu et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Among these, the ESRD-AQ is particularly comprehensive, as it evaluates multiple domains including diet, fluid restrictions, medication adherence, and dialysis attendance (Tu et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). It is also useful for identifying barriers and tailoring interventions to individual patient needs (Bikbov et al., 2020)\u003c/p\u003e\u003cp\u003eHowever, instruments like the ESRD-AQ, originally developed in Western settings, may not fully capture behavioral, social, and cultural nuances in other regions. Cultural adaptation is essential\u0026mdash;not just linguistic translation, but also ensuring contextual and conceptual equivalence (Beaton et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). In Indonesia, cultural factors such as religious beliefs, family-centered decision-making, and traditional healing practices significantly shape adherence behaviors (Nugroho et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Pratama et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e)For example, Islamic dietary rules, fasting during Ramadan, and the use of herbal remedies can intersect with medical guidance, requiring healthcare professionals to account for cultural sensitivities when advising patients. In many Indonesian families, caregivers actively participate in managing the patient\u0026rsquo;s treatment, which can either facilitate or hinder adherence depending on their understanding and support (Bossola et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCurrently, no standardized, validated tool exists in Bahasa Indonesia for assessing adherence among HD patients. This study aims to adapt and validate the ESRD-AQ for use in Indonesia to enable accurate, culturally appropriate assessment and support evidence-based clinical decision-making (Setiawan, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003eThis study utilized a sequential mixed-methods design, consisting of two integrated phases: (1) qualitative cultural adaptation and content validation, followed by (2) quantitative psychometric evaluation of the Indonesian version of the End-Stage Renal Disease-Adherence Questionnaire (ESRD-AQ). The study adhered to the Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures (Beaton et al., 2000) and the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) checklist for evaluating health-related questionnaires (Mokkink et al., 2018). The psychometric phase followed a cross-sectional, multi-center approach to ensure generalizability across patient populations undergoing maintenance hemodialysis (HD) in Indonesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003eParticipants were recruited from six hemodialysis (HD) centers, representing both public and private healthcare facilities across three provinces (West Java, Jakarta, and Banten), to capture geographical and sociocultural diversity. Eligible participants were adults (\u0026ge;18 years) diagnosed with end-stage renal disease and undergoing maintenance hemodialysis for at least six months. Additional inclusion criteria included the ability to read and understand Bahasa Indonesia, sufficient cognitive capacity to complete a questionnaire independently or with assistance, and provision of informed consent. Patients with acute clinical instability, severe psychiatric disorders, or cognitive impairments (e.g., dementia) were excluded based on medical records and clinical assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size and Sampling Method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003eSample size determination followed COSMIN recommendations and best practices in psychometric testing, requiring a minimum of 5\u0026ndash;10 participants per item for factor analysis (Kyriazos, 2018). Given the ESRD-AQ\u0026rsquo;s 46 items, a minimum target of 300 participants was set to allow for adequate power (0.80), model complexity in Confirmatory Factor Analysis (CFA), and attrition adjustment. Multistage purposive sampling was used to ensure representation across healthcare settings and population groups. A stratified approach ensured proportional representation by gender, age groups, and dialysis duration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstrument\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e \u003c/strong\u003eThe End-Stage Renal Disease-Adherence Questionnaire (ESRD-AQ) is a 46-item self-report tool designed to assess multidimensional adherence behaviors in ESRD patients (Kim et al., 2010). It comprises five sections: demographic and clinical history, adherence to hemodialysis sessions, medication adherence, fluid restriction, and dietary adherence. Items are rated using various formats, including Likert-type scales, dichotomous responses, and frequency-based indicators. Higher cumulative scores indicate better adherence. The original instrument demonstrated good internal consistency (Cronbach\u0026rsquo;s \u0026alpha; = 0.85) and has been employed in diverse clinical settings globally (Zhianfar et al., 2020). For this study, the ESRD-AQ was culturally and linguistically adapted to Bahasa Indonesia.