Transcultural Adaptation, Validity and Reliability Testing of Infertility Risk Self- Assessment Questionnaire (FertiSTAT) to Indonesian Language A Cross-Sectional Study

Transcultural Adaptation, Validity and Reliability Testing of Infertility Risk Self- Assessment Questionnaire (FertiSTAT) to Indonesian Language A Cross-Sectional Study | 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 Transcultural Adaptation, Validity and Reliability Testing of Infertility Risk Self- Assessment Questionnaire (FertiSTAT) to Indonesian Language A Cross-Sectional Study Andon Hestiantoro, Gita Pratama, Aria Kekalih, Utomo Budidarmo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9087134/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Background: Declining fertility rates and limited awareness of fertility risk factors pose major reproductive health challenges. FertiSTAT is a self-assessment tool for fertility risk awareness but has not been culturally adapted suitable for Indonesian population. Objective: To perform transcultural adaptation and evaluate the validity and reliability of the Indonesian version of FertiSTAT as a screening tool for fertility risk awareness for Indonesian population. Methods: A descriptive cross-sectional study was conducted involving 7 expert panel members, 4 certified translators, and 92 subjects, through a transcultural adaptation process which included expert content validation, forward–backward translation, face validation, cognitive debriefing, and test–retest reliability assessment. Content validity was measured using the Content Validity Index, while reliability was assessed using Cohen’s kappa and Spearman correlation. Results: All items retained conceptual equivalence and cultural relevance. Content validity showed CVI > 0.80 for all items and face validity demonstrated mean Likert scores > 3. Test–retest reliability showed variable agreement; several items achieved strong consistency, while lower values were mainly due to sensitive, subjective, fluctiative or strong homogenity of test-retest responses. Stability was acceptable for screening purposes. One additional item, tuberculosis was included on expert panel recommendations due to its prevalence and relevance to infertility in Indonesia. Conclusion: The Indonesian version of FertiSTAT has been succesfully adapted transculturally with good content and face validity, acceptable reliability and is suitable as an initial screening tool for fertility risk awareness among reproductive-aged women in Indonesia. FertiSTAT infertility awareness fertility risk transcultural adaptation validity reliability Introduction The Total Fertility Rate (TFR) has declined globally, and in several countries it has fallen below the population replacement level of 2.1 children per woman. A similar trend has been observed in Indonesia, where the TFR decreased from 5.61 in 1971 to 2.18 in 2020 1 , with the Capital Region of Jakarta recording the lowest rate at 1.71 2 . Without proper interventions, Indonesia’s TFR is projected to decline further to approximately 1.91 by 2045 3 . Globally, projections indicate that by 2050–2100 approximately 77% of high-income countries and 93% of countries worldwide will have total fertility rates below the population replacement level 4 ˒ 5 . This decline has the potential to alter demographic structures by increasing the proportion of older adults relative to the productive-age population, thereby raising the burden on national healthcare systems and social financing. 6 . Low awareness of fertility risk factors is one of the contributors to declining fertility. An international study involving 10,045 participants from 79 countries reported that the average level of fertility knowledge was only about 56.9%, with many respondents unaware of the decline in fertility after the age of 34 years as well as the impact of sexually transmitted infections on fertility. 7 . A survey conducted in Canada found that 91.4% of women believed that assisted reproductive technologies could overcome fertility decline until menopause 8 . A study conducted in the United States also showed that even among women with a medical educational background, approximately 55% overestimated fecundability after the age of 40, as well as the success rates of IVF beyond the age of 35 9 . This lack of knowledge contributes to delayed childbearing and increases the likelihood of requiring assisted reproductive technologies 9 . Understanding fertility risk factors is important for women of reproductive age to assess their reproductive health status and take appropriate preventive measures 10 ˒ 11 . One instrument developed to improve such awareness is FertiSTAT, published by Bunting and Boivin from Cardiff University, UK, which is a screening instrument consisting of 22 questions related to fertility risk factors, developed through a literature review and validated by an expert panel 11 ˒ 12 . This instrument assists women in identifying factors that may affect fertility, including lifestyle, medical conditions, and reproductive health history, while also providing clear and easily understandable guidance on when to seek medical assistance based on the urgency of the issue categorized with color based approach for easy understanding. 11 . Afterall, it has been widely known, based on the AIDA model (Awareness–Interest–Desire–Action), that increased awareness is expected to encourage individuals to take concrete actions, such as consulting healthcare professionals regarding fertility 13 . In Indonesia, FertiSTAT is not yet available in a linguistically and culturally adapted version, despite the considerable need for tools that assess fertility risk awareness 11 ˒ 14 . Low awareness of fertility risk factors may lead to delays in seeking medical care, older age at the time of attempting conception, and greater exposure to factors that negatively affect fertility 8 ˒ 15 . FertiSTAT has the potential to help obtain preliminary information regarding women’s reproductive health history prior to consultation with an obstetrician–gynecologist (Obstetrics and Gynecology specialist), thereby improving the efficiency and accuracy of clinical evaluation 11 . Therefore, this study aims to conduct a cross-cultural adaptation of the FertiSTAT questionnaire into the Indonesian language and to evaluate its validity and reliability so that it can be applied in fertility-related research and clinical practice in Indonesia 16 ˒ 17 . The Need for Adaptation of FertiSTAT for Indonesian Population Awareness is the perception or knowledge of something. 18 , In the health education/promotion context, this concept is also referred to as health awareness and health literacy, defined as an individual’s ability to access, understand, and use health information and services to make decisions and take actions for themselves or for others 19 ˒ 20 . Both concepts are ultimately expected to continue in appropriate health-related actions, including seeking assistance from appropriate healthcare professionals. 21 . In the context of fertility, insufficient accurate knowledge about fertility risk factors may lead to delayed childbearing beyond the biological limits of fertility, increase the risk of age-related pregnancy complications, and at the population level contribute to a decline in the total fertility rate (TFR) 4 ˒ 22 . Fertility risk factors include modifiable factors that may impair the ability to conceive or increase the risk of infertility 12 , therefore, increasing awareness is expected to help women of reproductive age undertake earlier preventive measures. Approaches that may be utilized to both assess and enhance awareness of health risks are the use of specifically designed screening tools, such as questionnaires, chatbots, informational media, digital applications or health chatbots, interactive educational platforms, and self-assessment instruments 11 – 13 , 15 , 23 . These approaches aim to assist individuals in recognizing their personal risk factors at an early stage, thereby enabling more informed health-related decisions. In this study, the instrument used is FertiSTAT, developed by Bunting and Boivin (2010) 11 . Globally, awareness of fertility risk factors among women remains limited, including among highly educated groups. Evidence from the International Fertility Decision-Making Study (IFDMS) demonstrated a correlation between a higher number of self-assessed risk factors identified using FertiSTAT and lower overall fertility knowledge 7 . This low level of awareness is influenced by limited exposure to reproductive health education 9 , 24 , 25 as well as misinformation, for example regarding the optimal age for conception and the impact of certain lifestyle factors on fertility 11 . Other contributing factors include social and cultural influences, such as the perception that by discussing fertility issues openly is considered taboo, which may hinder the dissemination of accurate information. 26 . Economic factors may also play a role, as the high cost of medical evaluation and treatment can discourage individuals from seeking early medical assistance. As a result, many couples only pursue professional help after fertility problems have persisted for a considerable period. Therefore, more accessible and cost-effective initial approaches are needed to help individuals identify fertility risk factors at an earlier stage. In this context, evidence-based interventions such as the FertiSTAT questionnaire are considered beneficial for improving fertility awareness in the general population 25 . Low awareness of fertility risk factors influences women’s knowledge and attitudes toward their reproductive health, including misconceptions regarding the effects of age, lifestyle, and health conditions on fertility. 11 , Even in a study comparing the general population with medical students or trainees, overestimation of fecundability after the age of 35 and the success of IVF at advanced maternal age has been observed among these educated groups 9 , as a result, individuals may delay seeking information and professional consultation, causing problems that could have been addressed earlier to be managed only at a later stage 27 , This situation is further worsen by less proactive family planning attitudes, with a tendency to postpone pregnancy without adequately considering the age-related decline in fertility. 26 . In the long term, low awareness may lead individuals to continue engaging in behaviors that adversely affect fertility, such as smoking, alcohol consumption, unprotected sex with multiple partners, and obesity. These behaviors may increase the risk of sexually transmitted infections that can damage the fallopian tubes, thereby elevating the likelihood of infertility and increasing the risk of pregnancy complications 22 , 28 – 30 . Once infertility has occurred, couples may require costly infertility treatments such as IVF. The lack of mental and financial preparedness for such interventions may subsequently reduce quality of life and negatively affect the psychological well-being of the couple. 31 . Therefore, education and screening using validated questionnaires are important to support better reproductive decision-making. Efforts to improve fertility awareness may utilize the AIDA model (Awareness–Interest–Desire–Action) 13 and may be implemented through various approaches, including practical tools such as questionnaires 11 , 15 . Among the evidence-based questionnaires assessing awareness of infertility risk factors is FertiSTAT, which has been evaluated in several countries and continues to be further developed and studied for its effectiveness 10 , 32 . FertiSTAT consists of 22 questions covering age, lifestyle, medical history, menstrual patterns, body mass index (BMI), sexually transmitted infections, smoking, and alcohol consumption, and provides recommended actions according to the level of risk identified. One of its strengths is the inclusion of quantified exposure to specific risk factors—such as the number of cigarettes smoked or the volume of alcohol consumed—which is generally not specified in other similar questionnaires. This feature can facilitate more structured pre-consultation information gathering, thereby supporting more efficient and comprehensive clinical evaluation 11 . However, FertiSTAT is not yet available in an Indonesian version that has undergone linguistic and cultural adaptation. Therefore, cross-cultural adaptation is necessary to ensure conceptual equivalence and user acceptability 33 , 34 , accompanied by testing of its validity (content, face, and linguistic/cross-cultural validity) 16 , 35 , 36 as well as reliability testing appropriate for categorical or ordinal data (e.g., Cohen’s kappa and Spearman’s rho) 37 – 43 . A systematic adaptation process includes a two-step translation procedure (forward and backward translation), evaluation by expert and lay panels, cognitive debriefing to ensure that each item is understood as intended in the original instrument, and refinement of the questionnaire continued with reliability testing prior to its use in the target population. 