Translation, Cross-Cultural Adaptation, and Validation of the Malay-Version of the Factors Influencing Community Willingness to Perform Cardiopulmonary Resuscitation and Use an Automated External Defibrillator Questionnaire

Limited factors influence community willingness to perform cardiopulmonary resuscitation and use an automated external defibrillator, making it difficult to take preventive and control measures to improve the survival of patients with out-of-hospital cardiac arrest. In this study, we translated and evaluated the Malay-language version of the cardiopulmonary resuscitation and an automated external defibrillator questionnaire. The translation and evaluation involved three phases: development, translation and cultural adaptation, and validation. Content validity was assessed by five experts, and demonstrated a content validity index of 0.98 and a Fleiss kappa index of 0.159. Construct validity for the multi-item scale performed using factor analysis and involving 100 participants was 0.777. Factor analysis using the varimax rotation method demonstrated the appropriateness of the data in the exploratory factor analysis. Cronbach’s alpha was 0.849, suggesting high reliability. Test–retest reliability involving 45 participants calculated using the intraclass correlation coefficient had a value of 0.723. The findings demonstrate that the Malay-version FIXED questionnaire is a valid and reliable instrument and is ready to be used by health care workers and policymakers to evaluate the factors influencing the community’s willingness to perform cardiopulmonary resuscitation and use an automated external defibrillator.


Introduction
Out-of-hospital cardiac arrest (OHCA) is a major health problem globally in terms of morbidity and mortality, with low survival rates related to community health [1,2]. Out-of-hospital cardiac arrest is defined as a condition in which cardiac mechanical activity suddenly ceases affecting hemodynamic conditions, as evidenced by the absence of signs of life outside the hospital [3,4]. The incidence is highly time-dependent and its high mortality is associated with a wide time gap between cardiac arrest and emergency medical services (EMSs) arrival [5]. Cases involving OHCA are the leading cause of death in the world, with over 135 million deaths recorded annually, especially in developing countries [1,6]. Globally, incidences involving OHCA involve 20-140 per 100,000 people, and the survival rate of patients with OHCA is only 2-11% [2,7]. Therefore, reducing the burden of OHCA-related diseases is a critical community health problem and should be addressed with constructive measures. The survival of OHCA patients during those critical minutes before EMS team arrival depends on the willingness of the bystanders close to the victim to perform cardiopulmonary resuscitation (CPR) until EMS assistance takes Int. J. Environ. Res. Public Health 2022, 19, 4882 2 of 20 over [8]. CPR performed by the community can help improve OHCA patient survival, provide better quality of life, and lead to higher hospital discharge rates [9][10][11].
The factors influencing community willingness to perform CPR and use an automated external defibrillator (AED) prior to EMS team arrival are limited, rendering it difficult for preventive and control measures to be taken to improve the survival of OHCA patients. To date, no standard instrument has been developed to assess the factors influencing the community's willingness to perform CPR and use an AED in an emergency situation. The purposes of this study were to translate and evaluate the Malay-language version of the Factors Influencing Community Willingness to Perform CPR and Use an AED (FIXED) questionnaire. The FIXED is the author's invention to explore the factors that influence community willingness to perform CPR and use an AED and has never been described before. There is a need to translate the questionnaire into Malay, the official language of Malaysia. As a result of the translation, cultural adaptation, and validation, we will be able to examine previously identified factors such as knowledge, training, perceptions, attitudes, perceived norms, self-efficacy, intentions, behaviours, and their barriers [5,12,13]. We report the translation and cultural adaptation, validation using content validation (content validity index, CVI; Fleiss kappa index, FKI), construct validation (exploratory factor analysis, EFA; principal component factor analysis, PCA), and reliability using internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficient, ICC).

Methods
The cross-cultural adaptation and evaluation process was designed by adapting the instrument development process proposed by Mohamad Marzuki et al. [14] and Wild et al. [15] (Figure 1). The process involves 14 steps grouped into three phases: development, translation and cultural adaptation, and validation.