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCross-Cultural Adaptation Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe instrument was adapted via a five-step cross-cultural protocol ensuring linguistic and conceptual equivalence. Two bilingual translators created initial translations, synthesized by a third. Independent back-translation was done for accuracy. A six-member expert panel reviewed equivalence, and pre-testing with 30 patients informed revisions for cultural relevance and clarity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was integrated into routine hemodialysis sessions to optimize accessibility and minimize patient burden. Trained staff explained the study to eligible patients and obtained written informed consent. Participants completed the Indonesian ESRD-AQ in their preferred format (paper or tablet), with neutral assistance provided as needed. Completion required approximately 15\u0026ndash;20 minutes. Subsequently, participants rated each section\u0026apos;s clarity on a 4-point Likert scale. Data collection occurred from March to July 2025 under the principal investigator\u0026rsquo;s supervision to ensure rigorous ethical and data quality standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were analyzed using SPSS 26 for descriptive and inferential statistics and AMOS 24 for structural modeling. Descriptive statistics summarized demographics and item responses. Psychometric evaluation included Exploratory Factor Analysis with principal axis factoring and oblique rotation. Sampling adequacy was confirmed by KMO \u0026gt; 0.80 and Bartlett\u0026rsquo;s test (p \u0026lt; 0.001), supporting factor analysis suitability. Confirmatory Factor Analysis (CFA) tested the factor structure fit using indices: CFI \u0026gt; 0.90, RMSEA \u0026lt; 0.08, SRMR \u0026lt; 0.08, and \u0026chi;\u0026sup2;/df \u0026lt; 3. Construct validity was examined via Pearson correlations between ESRD-AQ scores and validated instruments. Convergent validity used MMAS-8 correlations, while discriminant validity involved KDQOL-SF\u0026rsquo;s emotional well-being and physical functioning domains. Internal consistency was measured by Cronbach\u0026rsquo;s alpha (\u0026alpha; \u0026ge; 0.70). Test-retest reliability was evaluated in 30 participants after two weeks. Intraclass correlation coefficients (ICCs \u0026ge; 0.75) indicated good reliability. Analyses followed a two-tailed p \u0026lt; 0.05 significance threshold and COSMIN guidelines for methodological quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e Ethical approval was granted by the Institutional Review Board of STIKes Sukabumi (Ref: 000724/KEP STIKES SUKABUMI/2025). The study complied with the Declaration of Helsinki, and all participants were informed of voluntary participation, confidentiality, and the right to withdraw without consequence.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of \u003cstrong\u003e300\u003c/strong\u003e patients undergoing hemodialysis (HD) participated in the study. The demographic characteristics are summarized in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Demographic Characteristics of the Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellpadding=\"0\" width=\"522\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 122px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e60.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e39.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026le;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e41\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e54.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026gt;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eDuration of Hemodialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026lt;1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e3\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003e\u0026gt;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e22.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eEmployment Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 279px;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e224\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 122px;\"\u003e\n \u003cp\u003e74.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe exploratory factor analysis (EFA) of the Indonesian version of the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) revealed a clear five-factor structure, reflecting key domains of treatment adherence among hemodialysis patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. EFA of the ESRD-AQ\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eNumber of Items\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eEigenvalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eVariance Explained (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eHD Session Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eMedication Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eFluid Restriction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eDietary Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eUnderstanding \u0026amp; Perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. CFA of the ESRD-AQ\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eFit Indices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eValues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 285px;\"\u003e\n \u003cp\u003eRemarks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;/df\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 285px;\"\u003e\n \u003cp\u003eAcceptable (\u0026lt;3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eCFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 285px;\"\u003e\n \u003cp\u003eGood (\u0026gt;0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eTLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 285px;\"\u003e\n \u003cp\u003eGood (\u0026gt;0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eRMSEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 285px;\"\u003e\n \u003cp\u003eAcceptable (\u0026lt;0.08, 90% CI: 0.04\u0026ndash;0.