Validation of Knowledge, Attitude, and Perceptions Tool on Advance directives and End of Life Decisions in Adult Population Availing Services at Tertiary Care Hospitals of Karachi, Pakistan.

Abstract Background: Advance directives are legal documents written or drawn when the person has total mental capacity, noting the requirements of health care when/if he loses the ability to make decisions. The concept has not been explored in Pakistan; hence a valid instrument is not available that addresses the needs of an LMIC. We aimed to develop and validate a tool to assess knowledge, Attitude, and perceptions about advance directives of the adult population availing services at tertiary care hospitals in Karachi, Pakistan. Methodology: We carried out a validation study in three tertiary care hospitals in Karachi. The study was initiated by adapting from an American tool, modified following the Pakistani context. An estimated sample size of 389 using a purposive sampling technique was calculated. We checked the tool's relevancy using content validity. STATA software 16 was used for consistency, reliability, and factorial analysis. Results: All the components of the survey performed well with overall good reliability (α = 0.75), and for individuals, main features, including family support decisions (α = 0.64), sociocultural and religious (α = 0.72), physical health awareness experience (α = 0.93), knowledge (α = 0.99), attitude (α = 0.75), and perceptions (α = 0.64). Conclusion: This was the first validation study done in low-and-middle-income countries to develop a reliable and validated tool with the efforts made to make it contextual and comprehensive for both English and Urdu versions.