Phase 1: Development Phase
The items were generated based on a comprehensive literature review to identify publications assessing factors influencing the community's willingness to perform CPR and/or use an AED. The first step is identifying the constructs or domains to be measured. Constructs were selected using the 'intention-focused model for bystander CPR performance' [16] and the 'theory of planned behaviour with background factors (TPB)' [17]. Based on the two theoretical frameworks and coupled with the literature review, nine constructs of instruments for measuring the factors influencing community willingness to perform CPR and use an AED were identified: (1) knowledge, (2) training, (3) perception, (4) attitude, (5) perceived norms, (6) self-efficacy, (7) intention, (8) behaviour, and (9) barriers. A conceptual framework ( Figure 2) was constructed based on both theories to illustrate the relationship between the constructs of the variables to be studied.
The FIXED questionnaire was developed based on the above nine constructs using the deductive and inductive methods. The deductive method was used by adapting from the literature (i.e., knowledge of CPR and AED) [18,19] the attitudes, perceived norms, and self-efficacy [12]; intention [19]; and perceptions, barriers, and behaviours [20]. The inductive method was conducted through meeting with two community health experts to discuss the questionnaire contents, determine the appropriateness of the items to be used, and decide whether to include items to be used. The final decision was made based on the consensus reached with the researcher.  mance' [16] and the 'theory of planned behaviour with background factors (TPB)' [17]. Based on the two theoretical frameworks and coupled with the literature review, nine constructs of instruments for measuring the factors influencing community willingness to perform CPR and use an AED were identified: (1) knowledge, (2) training, (3) perception, (4) attitude, (5) perceived norms, (6) self-efficacy, (7) intention, (8) behaviour, and (9) barriers. A conceptual framework ( Figure 2) was constructed based on both theories to illustrate the relationship between the constructs of the variables to be studied. The FIXED questionnaire was developed based on the above nine constructs using the deductive and inductive methods. The deductive method was used by adapting from the literature (i.e., knowledge of CPR and AED) [18,19] the attitudes, perceived norms, and self-efficacy [12]; intention [19]; and perceptions, barriers, and behaviours [20]. The inductive method was conducted through meeting with two community health experts to discuss the questionnaire contents, determine the appropriateness of the items to be used, and decide whether to include items to be used. The final decision was made based on the consensus reached with the researcher.

Phase 2: Translation and Cultural Adaptation Phase
In this phase, two bilingual translators with the skills to translate the questionnaire from the original English into the Malay with general terms that are easily understood in Malaysia performed the forward translation. The conciliation stage involved determining the appropriate forward translation and changing items in the forward translation or changing the forward translation completely if necessary, reconciling and harmonising the Malay version of the instrument. Any discrepancies were resolved with intensive discussions among the experts and translators. A written report recording all synthesis processes, with each issue addressed and how they were resolved, was produced (Supplementary Materials Table S1).
The backward translation involved translating the reconciled questionnaire (Malay) back to the original language (English). To review the backward translation, the backward translated (English) items were compared with the original English version to identify any equivalent conceptual differences. Both the English and Malay versions were refined to reach agreement on a satisfactory equivalent version of the instrument.

Phase 2: Translation and Cultural Adaptation Phase
In this phase, two bilingual translators with the skills to translate the questionnaire from the original English into the Malay with general terms that are easily understood in Malaysia performed the forward translation. The conciliation stage involved determining the appropriate forward translation and changing items in the forward translation or changing the forward translation completely if necessary, reconciling and harmonising the Malay version of the instrument. Any discrepancies were resolved with intensive discussions among the experts and translators. A written report recording all synthesis processes, with each issue addressed and how they were resolved, was produced (Supplementary Materials Table S1).
The backward translation involved translating the reconciled questionnaire (Malay) back to the original language (English). To review the backward translation, the backward translated (English) items were compared with the original English version to identify any equivalent conceptual differences. Both the English and Malay versions were refined to reach agreement on a satisfactory equivalent version of the instrument.
In the harmonising stage, all translation items in the desired language were compared with the source version. Any discrepancies were resolved with intensive discussions among the experts and translators. At the cognitive briefing stage, pre-draft version of the questionnaire was field-tested among the target population. Ten respondents were recruited to answer the pre-test questions of the Malay version FIXED questionnaire, which was distributed online. The respondents, who were randomly selected based on their participation in the Melaka CPR Fun Run programme between 2018 and 2020, were at least 18 years old, Malaysian citizens, understood Malay, and were residents or permanent residents of Melaka State.
The cognitive debriefing review was guided by the respondents' feedback. The researcher and supervisor agreed via consensus to make changes to the items in terms of word substitution, word deletion, word addition, and sentence structure. The Malay translation was modified carefully to maintain the conceptual meaning of the item and the translation was finalised through discussion with the researcher and supervisor. The draft version would undergo validation before the FIXED instrument was finalised. These expert ratings were calculated using content validity index (CVI) to measure consensus, the content validity of individual items (I-CVI) to measure proportional agreement, and Fleiss Kappa (Cohen kappa adaptation for >3 evaluators) to measure expert agreements [21][22][23]. In the present study, the expert review panel comprised five people with various background specialisations, namely, cardiology, emergency medicine, curriculum development, CPR and AED instruction, and patient education (Supplementary Materials Table S2). The experts were required to evaluate the instrument, critically review the constructs and items, and assess the overall presentation of the instrument before scoring each item. Once they had finished reviewing the constructs and items, the experts were required to assign scores to each item independently based on the relevant evaluation scales.
Four levels of suitability for the questions and the answers were assessed on a 4-point scale: 1 = the item is not relevant to the measured construct; 2 = the item is somewhat relevant to the measured construct; 3 = the item is quite relevant to the measured construct; and 4 = the item is highly relevant to the measured construct [24]. Prior to CVI calculation, the relevance rating was recoded as 1 (rating scale, 3 or 4) or 0 (rating scale, 1 or 2). The CVIs were calculated at the item level (I-CVI) and scale level (S-CVI). The I-CVI was calculated as the number of experts who assigned a score of 3 or 4 divided by the total number of experts (22). Two indices were calculated to derive the S-CVI: (1) the proportion of items on a scale that the expert scores as valid (rating 3 or 4) (universal agreement (UA) by experts = S-CVI/UA), and (2) the average share of items on a scale rated 3 or 4 (average agreement (Ave) by experts = S-CVI/Ave) [25]. An I-CVI of >79% indicates that the item is appropriate, between 70% and 79% indicates that the item requires revision, and I-CVI of <70% indicates that the item should be eliminated [26].
After the expert panel had reviewed the items, their responses were analysed using the FKI due to its suitability to evaluate a large number of raters [27]. Based on the interpretation of the Fleiss kappa [28], κ ≤ 0 indicates that there is no agreement among the raters, κ between 0.0 and 0.20 indicates slight agreement, κ between 0.21 and 0.40 indicates fair agreement, κ between 0.41 and 0.60 indicates moderate agreement, κ between 0.61 and 0.80 indicates substantial agreement, and κ between 0.81 and 1.0 indicates almost perfect agreement.