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eCFA supports the five-factor structure of the ESRD-AQ, with each subscale, including HD Session Adherence, Medication Adherence, Fluid Restriction, Dietary Adherence, and Understanding \u0026amp; Perception demonstrating acceptable standardized factor loadings ranging from 0.61 to 0.88 (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Construct Validity and Reliability of the Indonesian Version of the ESRD-AQ\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"650\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eESRD-AQ Subscale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInter-Subscale Correlations (r)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMMAS-8 (Convergent Validity)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKDQOL-SF Emotion (Discriminant Validity)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eKDQOL-SF Physical (Discriminant Validity)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCronbach\u0026rsquo;s \u0026alpha;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eICC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHD Session Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash;0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedication Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.58 with HD\u003cbr\u003e\u0026nbsp;0.55 with Fluid\u003cbr\u003e\u0026nbsp;0.50 with Perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFluid Restriction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.52 with HD\u003cbr\u003e\u0026nbsp;0.55 with Medication\u003cbr\u003e\u0026nbsp;0.48 with Perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDietary Adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.46 with HD\u003cbr\u003e\u0026nbsp;0.47 with Medication\u003cbr\u003e\u0026nbsp;0.51 with Fluid\u003cbr\u003e\u0026nbsp;0.43 with Perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnderstanding \u0026amp; Perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.49 with HD\u003cbr\u003e\u0026nbsp;0.50 with Medication\u003cbr\u003e\u0026nbsp;0.48 with Fluid\u003cbr\u003e\u0026nbsp;0.43 with Diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026ndash;0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNotes:\u003c/strong\u003e\u003cbr\u003e\u003cem\u003eMMAS-8\u003c/em\u003e = Morisky Medication Adherence Scale (for convergent validity)\u003cbr\u003e\u003cem\u003eKDQOL-SF\u003c/em\u003e = Kidney Disease Quality of Life Short Form (for discriminant validity)\u003cbr\u003e\u0026nbsp;Bolded values indicate statistically significant correlations (p \u0026lt; 0.001)\u003cbr\u003e\u0026nbsp;Cronbach\u0026rsquo;s \u0026alpha; = internal consistency reliability\u003cbr\u003e\u0026nbsp;ICC = intraclass correlation coefficient (test\u0026ndash;retest reliability over 2 weeks)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Internal consistency and test-retest reliability of the ESRD-AQ\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eESRD-AQ Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eNo. of Items\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCronbach\u0026rsquo;s Alpha\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eICC (2-week retest)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eInterpretation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eTotal Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eExcellent internal and test-retest reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eDiet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eGood reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eExcellent reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eFluid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eAcceptable reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003eDialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eGood reliability\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study is the first to comprehensively validate the ESRD-AQ in Bahasa Indonesia, confirming factorial structure via CFA and demonstrating convergent and discriminant validity against established tools (MMAS-8 and KDQOL-SF). It reveals minimal links between emotional/physical health and adherence except fluid management, offering insights for culturally tailored interventions and advancing renal adherence research in Indonesia.\u003c/p\u003e\n\u003cp\u003eThe factor structure of the ESRD-AQ was rigorously examined using both exploratory and confirmatory factor analyses. The EFA yielded a five-factor solution explaining 67.4% of the total variance, and the CFA results (\u0026chi;\u0026sup2;/df = 2.54; CFI = 0.93; TLI = 0.91; RMSEA = 0.05) confirmed good model fit. These findings provide strong support for the construct validity of the instrument and are consistent with psychometric evaluations of the ESRD-AQ and similar instruments in other cultural and linguistic contexts (Lasanthika et al., 2023; Melo et al., 2024; Sharif-Nia et al., 2024). Notably, the five factors identified in this study, namely hd session adherence, medication adherence, fluid restriction, dietary adherence, and understanding \u0026amp; perception align with the multidimensional nature of treatment adherence in ESRD and reflect the original conceptual domains proposed by Kim et al., (2010). However, this study diverges from earlier validations in Turkish and Chinese populations, where slightly different factor solutions were reported, such as a combined \u0026apos;fluid-diet\u0026apos; factor or lower explained variance (Antony et al., 2020; Seng et al., 2020). The higher total variance explained in the current study (67.4%) underscores the cultural relevance and item clarity achieved through adaptation in the Indonesian setting.