34 , 35 , 44 – 46 . Materials and Methods Methodology This is a cross-sectional descriptive study aimed at performing the cross-cultural adaptation, validity assessment, and reliability testing of the FertiSTAT questionnaire into the Indonesian language for use among women of reproductive age in Indonesia. The adaptation process followed several stages recommended for cross-cultural instrument adaptation, including content validation by an expert panel, a two-step translation process (forward and backward translations), face validation by a lay panel, cognitive debriefing, and reliability testing using a test–retest method to assess the consistency of respondents’ answers over a specified time interval. These steps were conducted systematically to ensure that each questionnaire item preserved conceptual equivalence with the original version while remaining appropriate for the linguistic and cultural context of Indonesia. Prior to study, written permission by email was given from the original author Professor Jacky Boivin BA,MA,PhD from Cardiff University, UK on 31st December 2024 after official correspondence over telephone. Ethical approval by institutional review board of Medical Faculty University of Indonesia was obtained for the study. Duration This study was conducted over 12-months period, from January 2025 to December 2025. All data collection was carried out online among the Indonesian population to facilitate participant access and allow broader population coverage. The sampling method used was convenience purposive sampling, in which respondents were selected based on predefined criteria established by the researchers. This approach was chosen because instrument adaptation studies prioritize the representation of characteristics of the target population rather than statistical representation of the general population. All participants who met the inclusion criteria were provided with an explanation of the study objectives and were asked to give informed consent before completing the questionnaire. Participants The study participants were divided into several groups according to the stages of the study. The expert panel consisted of consultant obstetricians and gynecologists specializing in reproductive endocrinology and fertility (OB/GYN - REI) and social obstetrics and gynecology (Social OB/GYN subspecialists), language experts or professional translators with experience in medical terminology, as well as research methodology experts experienced in the development and validation of research instruments. The expert panel assessed content validity by evaluating the relevance of each questionnaire item to the concept of fertility risk awareness within the Indonesian context. The assessment was performed using a Likert scale, after which the Item Content Validity Index (I-CVI) was calculated as the ratio of the number of panelists assigning high relevance scores to the total number of panelists. Items with an I-CVI value greater than 0.8 were considered to have good content validity and were retained in the translated version. In addition to the expert panel, the study also involved a lay panel consisting of 5–10 women of reproductive age (18–45 years) with a minimum educational level equivalent to senior high school and without a medical background, but capable of representing the target population of questionnaire users (Table 1 ). The lay panel evaluated face validity to ensure that each questionnaire item was easily understood by the general public. The assessment used a Likert scale ranging from 1 to 5 to indicate the level of clarity of each question, after which the mean score for each item was calculated. Items with an average score of ≥ 3 were considered to have acceptable face validity. Furthermore, a cognitive debriefing panel consisting of 5–6 women of reproductive age with diverse educational backgrounds participated in a focused group discussion to evaluate respondents’ understanding of each questionnaire item, identify potential misinterpretations, and provide feedback on words or phrases that might be difficult to understand. Participants characteristic can be seen on Table 1 . Table 1 Participant Characteristics for Face Validation, Cognitive Debriefing, and Test–Retest Reliability Assessment Category Lay Panel Inclusion Criteria Women of reproductive age (18–45 years). Have a minimum educational level equivalent to senior high school. Do not have a medical/paramedical background but are able to represent the target population. Women of reproductive age with or without fertility risk factors. Do not have cognitive or mental disorders that could affect their ability to understand the questionnaire.. Exclusion Criteria Respondents who did not complete the questionnaire in full. Respondents with medical or psychiatric conditions that may affect their ability to participate. Additional Characteristics for the Cognitive Debriefing Panel Diverse educational backgrounds to represent population heterogeneity. Willing to provide detailed feedback on the comprehension of each questionnaire item. Procedure The sample size was determined based on recommendations from previous studies on instrument adaptation. The study stages involved a minimum of five expert panelists for content validity assessment, four professional translators for the translation process (two for forward translation and two for backward translation), ten lay panel members for face validity evaluation, and five participants for cognitive debriefing, consistent with prior methodological studies. According to the power analysis and reliability estimates described by de Raadt et al. (2021), a sample size of 50 or 100 participants is required to achieve a Pearson correlation coefficient (r) cutoff of 0.79 and 0.81 with a 95% confidence interval width of 0.22 and 0.14 42 . Values approaching 1 indicate stronger reliability, and this study established a minimum threshold of 0.80 for acceptable stability. With 100 respondents targeted for this phase, in addition to the experts, translators, and lay panelists involved in the earlier validation stages, the total number of participants recruited for this study was 123 individuals. Test–retest reliability was assessed by administering the questionnaire to respondents at two different time points with a two-week interval to evaluate the stability of responses. Reliability analysis was performed using Cohen’s kappa to measure the level of agreement between the first and second measurements, and Spearman’s correlation coefficient (Spearman’s rho) to assess the consistency of the relationship between the two sets of measurements. Interpretation of kappa values followed the classification proposed by Landis and Koch (1977), while interpretation of Spearman’s correlation coefficients was based on commonly used categories of correlation strength in statistical research. To facilitate interpretation, the classification of both the Kappa and Spearman’s rho values was performed using modified classification criteria, which was derived from a combined classification based on the Landis and Koch criteria (agreement based scale) and the classical Spearman correlation classification(weak-strong relationship), as shown in Table 3 below. Table 2 Modified Classification used for Reliability Testing Result Modified classification Interpretation < 0.2 Very weak 0.2–0.39 Weak 0.4–0.59 Moderate 0.6–0.79 Strong ≥0.8 Very Strong Data Analysis Data processing and statistical analyses were conducted using Microsoft Excel and SPSS version 29 to ensure systematic and accurate analysis.The findings of this study are expected to produce an Indonesian version of the FertiSTAT questionnaire that is valid, reliable, and culturally relevant, enabling its use as a research instrument, a reproductive health education tool, and an initial screening instrument for fertility risk awareness among women of reproductive age in Indonesia. Results This study involved several participant groups corresponding to the stages of cross-cultural adaptation of the FertiSTAT instrument, including an expert panel, sworn translators, a lay panel for face validity assessment, a cognitive debriefing panel, and a test–retest reliability panel. The expert panel consisted of consultant obstetricians and gynecologists subspecializing in reproductive endocrinology and infertility (OB/GYN-REI) and social obstetrics and gynecology (Social OB/GYN), language experts or professional translators experienced in medical terminology from the Language Center of Universitas Indonesia (LBI UI), as well as research methodology experts with experience in the development and validation of research instruments (Table 3). This panel was responsible for conducting content validation of the FertiSTAT questionnaire to ensure conceptual relevance and equivalence of meaning within the Indonesian cultural context. The discussion and content validity assessment were conducted online through Zoom ® meeting. In addition to the expert panel, the language translation process also involved four sworn translators consisting of two English language specialists and two Indonesian language specialists. The translators were affiliated with the International Language Institute, Faculty of Humanities, Universitas Indonesia (LBI FIB UI), and the LIA Translation Center. They conducted forward translation and back translation to ensure semantic equivalence between the English and Indonesian versions. Table 3 . Expert Panel for Content Validation No. Initials Sex Profession Expertise Remarks 1 AH Male Professor of FMUI OB/GYN REI Subspecialisr First Author. Ensure the clinical relevance and accuracy of fertility-related content 2 GP Male Lecturer of OB/GYN Departement FMUI OB/GYN REI Subspecialisr Second Author. Ensure the clinical relevance and accuracy of fertility-related content 3 AK Male Lecturer of Dept. Of Community Medicine FMUI Medical research, methodology, and information technology. Third Author. Ensure the clinical relevance and accuracy of fertility-related content 4 UB Male REI Subspecialist Trainee OB/GYN Fourth Author. Expert is community medicine and foreign questionnaire adaptation 5 BML Male Staff at Dept. of OB/GYN National Police Hospital Social OB/GYN subspecialist Due to their expertise in reproductive health and population determinants of fertility, social obstetrics and gynecology subspecialists were included 6 FP Male Staff at Dept. of OB/GYN National Police Hospital Social OB/GYN subspecialist 7 GJW Female Language Expert / Medical Linguistics Sworn Translator and English Language Specialist Ensure linguistic accuracy, clarity, and cultural appropriateness in the Indonesian adaptation of the questionnaire FMUI = Faculty of Medicine University of Indonesia; OB/GYN = Obstetrics and Gynecology; REI= Reproductive Endocrinology and Infertility The lay panel used for face validity assessment consisted of ten women of reproductive age without a medical background. This panel evaluated readability, clarity of language, and the ease of understanding of each questionnaire item. Most respondents in the lay panel were young adults, with a mean age of 22.2 ± 3.22 years and an age range of 18 to 27 years (Table 4). The educational distribution showed a balanced proportion between respondents with senior high school education and those with undergraduate (S1/D4) education. Characteristic of lay panel for face validity assesment may be seen in Table 5. Table 4 . Lay Panel Respondents for Face Validity Assessment No. Initial Age (year) Sex Education Province of Origin 1 FYN 23 Female Highchool Jakarta 2 El 28 Female S1/D4 Central Java 3 RT 21 Female Highschool Aceh 4 SIA 21 Female S1/D4 Lampung 5 A 20 Female Highschool East Java 6 M 19 Female Highschool Yogyakarta 7 JIO 18 Female Highschool Jakarta 8 D 22 Female S1/D4 Lampung 9 N 23 Female S1/D4 Central Java 10 YS 27 Female S1/D4 West Sumatera Mean ± SD 22,2 ± 3,22 S1 = academic bachelor’s degree; D4 = applied bachelor’s degree. The cognitive debriefing panel consisted of five women of reproductive age who did not have a background in health sciences and had not previously been exposed to the concept of FertiSTAT. This group participated in structured discussions to assess whether each questionnaire item was understood in accordance with the intended meaning of the original concept. The mean age of the cognitive debriefing panel was 21.8 ± 2.58 years. This panel can be seen in table 6. Table 5 . Lay Panel Respondents for Cognitive Debriefing No. Initial Age (year) Sex Education Province of Origin 1 N 22 Female Highschool Jakarta 2 YH 21 Female S1/D4 Central Java 3 R 25 Female Highschool Aceh 4 S 23 Female S1/D4 Lampung 5 CC 18 Female Highschool East Java Mean ± SD 21,8 ± 2,58 In the test–retest reliability testing, the Indonesian version of the FertiSTAT questionnaire was completed twice by women of reproductive age with a 14-day interval between administrations. Although the planned sample size for this stage was 100 respondents, and recruitment had been extended to 132 participants to anticipate potential dropouts, a total of 77 respondents completed the questionnaire again during the retest phase. Nevertheless, this did not compromise the validity of the results because, as shown in Table 2 above, the reliability coefficient (r) with a sample size of 77 remained at 0.80, which corresponds to the minimum reliability threshold predetermined for this study. The demographic characteristics (table 7) indicated that the median age of respondents was 21 years, with an age range of 18 to 33 years. The majority of respondents had a high school level of education (70.1%), followed by those with diploma or undergraduate education (26%). Table 6 . Demographic Characteristics of Test–Retest Reliability Respondents (n = 77) n % Mean ± SD / Median (Min – Max) Age; year Education Junior Highschool Highschool Bachelor’s Degree (S1/D4) Magistrate (S2), Doctorate (S3) 21 (18 – 33) 2 54 20 1 2,6 70,1 26,0 1,3 Content validation was conducted through expert panel discussions in which each questionnaire item in the FertiSTAT instrument was evaluated for its relevance to the cultural and reproductive health context in Indonesia. The assessment yielded a mean Content Validity Index (CVI) of 0.95, indicating very high content validity. Most items obtained CVI values above 0.8 and were therefore considered valid for use in the Indonesian context. One item related to marijuana use obtained a CVI value of 0.6 due to concerns that the term might not be easily understood by respondents and the potential for response bias given the sensitivity of the topic. Nevertheless, the item was retained because it remains a relevant risk factor for infertility. The results for content validation are shown in Table 7. [Insert Table 7 here] full table available in this file after references’ section The expert panel also provided several important recommendations regarding terminology adjustments to better align with the local context. For