Construct Validity
EFA was performed to determine how items on the FIXED questionnaire correlated with each other and whether they could be grouped into sub-constructs. A hundred respondents were recruited to answer the Malay version of the FIXED questionnaire. The respondents, who were randomly selected based on their participation in the Melaka CPR Fun Run programme between 2018 and 2020, were at least 18 years old, Malaysian citizens, understood Malay, and were residents or permanent residents of Melaka State. The sample size for EFA was calculated using an online Cronbach's alpha hypothesis testing calculator, which is available online at https://ptenklooster.nl/psychometric-sample-size-calculators/ cronbachs-alpha-hypothesis-testing/ (accessed on 6 April 2022) [29,30]. Based on an expected Cronbach's alpha of 0.80 for 59 items in a FIXED questionnaire and a desired power of 0.8 (80%), 100 subjects were needed to demonstrate that this Cronbach's alpha value was significantly different from a minimum acceptable Cronbach's alpha value of 0.70 at a significance level of 0.05 (two-tailed significance).
The sampling adequacy was measured between 0 and 1 with Kaiser-Meyer-Olkin (KMO) assessment, unbiased estimates of actual factor scores were produced using Bartlett's test of sphericity, the convergent validity of the items was demonstrated using communalities, and the number of factors to be retained was determined using the scree plot test [31][32][33]. A preliminary KMO test performed to determine the adequacy of sampling suggested 0.6 as the minimum value for factor analysis and interpreting KMO values; a value between 0.60 and 0.70 was considered adequate, that between 0.7 and 0.8 was good, that between 0.8 and 0.9 was great and a value of >0.9 was considered superb [33]. Item communalities were considered unrelated to each other if they had a value of <0.40, while a value of 0.40-0.70 indicated low to moderate communality and a value of >0.8 indicated high communality [34].
After confirming the suitability for factor analysis, factor extraction was performed using PCA. The factorability of the 44 multi-item scale was assessed to determine the suitability of the data for use in the EFA using the following tests: eigenvalue rule >1, at least 50% cumulative percentage of variance (CPV) extracted, and the scree plot test [35]. EFA was performed again using the rotation method to simplify and clarify the data structure through varimax orthogonal rotation to produce unrelated factors [36]. Varimax rotation factor matrix analysis with factor loading with a significant loading value set at 0.32 was used as the criterion to determine whether an item would be removed, and each component was evaluated to ensure that it had at least three items with loading >0.4 [37,38].
The test-retest reliability was assessed by calculating the ICC. ICC values <0.5 indicate poor reliability, that between 0.5 and 0.75 indicate moderate reliability, that between 0.75 and 0.9 indicate good reliability, and that >0.90 indicate excellent reliability [45].