\u003c/p\u003e\n\u003cp\u003eThe CFA standardized loadings (ranging from 0.61 to 0.88) further affirm that individual items meaningfully contribute to their respective constructs. This validation is particularly notable as it is among the first studies to comprehensively evaluate the ESRD-AQ using both EFA and CFA in an Indonesian population. Previous validations have largely focused on internal consistency alone or employed EFA without subsequent model confirmation (Karami et al., 2024; Zhianfar et al., 2020). The inclusion of CFA in this study fills a significant methodological gap in renal adherence research in Southeast Asia and supports the questionnaire\u0026rsquo;s structural soundness.\u003c/p\u003e\n\u003cp\u003eImportantly, inter-subscale correlations provide additional support for internal construct validity. All subscales were moderately to strongly correlated (r = 0.43\u0026ndash;0.58), suggesting that while conceptually distinct, the domains are functionally interrelated. For example, HD Session Adherence demonstrated strong associations with both Medication Adherence and Fluid Restriction, reinforcing the interconnected nature of adherence behaviors in ESRD treatment. These findings mirror patterns seen in a Brazilian study by Karami et al., (2024), yet this study extends that work by offering a full correlation matrix and clearly defined theoretical boundaries for each subscale.\u003c/p\u003e\n\u003cp\u003eConvergent validity was demonstrated by strong and statistically significant correlations between the ESRD-AQ and the MMAS-8, a gold standard for medication adherence measurement. The strongest associations were observed with the Medication (r = 1.00), Diet (r = 0.85), and Dialysis (r = 0.59) subscales. These findings support the ESRD-AQ\u0026rsquo;s capacity to measure key dimensions of adherence in line with established instruments, similar to results observed in validation studies conducted in Korea (Kim et al., 2010) and Portugal Karami et al., (2024). However, the present study is unique in concurrently validating multiple subdomains beyond medication against an external criterion, thereby offering a more comprehensive view of adherence behaviors.\u003c/p\u003e\n\u003cp\u003eDiscriminant validity was largely supported by weak and non-significant correlations with unrelated constructs from the KDQOL-SF Emotional and Physical Functioning subscales. This suggests that the ESRD-AQ measures specific behavioral domains rather than general well-being or quality of life. These results are congruent with prior research indicating that behavioral adherence tools should be functionally distinct from HRQoL instruments (Antony et al., 2020; Feij\u0026atilde;o \u0026amp; de Freitas Melo, 2020). Nonetheless, two exceptions emerged: moderate to strong correlations between the Fluid subscale and Emotional well-being (r = 0.70), and between the Dialysis subscale and Physical Functioning (r = 0.74). These findings may reflect the bidirectional influence between physical/emotional burden and specific adherence behaviors, particularly in fluid restriction and missed dialysis sessions. Although not anticipated, these results open new lines of inquiry into psychosomatic influences on adherence in ESRD\u0026mdash;an area underexplored in current literature.\u003c/p\u003e\n\u003cp\u003eThe ESRD-AQ also demonstrated excellent reliability. The total Cronbach\u0026rsquo;s alpha (0.89) and subscale alphas (ranging from 0.78 to 0.87) exceeded the accepted threshold for internal consistency and were comparable to or higher than those reported in prior studies from China (Meng et al., 2022) and Greece (Zhianfar et al., 2020). Test-retest reliability, assessed over a two-week interval, yielded strong intraclass correlation coefficients (ICC range = 0.79\u0026ndash;0.88), supporting the tool\u0026rsquo;s temporal stability. Previous validations often lacked longitudinal follow-up or used smaller subsamples; the current study\u0026rsquo;s structured two-week retest with 30 participants offers more robust evidence of score stability.\u003c/p\u003e\n\u003cp\u003eClinically, the Indonesian ESRD-AQ offers a reliable, culturally tailored instrument for evaluating adherence in routine care, aiding providers in identifying at-risk patients and developing personalized interventions. In research, it allows for standardized measurement of adherence behaviors, improving the quality and comparability of studies. As adherence is a key determinant of clinical outcomes in ESRD, including survival, hospitalization, and quality of life (Fisher et al., 2019; Mirzaei-Alavijeh et al., 2023; Wang et al., 2020), thus this tool can contribute to more effective chronic disease management frameworks.