example, the term marijuana was suggested to be replaced with the word “ganja,” which is more familiar to the Indonesian population, while the term class A drugs was recommended to be replaced with “narcotics” or “NAPZA” (narcotics, psychotropics, and addictive substances). The expert panel also proposed the addition of one questionnaire item related to tuberculosis, given its high prevalence in Indonesia and its known potential impact on reproductive health. The language adaptation process was conducted through forward translation and backward translation by four sworn translators. Comparison of the different translated versions indicated that the conceptual meaning of each item was well preserved throughout the translation process. Among the two available forward translation versions, the translation prepared by translator GJW, who holds a doctoral degree in linguistics, was selected. In addition to the translator’s high level of expertise, this version provided the most appropriate conceptual equivalence and was considered the most concise and easily understood. The results for forward and back translation by four sworn translator are shown in Table 8. [Insert Table 8 here] full table available in this file after references’ section Following the translation process, face validity assessment was conducted by the lay panel to evaluate the clarity and readability of each questionnaire item using a Likert scale. The results showed that the mean Likert scores for each item ranged from 4.5 to 4.9, indicating that the questions were considered clear and easily understood by the respondents. Subsequently, a cognitive debriefing process was carried out to identify potential misinterpretations or linguistic ambiguities within the questionnaire. The discussion results indicated that most items did not require modification, as they were already considered clear by the respondents. However, several technical terms were clarified to improve comprehension among lay participants, for example by adding an explanation of how to calculate ideal body weight. The results for face validation and cognitive debriefing are shown in Table 9. [Insert Table 9 here] full table available in this file after references’ section Based on the results of content validation, translation, face validation, and cognitive debriefing, the final Indonesian version of the FertiSTAT questionnaire was developed for use in the reliability testing phase. The final version consists of 23 questionnaire items covering the categories of attempting to conceive, reproductive history, and lifestyle. One additional item included in the final version addresses a history of tuberculosis, which is categorized by our expert panel as a moderate-level fertility risk factor. The final Indonesian version of the FertiSTAT questionnaire for test-retest reliability testing is shown in Table 10. [Insert Table 10 here] full table available in this file after references’ section Test–Retest Reliability Results Test–retest reliability was performed to evaluate the consistency of respondents’ answers across two measurement points separated by a 14-day interval. Reliability analysis was conducted using Cohen’s kappa statistic to assess categorical agreement and Spearman’s correlation coefficient to evaluate the consistency of ranked responses over time. The results showed that several items demonstrated strong to very strong reliability, particularly those related to medical diagnoses or clearly defined health conditions, such as endometriosis and a history of tuberculosis. In contrast, some items that were more subjective or related to behaviors that may vary over time, such as stress levels or caffeine consumption, showed lower reliability values. A few items could not have reliability coefficients calculated because there was no variation in responses across the two measurement points or because the responses were highly uniform. This situation occurred in questions involving sensitive or infrequent behaviors, such as illicit drug use or marijuana smoking, where nearly all respondents provided the same response. Overall, the reliability analysis indicates that most items in the Indonesian version of the FertiSTAT questionnaire demonstrate adequate consistency and can be used as a screening instrument to assess infertility risk awareness among women of reproductive age. Test-retest reliability testing result for Indonesian version of the FertiSTAT questionnaire is shown in Table 11. [Insert Table 11 here] full table available in this file after references’ section Discussion The initial stage of adapting the Indonesian version of the FertiSTAT instrument began with content validity assessment. This evaluation was conducted by an expert panel consisting of reproductive endocrinology and infertilty subspecialist, social OB/GYN subspecialists and related academic experts, who assessed each item based on content relevance, contextual appropriateness, and clarity of wording. Overall, the results indicated that all items were rated in the very good category, with high average scores, suggesting that the FertiSTAT questionnaire items were considered relevant and appropriate for use in the Indonesian population context. Some items needed cultural and contextual modifications to be more suitable with the Indonesian socio-cultural setting, such as not using terms like units instead of using household /general known measurement and types of liquor frequently consumed, from national survei data 47 . Methodologically, conducting content validity assessment prior to the translation process is important. By first evaluating the conceptual and clinical relevance of the original version, the subsequent translation process becomes more focused, as only items deemed truly relevant are carried forward into the language adaptation stage. This strategy improves the efficiency of the adaptation process while strengthening the conceptual foundation of the instrument before linguistic adjustments are performed After content validity had been confirmed, the process proceeded with forward translation and backward translation conducted by different translators. This procedure aimed to maintain semantic and conceptual equivalence between the original version and the Indonesian version. The translation results indicated that the meaning of each item was generally well preserved without substantial distortion. Thus, the translation process did not merely produce a literal translation, but also ensured that the questionnaire content remained consistent with the original intent of the instrument and could be appropriately understood within the Indonesian cultural context. Following the completion of content validation and translation, face validity was assessed by a lay panel consisting of women of reproductive age from diverse educational backgrounds. The results showed that all questionnaire items were considered clear, easy to understand, and free from ambiguity, indicating that the instrument had good readability for the target population. The next stage was cognitive debriefing, which aimed to evaluate whether each item was understood by respondents in accordance with the intended concept. The discussion results indicated that nearly all questions were well understood without requiring modification. Only one item required editorial adjustment, namely the question regarding overweight status. This revision was made to make the sentence more natural, operational, and easier for lay respondents to understand. These findings suggest that the overall linguistic structure of the questionnaire was already appropriate, and that the changes made were minor and primarily intended to improve practical clarity. The results of the test–retest reliability analysis showed variation across questionnaire items. At first glance some items appeared to have low reliability or even yielded coefficients that could not be calculated, this does not necessarily indicate that the instrument is unsuitable for use. The instrument had previously undergone content validity assessment and cognitive debriefing, ensuring a strong conceptual and cultural foundation. In other words, before quantitative testing was performed, the items had already been confirmed to be relevant and appropriately understood by the target respondents. Several items related to sensitive topics or very rare events, such as alcohol consumption, drug use, or certain behaviors of a partner, produced highly homogeneous responses. Under such conditions, Cohen’s kappa or Spearman’s rho values may become unavailable (N/A) because there is no variation in responses, rather than because the item lacks reliability. Methodologically, homogeneous responses may actually reflect very high consistency over time, even though the coefficient cannot be calculated by the statistical software used. On the contrary, items related to subjective perceptions or conditions that may change over time, such as stress, menstrual pain, or perceptions of menstrual cycle patterns, tended to show lower reliability values. This pattern is a common characteristic of self-report instruments measuring psychosocial or behavioral aspects. Therefore, variation in reliability across items should be interpreted as reflecting the nature of the constructs being measured rather than indicating a fundamental weakness of the instrument.. Overall, the Indonesian version of FertiSTAT can still be considered appropriate for use, especially in the context of screening or initial assessment of fertility risk factors among women of reproductive age. The value of the instrument should not be judged solely by the perfection of reliability coefficients, but also by its ability to properly represent respondents’ experiences and relevant fertility risk factors. This study has several important strengths. From a novelty perspective, it represents the first cross-cultural adaptation of the FertiSTAT questionnaire into the Indonesian language, thereby providing a fertility screening tool that had previously been unavailable in the local context. In addition, the study introduced an additional item regarding tuberculosis, a disease with high relevance in Indonesia that may affect fertility but is not included in the original FertiSTAT version. Methodologically, the study applied a comprehensive and rigorous adaptation process, including content validation, forward–backward translation, face validation, cognitive debriefing, and test–retest reliability assessment. The involvement of a multidisciplinary expert panel further strengthened the quality of the adaptation process. As a result, the instrument developed is not only theoretically valid but also better aligned with the clinical and cultural context of Indonesia. The study also has broad potential for implementation. The Indonesian version of FertiSTAT may be used in obstetrics and gynecology clinical practice, reproductive health education, public health research, and evidence-based fertility program planning. Despite being conducted systematically, the study has several limitations. The primary limitation lies in the potential for self-report bias, as all responses were provided directly by the participants. This may introduce social desirability bias, perceptual errors, or limited understanding of certain medical terms. This limitation is particularly relevant for items involving sensitive topics or requiring more specific medical knowledge. The findings of this study also have important clinical implications, as they provide a validated and reasonably reliable Indonesian version of FertiSTAT that can be used as an initial screening instrument. In clinical practice, this tool may assist obstetricians and gynecologists, midwives, and other reproductive health professionals in identifying fertility risk factors more quickly and systematically. The use of FertiSTAT may also improve consultation efficiency, as the preliminary information obtained from patients can help guide clinical history-taking in a more focused manner. Furthermore, as a self-screening tool, FertiSTAT may increase women’s awareness of their fertility risks, thereby encouraging earlier consultation before problems become more complex. Because of its simplicity and easily understood questions to answer, the instrument also has the potential to be widely used in various healthcare settings, including primary healthcare centers, fertility clinics, and reproductive health promotion and prevention programs. Therefore, its uses are not limited to research but can also extend to clinical services and community health education. Recommendation The Indonesian version of FertiSTAT may first be pilot-tested on a small sample representing diverse characteristics of women of reproductive age in Indonesia to ensure that its application aligns with the local context. Following this preliminary evaluation, broader implementation may be employed in population-based research or clinical services. The use of this instrument may also be accompanied by brief explanations to respondents regarding items that involve sensitive or medical concepts in order to minimize potential misunderstanding bias. Future research may explore behavioral changes following completion of the FertiSTAT questionnaire or evaluate its acceptability when applied in primary healthcare settings. Furthermore, in future development, the Indonesian-language FertiSTAT questionnaire could be integrated with the official online FertiSTAT platform developed by Cardiff University for use among Indonesian-speaking populations. Conclusion The Indonesian version of the FertiSTAT questionnaire has been successfully adapted through a comprehensive process while maintaining conceptual equivalence with the original instrument. This adaptation included forward–backward translation, content validation by an expert panel, face validation, cognitive debriefing, and test–retest reliability assessment. The study results demonstrate that the instrument has excellent content validity, with the Content Validity Index (CVI) for all items exceeding the recommended threshold. In addition, evaluation by the lay panel indicated good face validity, as all items were considered clear, easy to understand, and appropriate within the cultural context of the respondents. Test–retest reliability analysis showed that most items demonstrated satisfactory consistency. Variations in reliability observed in some items were mainly influenced by the sensitive or subjective nature of the questions, the possibility of natural changes over time, and the extreme homogeneity of responses for certain items. Overall, the Indonesian version of FertiSTAT can be considered an instrument with adequate validity and reliability for use as an initial screening tool to assess awareness of fertility risk factors among women of reproductive age in Indonesia, both in research settings and in clinical reproductive health practice. Abbreviations FertiSTAT Fertility Status Awareness Tools TFR Total Fertility Rate DKI Daerah Khusus Ibukota PPN Perencanaan Pembangunan Nasional OBGYN Obstetrics and Gynecologist IFDMS International Fertility Decision-Making Study IVF In Vitro Fertilization IMT Indeks Massa Tubuh IMS Infeksi Menular Seksual Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Health Research Ethics Committee of the Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo Hospital (FKUI-RSCM) . All participants provided informed consent prior to participation in the study. Participation was voluntary, and respondents were informed about the objectives of the research and their right to withdraw at any time without consequences. Ethical approval number: KET-1105/UN2.F1/ETIK/PPM.00.02/2025 Date of approval: 25 July 2025 Original scanned approval on the next page Availability of data and materials The datasets supporting the conclusions of this article are included within the article. Competing interests The authors declare that they have no competing interests. Funding This research received funding from Lembaga Pengelola Dana Pendidikan Kementerian Keuangan Republik Indonesia (Indonesia Endowment Fund for Education Agency from Ministry of Finance of the Republic of Indonesia). Author Contributions Statement U.B. , A.H. and A.K. conceived the study and designed the transcultural adaptation methodology. G.P. and A.K. were responsible for ensuring the clinical relevance and statistical accuracy of the fertility-related content and research data. U.B. performed the data collection, interviews and coordination to language experts and all respondents and A.K. did statistical analysis using Microsoft Excel and SPSS. U.B. wrote the main manuscript text and prepared all tables. All authors reviewed and approved the final manuscript. Key for Initials used: A.H.: Prof. Dr. Andon Hestiantoro, MD, OB/GYN-REI (First Author) G.P.: Dr. Gita Pratama, MD, OB/GYN-REI, M.RepSc (Second Author) A.K.: Dr.Aria Kekalih, MD, M.IT (Third Author) U.B.: Utomo Budidarmo, MD, OB/GYN. (Corresponding/Fourth Author) Consent for publication Not applicable. This study did not include identifiable individual participant data. Acknowledgements The authors would like to thank the expert panel members, the translators from the Language Center of Universitas Indonesia (LBI FIB UI) and LIA Language Institute – Salemba Branch, , and all participants who contributed to the face validation, cognitive debriefing, and reliability testing phases of this study. The authors also express gratitude to the Division of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, and Department of Community Medicine Faculty of Medicine Universitas Indonesia for their support in the conduct of this research. The authors also express gratitude to Department of Obstetrics and Gynecology Indonesian National Police Central (Level 1) Hospital for their support in the conduct of this research Authors’ information Andon Hestiantoro is a Professor of Reproductive Endocrinology and Fertility at the Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia also associate editor in Middle East Fertility Society Journal . Gita Pratama is a consultant/subspecialist in Reproductive Endocrinology and Fertility and also lecturer at the same institution. Aria Kekalih is a lecturer at the Department of Community Medicine, Faculty of Medicine Universitas Indonesia, with expertise in research methodology and health informatics. Utomo Budidarmo is an Obstetrics Gynecologist currently enrolled in the Reproductive Endocrinology and Fertility subspecialty training program at Faculty of Medicine Universitas Indonesia. References Adi Ahdiat. 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BMJ Open. 2022 Jan 3;12(1). doi:10.1136/bmjopen-2021-051710 PubMed PMID: 34980614. Gjersing L, Caplehorn JRM, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Med Res Methodol. 2010;10(1):13. doi:10.1186/1471-2288-10-13 Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine (Phila Pa 1976) [Internet]. 2000;25(24). Available from: https://journals.lww.com/spinejournal/fulltext/2000/12150/guidelines_for_the_process_of_cross_cultural.14.aspx Sousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011 Apr 1;17(2):268–74. doi:https://doi.org/10.1111/j.1365-2753.2010.01434.x Guillemin,’ F, Bombardier C, Beaton~ D. 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Tables Tables 7 to 11 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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A similar trend has been observed in Indonesia, where the TFR decreased from 5.61 in 1971 to 2.18 in 2020\u003csup\u003e1\u003c/sup\u003e, with the Capital Region of Jakarta recording the lowest rate at 1.71\u003csup\u003e2\u003c/sup\u003e. Without proper interventions, Indonesia\u0026rsquo;s TFR is projected to decline further to approximately 1.91 by 2045\u003csup\u003e3\u003c/sup\u003e. Globally, projections indicate that by 2050\u0026ndash;2100 approximately 77% of high-income countries and 93% of countries worldwide will have total fertility rates below the population replacement level\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e5\u003c/sup\u003e. This decline has the potential to alter demographic structures by increasing the proportion of older adults relative to the productive-age population, thereby raising the burden on national healthcare systems and social financing.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLow awareness of fertility risk factors is one of the contributors to declining fertility. An international study involving 10,045 participants from 79 countries reported that the average level of fertility knowledge was only about 56.9%, with many respondents unaware of the decline in fertility after the age of 34 years as well as the impact of sexually transmitted infections on fertility.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. A survey conducted in Canada found that 91.4% of women believed that assisted reproductive technologies could overcome fertility decline until menopause \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. A study conducted in the United States also showed that even among women with a medical educational background, approximately 55% overestimated fecundability after the age of 40, as well as the success rates of IVF beyond the age of 35\u003csup\u003e9\u003c/sup\u003e. This lack of knowledge contributes to delayed childbearing and increases the likelihood of requiring assisted reproductive technologies \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eUnderstanding fertility risk factors is important for women of reproductive age to assess their reproductive health status and take appropriate preventive measures\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e11\u003c/sup\u003e. One instrument developed to improve such awareness is FertiSTAT, published by Bunting and Boivin from Cardiff University, UK, which is a screening instrument consisting of 22 questions related to fertility risk factors, developed through a literature review and validated by an expert panel\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e12\u003c/sup\u003e. This instrument assists women in identifying factors that may affect fertility, including lifestyle, medical conditions, and reproductive health history, while also providing clear and easily understandable guidance on when to seek medical assistance based on the urgency of the issue categorized with color based approach for easy understanding.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Afterall, it has been widely known, based on the AIDA model (Awareness\u0026ndash;Interest\u0026ndash;Desire\u0026ndash;Action), that increased awareness is expected to encourage individuals to take concrete actions, such as consulting healthcare professionals regarding fertility\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn Indonesia, FertiSTAT is not yet available in a linguistically and culturally adapted version, despite the considerable need for tools that assess fertility risk awareness \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e14\u003c/sup\u003e. Low awareness of fertility risk factors may lead to delays in seeking medical care, older age at the time of attempting conception, and greater exposure to factors that negatively affect fertility\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e15\u003c/sup\u003e. FertiSTAT has the potential to help obtain preliminary information regarding women\u0026rsquo;s reproductive health history prior to consultation with an obstetrician\u0026ndash;gynecologist (Obstetrics and Gynecology specialist), thereby improving the efficiency and accuracy of clinical evaluation\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Therefore, this study aims to conduct a cross-cultural adaptation of the FertiSTAT questionnaire into the Indonesian language and to evaluate its validity and reliability so that it can be applied in fertility-related research and clinical practice in Indonesia\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe Need for Adaptation of FertiSTAT for Indonesian Population\u003c/p\u003e \u003cp\u003eAwareness is the perception or knowledge of something. \u003csup\u003e18\u003c/sup\u003e, In the health education/promotion context, this concept is also referred to as health awareness and health literacy, defined as an individual\u0026rsquo;s ability to access, understand, and use health information and services to make decisions and take actions for themselves or for others\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e20\u003c/sup\u003e. Both concepts are ultimately expected to continue in appropriate health-related actions, including seeking assistance from appropriate healthcare professionals.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. In the context of fertility, insufficient accurate knowledge about fertility risk factors may lead to delayed childbearing beyond the biological limits of fertility, increase the risk of age-related pregnancy complications, and at the population level contribute to a decline in the total fertility rate (TFR)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e˒\u003csup\u003e22\u003c/sup\u003e. Fertility risk factors include modifiable factors that may impair the ability to conceive or increase the risk of infertility\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, therefore, increasing awareness is expected to help women of reproductive age undertake earlier preventive measures.\u003c/p\u003e \u003cp\u003eApproaches that may be utilized to both assess and enhance awareness of health risks are the use of specifically designed screening tools, such as questionnaires, chatbots, informational media, digital applications or health chatbots, interactive educational platforms, and self-assessment instruments\u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. These approaches aim to assist individuals in recognizing their personal risk factors at an early stage, thereby enabling more informed health-related decisions. In this study, the instrument used is FertiSTAT, developed by Bunting and Boivin (2010)\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Globally, awareness of fertility risk factors among women remains limited, including among highly educated groups. Evidence from the International Fertility Decision-Making Study (IFDMS) demonstrated a correlation between a higher number of self-assessed risk factors identified using FertiSTAT and lower overall fertility knowledge\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. This low level of awareness is influenced by limited exposure to reproductive health education\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e as well as misinformation, for example regarding the optimal age for conception and the impact of certain lifestyle factors on fertility \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Other contributing factors include social and cultural influences, such as the perception that by discussing fertility issues openly is considered taboo, which may hinder the dissemination of accurate information.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Economic factors may also play a role, as the high cost of medical evaluation and treatment can discourage individuals from seeking early medical assistance. As a result, many couples only pursue professional help after fertility problems have persisted for a considerable period. Therefore, more accessible and cost-effective initial approaches are needed to help individuals identify fertility risk factors at an earlier stage. In this context, evidence-based interventions such as the FertiSTAT questionnaire are considered beneficial for improving fertility awareness in the general population \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLow awareness of fertility risk factors influences women\u0026rsquo;s knowledge and attitudes toward their reproductive health, including misconceptions regarding the effects of age, lifestyle, and health conditions on fertility.