\u003c/p\u003e\n\u003cp\u003eHowever, this study is not without limitations. First, the validation process was conducted in a single geographic region, which may limit the generalizability of the findings to other parts of Indonesia. Future studies should replicate the validation process in diverse settings to confirm the questionnaire\u0026apos;s applicability across different regions. Second, the study focused on psychometric properties without examining the longitudinal predictive validity of the questionnaire. Future research could explore the ability of the ESRD-AQ to predict clinical outcomes such as hospitalization rates and survival among hemodialysis patients.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn summary, this study advances the literature by providing the first full psychometric validation of the ESRD-AQ in Bahasa Indonesia, incorporating both factor structure analysis and construct validity. The higher variance explained, strong model fit, and domain-specific validation distinguish this work from earlier studies. By contextualizing the ESRD-AQ for the Indonesian setting and empirically validating its theoretical structure, this research addresses a crucial gap in global adherence measurement tools and enhances the capacity for both clinical monitoring and research on treatment behaviors in ESRD populations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAntony, E., James, M., Roy, A., \u0026amp; George, S. (2020). 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Cross-cultural adaptation and reliability testing of Chinese version of the living with medicines questionnaire in elderly patients with chronic diseases. \u003cem\u003ePatient Preference and Adherence\u003c/em\u003e, 2477\u0026ndash;2487.\u003c/li\u003e\n\u003cli\u003eZhianfar, L., Nadrian, H., Asghari Jafarabadi, M., Espahbodi, F., \u0026amp; Shaghaghi, A. (2020). Effectiveness of a multifaceted educational intervention to enhance therapeutic regimen adherence and quality of life amongst iranian hemodialysis patients: A randomized controlled trial (MEITRA study). \u003cem\u003eJournal of Multidisciplinary Healthcare\u003c/em\u003e, 361\u0026ndash;372.\u003c/li\u003e\n\u003cli\u003eYulianti, Y. (2025). informed consent. Zenodo. https://doi.org/10.5281/zenodo.17254380\u003c/li\u003e\n\u003cli\u003eYulianti, Y. (2025). Research Ethics Approval. Zenodo. https://doi.org/10.5281/zenodo.17238613 \u003c/li\u003e\n\u003cli\u003eYulianti, Y. (2025). Master Data Excel Table for Validity Testing. Zenodo. https://doi.org/10.5281/zenodo.17231628 \u003c/li\u003e\n\u003cli\u003eYulianti, Y. (2025). Email for permission to use a questionnaire. Zenodo. https://doi.org/10.5281/zenodo.17231574 \u003c/li\u003e\n\u003cli\u003eYulianti, Y. (2025). Psychometric Properties Of End Stage Renal Disease-Adherence Questionnaire-Indonesian Version Among Patients Receiving Haemodialysis. Zenodo. https://doi.org/10.5281/zenodo.17254462 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Lincoln University College, Selangor, Malaysia","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Renal Dialysis, Patient Compliance, Questionnaires, Psychometrics, Indonesia, Validation Study","lastPublishedDoi":"10.21203/rs.3.rs-8026418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8026418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e This study aimed to validate the Indonesian version of the End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) to assess treatment adherence among hemodialysis patients, ensuring its reliability and cultural relevance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional validation was conducted with 300 adult hemodialysis patients in West Java. Exploratory factor analysis (EFA) identified the scale's structure, followed by confirmatory factor analysis (CFA) for model fit. Construct validity was examined using the Morisky Medication Adherence Scale-8 (MMAS-8) and selected domains of the Kidney Disease Quality of Life Short Form (KDQOL-SF). Internal consistency was evaluated using Cronbach’s alpha, and test-retest reliability over a two-week interval was assessed via intraclass correlation coefficients (ICCs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e EFA revealed a five-factor model: Hemodialysis Session Adherence, Medication Adherence, Fluid Restriction, Dietary Adherence, and Understanding \u0026amp; Perception, explaining 67.4% of the variance. CFA indicated a good model fit (χ²/df = 2.54; CFI = 0.93; TLI = 0.91; RMSEA = 0.05). The questionnaire showed strong convergent validity with MMAS-8 scores (r = 0.57–1.00, p \u0026lt; 0.001) and satisfactory discriminant validity with unrelated KDQOL-SF subscales. Internal consistency was high (Cronbach’s α = 0.78–0.89), and test-retest reliability was good to excellent (ICC = 0.79–0.88).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The Indonesian ESRD-AQ is a valid and reliable tool for assessing treatment adherence in Indonesian hemodialysis patients. Its use can enhance clinical monitoring and guide culturally sensitive interventions to improve adherence.\u003c/p\u003e","manuscriptTitle":"Psychometric Properties of End Stage Renal Disease-adherence Questionnaire-indonesian Version Among Patients Receiving Haemodialysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 06:43:22","doi":"10.21203/rs.3.rs-8026418/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d860946-6987-41d8-927f-89ac3691315d","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T06:43:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 06:43:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8026418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8026418","identity":"rs-8026418","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}