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, Even in a study comparing the general population with medical students or trainees, overestimation of fecundability after the age of 35 and the success of IVF at advanced maternal age has been observed among these educated groups\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, as a result, individuals may delay seeking information and professional consultation, causing problems that could have been addressed earlier to be managed only at a later stage \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, This situation is further worsen by less proactive family planning attitudes, with a tendency to postpone pregnancy without adequately considering the age-related decline in fertility.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. In the long term, low awareness may lead individuals to continue engaging in behaviors that adversely affect fertility, such as smoking, alcohol consumption, unprotected sex with multiple partners, and obesity. These behaviors may increase the risk of sexually transmitted infections that can damage the fallopian tubes, thereby elevating the likelihood of infertility and increasing the risk of pregnancy complications\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Once infertility has occurred, couples may require costly infertility treatments such as IVF. The lack of mental and financial preparedness for such interventions may subsequently reduce quality of life and negatively affect the psychological well-being of the couple.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Therefore, education and screening using validated questionnaires are important to support better reproductive decision-making.\u003c/p\u003e \u003cp\u003eEfforts to improve fertility awareness may utilize the AIDA model (Awareness\u0026ndash;Interest\u0026ndash;Desire\u0026ndash;Action)\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and may be implemented through various approaches, including practical tools such as questionnaires \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Among the evidence-based questionnaires assessing awareness of infertility risk factors is FertiSTAT, which has been evaluated in several countries and continues to be further developed and studied for its effectiveness\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. FertiSTAT consists of 22 questions covering age, lifestyle, medical history, menstrual patterns, body mass index (BMI), sexually transmitted infections, smoking, and alcohol consumption, and provides recommended actions according to the level of risk identified. One of its strengths is the inclusion of quantified exposure to specific risk factors\u0026mdash;such as the number of cigarettes smoked or the volume of alcohol consumed\u0026mdash;which is generally not specified in other similar questionnaires. This feature can facilitate more structured pre-consultation information gathering, thereby supporting more efficient and comprehensive clinical evaluation\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, FertiSTAT is not yet available in an Indonesian version that has undergone linguistic and cultural adaptation. Therefore, cross-cultural adaptation is necessary to ensure conceptual equivalence and user acceptability\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, accompanied by testing of its validity (content, face, and linguistic/cross-cultural validity)\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e as well as reliability testing appropriate for categorical or ordinal data (e.g., Cohen\u0026rsquo;s kappa and Spearman\u0026rsquo;s rho)\u003csup\u003e\u003cspan additionalcitationids=\"CR38 CR39 CR40 CR41 CR42\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. A systematic adaptation process includes a two-step translation procedure (forward and backward translation), evaluation by expert and lay panels, cognitive debriefing to ensure that each item is understood as intended in the original instrument, and refinement of the questionnaire continued with reliability testing prior to its use in the target population.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eMethodology\u003c/p\u003e \u003cp\u003eThis is a cross-sectional descriptive study aimed at performing the cross-cultural adaptation, validity assessment, and reliability testing of the FertiSTAT questionnaire into the Indonesian language for use among women of reproductive age in Indonesia. The adaptation process followed several stages recommended for cross-cultural instrument adaptation, including content validation by an expert panel, a two-step translation process (forward and backward translations), face validation by a lay panel, cognitive debriefing, and reliability testing using a test\u0026ndash;retest method to assess the consistency of respondents\u0026rsquo; answers over a specified time interval. These steps were conducted systematically to ensure that each questionnaire item preserved conceptual equivalence with the original version while remaining appropriate for the linguistic and cultural context of Indonesia. Prior to study, written permission by email was given from the original author Professor Jacky Boivin BA,MA,PhD from Cardiff University, UK on 31st December 2024 after official correspondence over telephone. Ethical approval by institutional review board of Medical Faculty University of Indonesia was obtained for the study.\u003c/p\u003e \u003cp\u003eDuration\u003c/p\u003e \u003cp\u003eThis study was conducted over 12-months period, from January 2025 to December 2025. All data collection was carried out online among the Indonesian population to facilitate participant access and allow broader population coverage. The sampling method used was convenience purposive sampling, in which respondents were selected based on predefined criteria established by the researchers. This approach was chosen because instrument adaptation studies prioritize the representation of characteristics of the target population rather than statistical representation of the general population. All participants who met the inclusion criteria were provided with an explanation of the study objectives and were asked to give informed consent before completing the questionnaire.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eThe study participants were divided into several groups according to the stages of the study. The expert panel consisted of consultant obstetricians and gynecologists specializing in reproductive endocrinology and fertility (OB/GYN - REI) and social obstetrics and gynecology (Social OB/GYN subspecialists), language experts or professional translators with experience in medical terminology, as well as research methodology experts experienced in the development and validation of research instruments. The expert panel assessed content validity by evaluating the relevance of each questionnaire item to the concept of fertility risk awareness within the Indonesian context. The assessment was performed using a Likert scale, after which the Item Content Validity Index (I-CVI) was calculated as the ratio of the number of panelists assigning high relevance scores to the total number of panelists. Items with an I-CVI value greater than 0.8 were considered to have good content validity and were retained in the translated version.\u003c/p\u003e \u003cp\u003eIn addition to the expert panel, the study also involved a lay panel consisting of 5\u0026ndash;10 women of reproductive age (18\u0026ndash;45 years) with a minimum educational level equivalent to senior high school and without a medical background, but capable of representing the target population of questionnaire users (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The lay panel evaluated face validity to ensure that each questionnaire item was easily understood by the general public. The assessment used a Likert scale ranging from 1 to 5 to indicate the level of clarity of each question, after which the mean score for each item was calculated. Items with an average score of \u0026ge;\u0026thinsp;3 were considered to have acceptable face validity.\u003c/p\u003e \u003cp\u003eFurthermore, a cognitive debriefing panel consisting of 5\u0026ndash;6 women of reproductive age with diverse educational backgrounds participated in a focused group discussion to evaluate respondents\u0026rsquo; understanding of each questionnaire item, identify potential misinterpretations, and provide feedback on words or phrases that might be difficult to understand. Participants characteristic can be seen on Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Characteristics for Face Validation, Cognitive Debriefing, and Test\u0026ndash;Retest Reliability Assessment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLay Panel\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eInclusion Criteria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen of reproductive age (18\u0026ndash;45 years).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHave a minimum educational level equivalent to senior high school.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not have a medical/paramedical background but are able to represent the target population.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen of reproductive age with or without fertility risk factors.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDo not have cognitive or mental disorders that could affect their ability to understand the questionnaire..\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRespondents who did not complete the questionnaire in full.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRespondents with medical or psychiatric conditions that may affect their ability to participate.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAdditional Characteristics for the Cognitive Debriefing Panel\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiverse educational backgrounds to represent population heterogeneity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWilling to provide detailed feedback on the comprehension of each questionnaire item.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003cp\u003eThe sample size was determined based on recommendations from previous studies on instrument adaptation. The study stages involved a minimum of five expert panelists for content validity assessment, four professional translators for the translation process (two for forward translation and two for backward translation), ten lay panel members for face validity evaluation, and five participants for cognitive debriefing, consistent with prior methodological studies. According to the power analysis and reliability estimates described by de Raadt et al. (2021), a sample size of 50 or 100 participants is required to achieve a Pearson correlation coefficient (r) cutoff of 0.79 and 0.81 with a 95% confidence interval width of 0.22 and 0.14\u003csup\u003e42\u003c/sup\u003e. Values approaching 1 indicate stronger reliability, and this study established a minimum threshold of 0.80 for acceptable stability. With 100 respondents targeted for this phase, in addition to the experts, translators, and lay panelists involved in the earlier validation stages, the total number of participants recruited for this study was 123 individuals.\u003c/p\u003e \u003cp\u003eTest\u0026ndash;retest reliability was assessed by administering the questionnaire to respondents at two different time points with a two-week interval to evaluate the stability of responses. Reliability analysis was performed using Cohen\u0026rsquo;s kappa to measure the level of agreement between the first and second measurements, and Spearman\u0026rsquo;s correlation coefficient (Spearman\u0026rsquo;s rho) to assess the consistency of the relationship between the two sets of measurements. Interpretation of kappa values followed the classification proposed by Landis and Koch (1977), while interpretation of Spearman\u0026rsquo;s correlation coefficients was based on commonly used categories of correlation strength in statistical research. To facilitate interpretation, the classification of both the Kappa and Spearman\u0026rsquo;s rho values was performed using modified classification criteria, which was derived from a combined classification based on the Landis and Koch criteria (agreement based scale) and the classical Spearman correlation classification(weak-strong relationship), as shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eModified Classification used for Reliability Testing Result\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified classification\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery weak\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.2\u0026ndash;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.4\u0026ndash;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.6\u0026ndash;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVery Strong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData processing and statistical analyses were conducted using Microsoft Excel and SPSS version 29 to ensure systematic and accurate analysis.The findings of this study are expected to produce an Indonesian version of the FertiSTAT questionnaire that is valid, reliable, and culturally relevant, enabling its use as a research instrument, a reproductive health education tool, and an initial screening instrument for fertility risk awareness among women of reproductive age in Indonesia.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study involved several participant groups corresponding to the stages of cross-cultural adaptation of the FertiSTAT instrument, including an expert panel, sworn translators, a lay panel for face validity assessment, a cognitive debriefing panel, and a test\u0026ndash;retest reliability panel.\u003c/p\u003e\n\u003cp\u003eThe expert panel consisted of consultant obstetricians and gynecologists subspecializing in reproductive endocrinology \u0026nbsp;and infertility (OB/GYN-REI) \u0026nbsp;and social obstetrics and gynecology (Social OB/GYN), language experts or professional translators experienced in medical terminology from the Language Center of Universitas Indonesia (LBI UI), as well as research methodology experts with experience in the development and validation of research instruments (Table 3). This panel was responsible for conducting content validation of the FertiSTAT questionnaire to ensure conceptual relevance and equivalence of meaning within the Indonesian cultural context. The discussion and content validity assessment were conducted online through Zoom\u003csup\u003e\u0026reg;\u003c/sup\u003e meeting. In addition to the expert panel, the language translation process also involved four sworn translators consisting of two English language specialists and two Indonesian language specialists. The translators were affiliated with the International Language Institute, Faculty of Humanities, Universitas Indonesia (LBI FIB UI), and the LIA Translation Center. They conducted forward translation and back translation to ensure semantic equivalence between the English and Indonesian versions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e. Expert Panel for Content Validation\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"571\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfession\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpertise\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRemarks\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProfessor of FMUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOB/GYN REI Subspecialisr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFirst Author. Ensure the clinical relevance and accuracy of fertility-related content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLecturer of \u0026nbsp;OB/GYN Departement FMUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOB/GYN REI Subspecialisr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecond Author. Ensure the clinical relevance and accuracy of fertility-related content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLecturer of \u0026nbsp;Dept. Of Community Medicine FMUI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical research, methodology, and information technology.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThird Author. Ensure the clinical relevance and accuracy of fertility-related content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eREI Subspecialist Trainee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOB/GYN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFourth Author. Expert is community medicine and foreign questionnaire adaptation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBML\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStaff at Dept. of OB/GYN National Police Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocial OB/GYN subspecialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDue to their expertise in reproductive health and population determinants of fertility, social obstetrics and gynecology subspecialists were included\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStaff at Dept. of OB/GYN National Police Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSocial OB/GYN subspecialist\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGJW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLanguage Expert / Medical Linguistics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSworn Translator and English Language Specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEnsure linguistic accuracy, clarity, and cultural appropriateness in the Indonesian adaptation of the questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 571px;\"\u003e\n \u003cp\u003eFMUI = Faculty of Medicine University of Indonesia; OB/GYN = Obstetrics and Gynecology; REI= Reproductive Endocrinology and Infertility\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe lay panel used for face validity assessment consisted of ten women of reproductive age without a medical background. This panel evaluated readability, clarity of language, and the ease of understanding of each questionnaire item. Most respondents in the lay panel were young adults, with a mean age of 22.2 \u0026plusmn; 3.22 years and an age range of 18 to 27 years (Table 4). The educational distribution showed a balanced proportion between respondents with senior high school education and those with undergraduate (S1/D4) education. Characteristic of lay panel for face validity assesment may be seen in Table 5.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003cstrong\u003e. Lay Panel Respondents for Face Validity Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvince of Origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFYN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighchool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJakarta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCentral Java\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAceh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSIA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLampung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEast Java\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYogyakarta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJIO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJakarta\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLampung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCentral Java\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWest Sumatera\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22,2\u0026nbsp;\u0026plusmn;\u0026nbsp;3,22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 99.8205%;\"\u003e\n \u003cp\u003e\u0026nbsp;S1 = academic bachelor\u0026rsquo;s degree; D4 = applied bachelor\u0026rsquo;s degree.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe cognitive debriefing panel consisted of five women of reproductive age who did not have a background in health sciences and had not previously been exposed to the concept of FertiSTAT. This group participated in structured discussions to assess whether each questionnaire item was understood in accordance with the intended meaning of the original concept. The mean age of the cognitive debriefing panel was 21.8 \u0026plusmn; 2.58 years. This panel can be seen in table 6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003cstrong\u003e. Lay Panel Respondents for Cognitive Debriefing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"556\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvince of Origin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJakarta\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCentral Java\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAceh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eS1/D4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLampung\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHighschool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEast Java\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eMean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21,8\u0026nbsp;\u0026plusmn;\u0026nbsp;2,58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the test\u0026ndash;retest reliability testing, the Indonesian version of the FertiSTAT questionnaire was completed twice by women of reproductive age with a 14-day interval between administrations. Although the planned sample size for this stage was 100 respondents, and recruitment had been extended to 132 participants to anticipate potential dropouts, a total of 77 respondents completed the questionnaire again during the retest phase. Nevertheless, this did not compromise the validity of the results because, as shown in Table 2 above, the reliability coefficient (r) with a sample size of 77 remained at 0.80, which corresponds to the minimum reliability threshold predetermined for this study.\u003c/p\u003e\n\u003cp\u003eThe demographic characteristics (table 7) indicated that the median age of respondents was 21 years, with an age range of 18 to 33 years. The majority of respondents had a high school level of education (70.1%), followed by those with diploma or undergraduate education (26%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003cstrong\u003e. Demographic Characteristics of Test\u0026ndash;Retest Reliability Respondents (n = 77)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD / Median (Min \u0026ndash; Max)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eAge; year\u003c/p\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Junior Highschool\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Highschool\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Bachelor\u0026rsquo;s Degree (S1/D4)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Magistrate (S2), Doctorate (S3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e21 (18 \u0026ndash; 33)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2,6\u003c/p\u003e\n \u003cp\u003e70,1\u003c/p\u003e\n \u003cp\u003e26,0\u003c/p\u003e\n \u003cp\u003e1,3\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\u003eContent validation was conducted through expert panel discussions in which each questionnaire item in the FertiSTAT instrument was evaluated for its relevance to the cultural and reproductive health context in Indonesia. The assessment yielded a mean Content Validity Index (CVI) of 0.95, indicating very high content validity. Most items obtained CVI values above 0.8 and were therefore considered valid for use in the Indonesian context. One item related to marijuana use obtained a CVI value of 0.6 due to concerns that the term might not be easily understood by respondents and the potential for response bias given the sensitivity of the topic. Nevertheless, the item was retained because it remains a relevant risk factor for infertility. The results for content validation are shown in Table 7.\u003c/p\u003e\n\u003cp\u003e[Insert Table 7 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003efull table available in this file after references\u0026rsquo; section\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe expert panel also provided several important recommendations regarding terminology adjustments to better align with the local context. For example, the term marijuana was suggested to be replaced with the word \u0026ldquo;ganja,\u0026rdquo; which is more familiar to the Indonesian population, while the term class A drugs was recommended to be replaced with \u0026ldquo;narcotics\u0026rdquo; or \u0026ldquo;NAPZA\u0026rdquo; (narcotics, psychotropics, and addictive substances). The expert panel also proposed the addition of one questionnaire item related to tuberculosis, given its high prevalence in Indonesia and its known potential impact on reproductive health.\u003c/p\u003e\n\u003cp\u003eThe language adaptation process was conducted through forward translation and backward translation by four sworn translators. Comparison of the different translated versions indicated that the conceptual meaning of each item was well preserved throughout the translation process. Among the two available forward translation versions, the translation prepared by translator GJW, who holds a doctoral degree in linguistics, was selected. In addition to the translator\u0026rsquo;s high level of expertise, this version provided the most appropriate conceptual equivalence and was considered the most concise and easily understood. The results for forward and back translation by four sworn translator are shown in Table 8.\u003c/p\u003e\n\u003cp\u003e[Insert Table 8 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003efull table available in this file after references\u0026rsquo; section\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the translation process, face validity assessment was conducted by the lay panel to evaluate the clarity and readability of each questionnaire item using a Likert scale. The results showed that the mean Likert scores for each item ranged from 4.5 to 4.9, indicating that the questions were considered clear and easily understood by the respondents.\u003c/p\u003e\n\u003cp\u003eSubsequently, a cognitive debriefing process was carried out to identify potential misinterpretations or linguistic ambiguities within the questionnaire. The discussion results indicated that most items did not require modification, as they were already considered clear by the respondents. However, several technical terms were clarified to improve comprehension among lay participants, for example by adding an explanation of how to calculate ideal body weight. The results for face validation and cognitive debriefing are shown in Table 9.\u003c/p\u003e\n\u003cp\u003e[Insert Table 9 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003efull table available in this file after references\u0026rsquo; section\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on the results of content validation, translation, face validation, and cognitive debriefing, the final Indonesian version of the FertiSTAT questionnaire was developed for use in the reliability testing phase. The final version consists of 23 questionnaire items covering the categories of attempting to conceive, reproductive history, and lifestyle. One additional item included in the final version addresses a history of tuberculosis, which is categorized by our expert panel as a moderate-level fertility risk factor. The final Indonesian version of the FertiSTAT questionnaire for test-retest reliability testing is shown in Table 10.\u003c/p\u003e\n\u003cp\u003e[Insert Table 10 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003efull table available in this file after references\u0026rsquo; section\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTest\u0026ndash;Retest Reliability Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTest\u0026ndash;retest reliability was performed to evaluate the consistency of respondents\u0026rsquo; answers across two measurement points separated by a 14-day interval. Reliability analysis was conducted using Cohen\u0026rsquo;s kappa statistic to assess categorical agreement and Spearman\u0026rsquo;s correlation coefficient to evaluate the consistency of ranked responses over time.\u003c/p\u003e\n\u003cp\u003eThe results showed that several items demonstrated strong to very strong reliability, particularly those related to medical diagnoses or clearly defined health conditions, such as endometriosis and a history of tuberculosis. In contrast, some items that were more subjective or related to behaviors that may vary over time, such as stress levels or caffeine consumption, showed lower reliability values. A few items could not have reliability coefficients calculated because there was no variation in responses across the two measurement points or because the responses were highly uniform. This situation occurred in questions involving sensitive or infrequent behaviors, such as illicit drug use or marijuana smoking, where nearly all respondents provided the same response.\u003c/p\u003e\n\u003cp\u003eOverall, the reliability analysis indicates that most items in the Indonesian version of the FertiSTAT questionnaire demonstrate adequate consistency and can be used as a screening instrument to assess infertility risk awareness among women of reproductive age. Test-retest reliability testing result for Indonesian version of the FertiSTAT questionnaire is shown in Table 11.\u003c/p\u003e\n\u003cp\u003e[Insert Table 11 here]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003efull table available in this file after references\u0026rsquo; section\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe initial stage of adapting the Indonesian version of the FertiSTAT instrument began with content validity assessment. This evaluation was conducted by an expert panel consisting of reproductive endocrinology and infertilty subspecialist, social OB/GYN subspecialists and related academic experts, who assessed each item based on content relevance, contextual appropriateness, and clarity of wording. Overall, the results indicated that all items were rated in the very good category, with high average scores, suggesting that the FertiSTAT questionnaire items were considered relevant and appropriate for use in the Indonesian population context. Some items needed cultural and contextual modifications to be more suitable with the Indonesian socio-cultural setting, such as not using terms like units instead of using household /general known measurement and types of liquor frequently consumed, from national survei data\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMethodologically, conducting content validity assessment prior to the translation process is important. By first evaluating the conceptual and clinical relevance of the original version, the subsequent translation process becomes more focused, as only items deemed truly relevant are carried forward into the language adaptation stage. This strategy improves the efficiency of the adaptation process while strengthening the conceptual foundation of the instrument before linguistic adjustments are performed\u003c/p\u003e \u003cp\u003eAfter content validity had been confirmed, the process proceeded with forward translation and backward translation conducted by different translators. This procedure aimed to maintain semantic and conceptual equivalence between the original version and the Indonesian version. The translation results indicated that the meaning of each item was generally well preserved without substantial distortion. Thus, the translation process did not merely produce a literal translation, but also ensured that the questionnaire content remained consistent with the original intent of the instrument and could be appropriately understood within the Indonesian cultural context.\u003c/p\u003e \u003cp\u003eFollowing the completion of content validation and translation, face validity was assessed by a lay panel consisting of women of reproductive age from diverse educational backgrounds. The results showed that all questionnaire items were considered clear, easy to understand, and free from ambiguity, indicating that the instrument had good readability for the target population.\u003c/p\u003e \u003cp\u003eThe next stage was cognitive debriefing, which aimed to evaluate whether each item was understood by respondents in accordance with the intended concept. The discussion results indicated that nearly all questions were well understood without requiring modification. Only one item required editorial adjustment, namely the question regarding overweight status. This revision was made to make the sentence more natural, operational, and easier for lay respondents to understand. These findings suggest that the overall linguistic structure of the questionnaire was already appropriate, and that the changes made were minor and primarily intended to improve practical clarity.\u003c/p\u003e \u003cp\u003eThe results of the test\u0026ndash;retest reliability analysis showed variation across questionnaire items. At first glance some items appeared to have low reliability or even yielded coefficients that could not be calculated, this does not necessarily indicate that the instrument is unsuitable for use. The instrument had previously undergone content validity assessment and cognitive debriefing, ensuring a strong conceptual and cultural foundation. In other words, before quantitative testing was performed, the items had already been confirmed to be relevant and appropriately understood by the target respondents.\u003c/p\u003e \u003cp\u003eSeveral items related to sensitive topics or very rare events, such as alcohol consumption, drug use, or certain behaviors of a partner, produced highly homogeneous responses. Under such conditions, Cohen\u0026rsquo;s kappa or Spearman\u0026rsquo;s rho values may become unavailable (N/A) because there is no variation in responses, rather than because the item lacks reliability. Methodologically, homogeneous responses may actually reflect very high consistency over time, even though the coefficient cannot be calculated by the statistical software used.\u003c/p\u003e \u003cp\u003eOn the contrary, items related to subjective perceptions or conditions that may change over time, such as stress, menstrual pain, or perceptions of menstrual cycle patterns, tended to show lower reliability values. This pattern is a common characteristic of self-report instruments measuring psychosocial or behavioral aspects. Therefore, variation in reliability across items should be interpreted as reflecting the nature of the constructs being measured rather than indicating a fundamental weakness of the instrument..\u003c/p\u003e \u003cp\u003eOverall, the Indonesian version of FertiSTAT can still be considered appropriate for use, especially in the context of screening or initial assessment of fertility risk factors among women of reproductive age. The value of the instrument should not be judged solely by the perfection of reliability coefficients, but also by its ability to properly represent respondents\u0026rsquo; experiences and relevant fertility risk factors.\u003c/p\u003e \u003cp\u003eThis study has several important strengths. From a novelty perspective, it represents the first cross-cultural adaptation of the FertiSTAT questionnaire into the Indonesian language, thereby providing a fertility screening tool that had previously been unavailable in the local context. In addition, the study introduced an additional item regarding tuberculosis, a disease with high relevance in Indonesia that may affect fertility but is not included in the original FertiSTAT version.\u003c/p\u003e \u003cp\u003eMethodologically, the study applied a comprehensive and rigorous adaptation process, including content validation, forward\u0026ndash;backward translation, face validation, cognitive debriefing, and test\u0026ndash;retest reliability assessment. The involvement of a multidisciplinary expert panel further strengthened the quality of the adaptation process. As a result, the instrument developed is not only theoretically valid but also better aligned with the clinical and cultural context of Indonesia.\u003c/p\u003e \u003cp\u003eThe study also has broad potential for implementation. The Indonesian version of FertiSTAT may be used in obstetrics and gynecology clinical practice, reproductive health education, public health research, and evidence-based fertility program planning.\u003c/p\u003e \u003cp\u003eDespite being conducted systematically, the study has several limitations. The primary limitation lies in the potential for self-report bias, as all responses were provided directly by the participants. This may introduce social desirability bias, perceptual errors, or limited understanding of certain medical terms. This limitation is particularly relevant for items involving sensitive topics or requiring more specific medical knowledge.\u003c/p\u003e \u003cp\u003eThe findings of this study also have important clinical implications, as they provide a validated and reasonably reliable Indonesian version of FertiSTAT that can be used as an initial screening instrument. In clinical practice, this tool may assist obstetricians and gynecologists, midwives, and other reproductive health professionals in identifying fertility risk factors more quickly and systematically.\u003c/p\u003e \u003cp\u003eThe use of FertiSTAT may also improve consultation efficiency, as the preliminary information obtained from patients can help guide clinical history-taking in a more focused manner. Furthermore, as a self-screening tool, FertiSTAT may increase women\u0026rsquo;s awareness of their fertility risks, thereby encouraging earlier consultation before problems become more complex.\u003c/p\u003e \u003cp\u003eBecause of its simplicity and easily understood questions to answer, the instrument also has the potential to be widely used in various healthcare settings, including primary healthcare centers, fertility clinics, and reproductive health promotion and prevention programs. Therefore, its uses are not limited to research but can also extend to clinical services and community health education.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecommendation\u003c/h2\u003e \u003cp\u003eThe Indonesian version of FertiSTAT may first be pilot-tested on a small sample representing diverse characteristics of women of reproductive age in Indonesia to ensure that its application aligns with the local context. Following this preliminary evaluation, broader implementation may be employed in population-based research or clinical services. The use of this instrument may also be accompanied by brief explanations to respondents regarding items that involve sensitive or medical concepts in order to minimize potential misunderstanding bias. Future research may explore behavioral changes following completion of the FertiSTAT questionnaire or evaluate its acceptability when applied in primary healthcare settings.\u003c/p\u003e \u003cp\u003eFurthermore, in future development, the Indonesian-language FertiSTAT questionnaire could be integrated with the official online FertiSTAT platform developed by Cardiff University for use among Indonesian-speaking populations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Indonesian version of the FertiSTAT questionnaire has been successfully adapted through a comprehensive process while maintaining conceptual equivalence with the original instrument. This adaptation included forward\u0026ndash;backward translation, content validation by an expert panel, face validation, cognitive debriefing, and test\u0026ndash;retest reliability assessment.\u003c/p\u003e \u003cp\u003eThe study results demonstrate that the instrument has excellent content validity, with the Content Validity Index (CVI) for all items exceeding the recommended threshold. In addition, evaluation by the lay panel indicated good face validity, as all items were considered clear, easy to understand, and appropriate within the cultural context of the respondents.\u003c/p\u003e \u003cp\u003eTest\u0026ndash;retest reliability analysis showed that most items demonstrated satisfactory consistency. Variations in reliability observed in some items were mainly influenced by the sensitive or subjective nature of the questions, the possibility of natural changes over time, and the extreme homogeneity of responses for certain items.\u003c/p\u003e \u003cp\u003eOverall, the Indonesian version of FertiSTAT can be considered an instrument with adequate validity and reliability for use as an initial screening tool to assess awareness of fertility risk factors among women of reproductive age in Indonesia, both in research settings and in clinical reproductive health practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eFertiSTAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eFertility Status Awareness Tools\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eTFR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal Fertility Rate\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eDKI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eDaerah Khusus Ibukota\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003ePPN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003ePerencanaan Pembangunan Nasional\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eOBGYN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eObstetrics and Gynecologist\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIFDMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eInternational Fertility Decision-Making Study\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIVF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003e\u003cem\u003eIn Vitro Fertilization\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIMT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eIndeks Massa Tubuh\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eIMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 520px;\"\u003e\n \u003cp\u003eInfeksi Menular Seksual\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the \u003cstrong\u003eHealth Research Ethics Committee of the Faculty of Medicine, Universitas Indonesia \u0026ndash; Cipto Mangunkusumo Hospital (FKUI-RSCM)\u003c/strong\u003e. All participants provided informed consent prior to participation in the study. Participation was voluntary, and respondents were informed about the objectives of the research and their right to withdraw at any time without consequences.\u003c/p\u003e\n\u003cp\u003eEthical approval number: \u003cstrong\u003eKET-1105/UN2.F1/ETIK/PPM.00.02/2025\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDate of approval: 25 July 2025\u003c/p\u003e\n\u003cp\u003eOriginal scanned approval on the next page\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received funding from Lembaga Pengelola Dana Pendidikan Kementerian Keuangan Republik Indonesia (Indonesia Endowment Fund for Education Agency from Ministry of Finance of the Republic of Indonesia).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthor Contributions Statement\u003c/h2\u003e\n\u003cp\u003eU.B. , A.H. and A.K. conceived the study and designed the transcultural adaptation methodology. G.P. and A.K. were responsible for ensuring the clinical relevance and statistical accuracy of the fertility-related content and research data. U.B. performed the data collection, interviews and coordination to language experts and all respondents and A.K. did statistical analysis using Microsoft Excel and SPSS. U.B. wrote the main manuscript text and prepared all tables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eKey for Initials used:\u003c/p\u003e\n\u003cp\u003eA.H.: Prof. Dr. Andon Hestiantoro, MD, OB/GYN-REI (First Author)\u003c/p\u003e\n\u003cp\u003eG.P.: Dr. Gita Pratama, MD, OB/GYN-REI, M.RepSc (Second Author)\u003c/p\u003e\n\u003cp\u003eA.K.: Dr.Aria Kekalih, MD, M.IT (Third Author)\u003c/p\u003e\n\u003cp\u003eU.B.: Utomo Budidarmo, MD, OB/GYN. (Corresponding/Fourth Author)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study did not include identifiable individual participant data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the expert panel members, the translators from the Language Center of Universitas Indonesia (LBI FIB UI) and LIA Language Institute \u0026ndash; Salemba Branch, , and all participants who contributed to the face validation, cognitive debriefing, and reliability testing phases of this study.\u003c/p\u003e\n\u003cp\u003eThe authors also express gratitude to the Division of Reproductive Endocrinology and Fertility, Department of Obstetrics and Gynecology, and Department of Community Medicine Faculty of Medicine Universitas Indonesia for their support in the conduct of this research.\u003c/p\u003e\n\u003cp\u003eThe authors also express gratitude to Department of Obstetrics and Gynecology Indonesian National Police Central (Level 1) Hospital for their support in the conduct of this research\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003eAndon Hestiantoro is a Professor of Reproductive Endocrinology and Fertility at the Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Indonesia also associate editor in Middle East Fertility Society Journal .\u003c/p\u003e\n\u003cp\u003eGita Pratama is a consultant/subspecialist \u0026nbsp;in Reproductive Endocrinology and Fertility and also lecturer \u0026nbsp;at the same institution.\u003c/p\u003e\n\u003cp\u003eAria Kekalih is \u0026nbsp;a lecturer at the Department of Community Medicine, Faculty of Medicine Universitas Indonesia, with expertise in research methodology and health informatics.\u003cbr\u003e\u0026nbsp;Utomo Budidarmo is an Obstetrics Gynecologist currently enrolled in the Reproductive Endocrinology and Fertility subspecialty training program at Faculty of Medicine Universitas Indonesia.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAdi Ahdiat. 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J Multidiscip Healthc. 2024;17:2701\u0026ndash;28. doi:10.2147/JMDH.S419714\u003c/li\u003e\n\u003cli\u003eVandenbos GR. American Psychology Association [Internet]. 2018 [cited 2024 Aug 17]. APA Dictionary of Psychology. Available from: https://dictionary.apa.org/awareness\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Health literacy [Internet]. 2024 [cited 2024 Dec 26]. Available from: https://www.who.int/news-room/fact-sheets/detail/health-literacy?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eFarlex. Awareness | definition of awareness by Medical dictionary [Internet]. 2024 [cited 2024 Dec 26]. Available from: https://medical-dictionary.thefreedictionary.com/awareness?utm_source=chatgpt.com\u003c/li\u003e\n\u003cli\u003eChimezie RO. Health Awareness: A Significant Factor in Chronic Diseases Prevention and Access to Care. J Biosci Med (Irvine). 2023 Feb;11(2).\u003c/li\u003e\n\u003cli\u003eSchmidt L, Sobotka T, Bentzen JG, Nyboe Andersen A, Force on behalf of the ER and ST. Demographic and medical consequences of the postponement of parenthood. Hum Reprod Update. 2012 Jan 1;18(1):29\u0026ndash;43. doi:10.1093/humupd/dmr040\u003c/li\u003e\n\u003cli\u003eMaeda E, Miyata A, Boivin J, Nomura K, Kumazawa Y, Shirasawa H, et al. Promoting fertility awareness and preconception health using a chatbot: a randomized controlled trial. Reprod Biomed Online. 2020;41(6):1133\u0026ndash;43. doi:10.1016/j.rbmo.2020.09.006\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a D, Vassena R, Prat A, Vernaeve V. Increasing fertility knowledge and awareness by tailored education: a randomized controlled trial. Reprod Biomed Online. 2016;32(1):113\u0026ndash;20. doi:https://doi.org/10.1016/j.rbmo.2015.10.008\u003c/li\u003e\n\u003cli\u003eFulford B, Bunting L, Tsibulsky I, Boivin J. 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Available from: https://doi.org/10.1016/j.ajog.2016.08.008 doi:10.1016/j.ajog.2016.08.008 PubMed PMID: 28007229.\u003c/li\u003e\n\u003cli\u003eCousineau TM, Domar AD. Psychological impact of infertility. Best Pract Res Clin Obstet Gynaecol. 2007;21(2):293\u0026ndash;308. doi:https://doi.org/10.1016/j.bpobgyn.2006.12.003\u003c/li\u003e\n\u003cli\u003eChan SL, Thumboo J, Boivin J, Saffari SE, Yin S, Yeo SR, et al. Effect of fertility health awareness strategies on fertility knowledge and childbearing in young married couples (FertStart): study protocol for an effectiveness-implementation hybrid type I multicentre three-arm parallel group open-label randomised clinical trial. BMJ Open. 2022 Jan 3;12(1). doi:10.1136/bmjopen-2021-051710 PubMed PMID: 34980614.\u003c/li\u003e\n\u003cli\u003eGjersing L, Caplehorn JRM, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Med Res Methodol. 2010;10(1):13. doi:10.1186/1471-2288-10-13\u003c/li\u003e\n\u003cli\u003eBeaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures. Spine (Phila Pa 1976) [Internet]. 2000;25(24). Available from: https://journals.lww.com/spinejournal/fulltext/2000/12150/guidelines_for_the_process_of_cross_cultural.14.aspx\u003c/li\u003e\n\u003cli\u003eSousa VD, Rojjanasrirat W. Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. J Eval Clin Pract. 2011 Apr 1;17(2):268\u0026ndash;74. doi:https://doi.org/10.1111/j.1365-2753.2010.01434.x\u003c/li\u003e\n\u003cli\u003eGuillemin,\u0026rsquo; F, Bombardier C, Beaton~ D. Cross-Cultural Adaptation of Health-Related Quality of Life Measures: Literature Review and Proposed Guidelines. J Clio itpidemiol. 1993. 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Jornal Brasileiro de Pneumologia. 2016 Jul 1;42(4):266\u0026ndash;72. doi:10.1590/S1806-37562015000000243 PubMed PMID: 27832234.\u003c/li\u003e\n\u003cli\u003eWild D, Grove A, Martin M, Eremenco S, McElroy S, Verjee-Lorenz A, et al. Principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (PRO) measures: Report of the ISPOR Task Force for Translation and Cultural Adaptation. Value in Health. 2005;8(2):94\u0026ndash;104. doi:10.1111/j.1524-4733.2005.04054.x PubMed PMID: 15804318.\u003c/li\u003e\n\u003cli\u003eCheng KKF, Clark AM. Qualitative Methods and Patient-Reported Outcomes: Measures Development and Adaptation. International Journal of Qualitative Methods. SAGE Publications Inc.; 2017. doi:10.1177/1609406917702983\u003c/li\u003e\n\u003cli\u003eAnggur dan Arak, Alkohol Paling Banyak Dikonsumsi Warga RI [Internet]. [cited 2026 Mar 10]. Available from: https://databoks.katadata.co.id/produk-konsumen/statistik/34cec0e6254072c/anggur-dan-arak-alkohol-paling-banyak-dikonsumsi-warga-ri\u003c/li\u003e\n\u003cli\u003eCooney MA, Buck Louis GM, Sundaram R, McGuiness BM, Lynch CD. Validity of self-reported time to pregnancy. Epidemiology. 2009 Jan;20(1):56\u0026ndash;9. doi:10.1097/EDE.0b013e31818ef47e PubMed PMID: 19057382.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 7 to 11 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-fertility-society-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mefj","sideBox":"Learn more about [High Temperature Corrosion of Materials](https://www.springer.com/journal/43043)","snPcode":"43043","submissionUrl":"https://submission.nature.com/new-submission/43043/3","title":"Middle East Fertility Society Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"FertiSTAT, infertility awareness, fertility risk, transcultural adaptation, validity, reliability","lastPublishedDoi":"10.21203/rs.3.rs-9087134/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9087134/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eDeclining fertility rates and limited awareness of fertility risk factors pose major reproductive health challenges. FertiSTAT is a self-assessment tool for fertility risk awareness but has not been culturally adapted suitable for Indonesian population.\u003c/p\u003e\u003ch2\u003eObjective:\u003c/h2\u003e \u003cp\u003eTo perform transcultural adaptation and evaluate the validity and reliability of the Indonesian version of FertiSTAT as a screening tool for fertility risk awareness for Indonesian population.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA descriptive cross-sectional study was conducted involving 7 expert panel members, 4 certified translators, and 92 subjects, through a transcultural adaptation process which included expert content validation, forward\u0026ndash;backward translation, face validation, cognitive debriefing, and test\u0026ndash;retest reliability assessment. Content validity was measured using the Content Validity Index, while reliability was assessed using Cohen\u0026rsquo;s kappa and Spearman correlation.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eAll items retained conceptual equivalence and cultural relevance. Content validity showed CVI\u0026thinsp;\u0026gt;\u0026thinsp;0.80 for all items and face validity demonstrated mean Likert scores\u0026thinsp;\u0026gt;\u0026thinsp;3. Test\u0026ndash;retest reliability showed variable agreement; several items achieved strong consistency, while lower values were mainly due to sensitive, subjective, fluctiative or strong homogenity of test-retest responses. Stability was acceptable for screening purposes. One additional item, tuberculosis was included on expert panel recommendations due to its prevalence and relevance to infertility in Indonesia.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe Indonesian version of FertiSTAT has been succesfully adapted transculturally with good content and face validity, acceptable reliability and is suitable as an initial screening tool for fertility risk awareness among reproductive-aged women in Indonesia.\u003c/p\u003e","manuscriptTitle":"Transcultural Adaptation, Validity and Reliability Testing of Infertility Risk Self- Assessment Questionnaire (FertiSTAT) to Indonesian Language A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-27 15:03:10","doi":"10.21203/rs.3.rs-9087134/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-10T17:08:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-07T04:08:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T05:22:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T15:21:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-30T12:47:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-28T07:09:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324867293595840747953019649019777828494","date":"2026-03-28T04:56:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"34114872048151024820912009132239006943","date":"2026-03-27T09:09:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T20:59:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T02:53:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82520078093680123297473808110447269030","date":"2026-03-25T14:02:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246603996698147041481408404434045478542","date":"2026-03-25T12:26:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15696306088955109836859290867095240717","date":"2026-03-25T12:00:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224108609802923669408757151601035761198","date":"2026-03-25T11:42:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25028699712469552494253337854624730792","date":"2026-03-25T08:55:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-25T08:45:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-18T10:32:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-17T03:14:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Fertility Society Journal","date":"2026-03-10T18:48:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-fertility-society-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mefj","sideBox":"Learn more about [High Temperature Corrosion of Materials](https://www.springer.com/journal/43043)","snPcode":"43043","submissionUrl":"https://submission.nature.com/new-submission/43043/3","title":"Middle East Fertility Society Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e7c20e06-0ebe-4c10-a86c-1915829dcbd0","owner":[],"postedDate":"March 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T11:53:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-27 15:03:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9087134","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9087134","identity":"rs-9087134","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}