Sociodemographic Characteristics of the Participants
The mean age of participants was 31.43 years (SD = 9.01, range: 18-63). The gender ratio was almost 1:1 and most participants had a higher education background (85%), were married (53%), lived in city residential areas (61%), and were from the B40 group (household income <RM 4850) (59%). Most participants did not have any medical history of chronic illness (97%), no medical history of family members with chronic illnesses (66%), no experience of witnessing the incidence of cardiac arrest (62%), and had never performed CPR on a victim of cardiac arrest (65%) ( Table 1).

Conceptualisation of FIXED
Based on deductive and inductive methods, 59 items in nine constructs were generated and prepared for the validation process. The conceptual and operational definition of the instrument was defined for each construct (Supplementary Materials Table S3). All items were previously written in Malay as it was easier for all experts and respondents to understand.

Content Validity
All content validity (CVI) calculations were from the FIXED questionnaire development (nine constructs, 59 items). Five experts performed the relevant assessments on the item scale (Supplementary Materials Table S4). No item dropped had an I-CVI value < 0.79. The average I-CVI rated as relevant across the five experts was 0.98. Table 2 shows the five experts' construct-based CVI. The averaging calculation method (S-CVI/Ave) obtained for all constructs was 0.98, while the universal agreement calculation method (S-CVI/UA) was 0.90. The S-CVI/UA was 1.00, 1.0, 1.0, 0.38, 0.75, 1.0, 1.0, 1.00, and 1.0 for constructs 1, 2, 3, 4, 5, 6, 7, 8, and 9, respectively. Based on the calculations, it can be concluded that the I-CVI, S-CVI/Ave, and S-CVI/UA were satisfactory. The Fleiss kappa statistic had a kappa value of 0.159 (95%CI: 0.047, 0.268, p = 0.001) (Supplementary Materials Table S5), which indicates little agreement [28].  Table 2. Content validity index based on the construct to measure the factors influencing the community willingness to perform CPR and use an AED by five experts.

Construct Validity
The KMO value of 0.777 obtained from the data indicated good correlation between items and factor analysis was appropriate for this dataset. The p-value for the Bartlett test of sphericity was significant (χ 2 (946) = 3346, p < 0.001), indicating that there was appropriate correlation between items based on the correlation matrix. After the overall suitability of the items for factor analysis had been confirmed, construct-based analysis was performed. A KMO value of 0.802 was obtained for perception, 0.643 for attitude, 0.582 for perceived norms, 0.786 for self-efficacy, 0.854 for intention, 0.818 for behaviour, and 0.812 for the barriers. All constructs had KMO values >0.6, except for the perceived norms (KMO = 0.582). The Bartlett test of sphericity clearly showed that all constructs had significant values (p < 0.001) ( Table 3). The communality values for all 44 items on the multi-item scale were 0.296-0.853 (Supplementary Materials Table S6). However, one item had a communality value of <0.4: "knowing the importance of starting a resuscitation before EMS arrival" (0.296), which was considered unrelated to other items [36]. The other 43 items had communality values between 0.454 and 0.853, indicating that the relationship with other items had low to moderate communality.
EFA was performed again using the varimax orthogonal rotation method for the seven constructs (i.e., perception, attitude, perceived norms, self-efficacy, intention, behaviour, and barriers) ( Table 4). All items in all constructs had a factor loading >0.4 and were considered acceptable [46]. The factor loading for the perception construct revealed three factors with an eigenvalue of >1 and 72.8% CPV. The first, second, and third component had a variance value of 41.2%, 18.8%, and 12.7%, respectively. Two items (9 and 10) were loaded on one component. The extracted perception sub-constructs were labelled Factor 1, "AED implementation strategies"; Factor 2, "community perception on the importance of CPR and AED"; and Factor 3, "community perception on AED handling training".   For the attitude constructs, three factors with an eigenvalue of >1 with 69% CPV were extracted for the FIXED attitude sub-construct. The first, second, and third component had a variance value of 31.2%, 24.4%, and 13.3%, respectively. One item (12) was loaded on one component. The extracted attitude sub-constructs were labelled Factor 1, "fearful of CPR and AED"; Factor 2, "courage for CPR and AED"; and Factor 3, "importance of CPR and AED". For the perceived norms construct, two factors with an eigenvalue of >1 and 70.9% CPV were extracted. The first and second component had a variance value of 44.6% and 26.3%, respectively. One item (22) was loaded on one component. The sub-constructs of the perceived norms extracted were labelled Factor 1, "relatives" and Factor 2, "community".
For the self-efficacy constructs, two factors with an eigenvalue of >1 and 76.8% CPV were extracted. The first and second component had a variance value of 55.5% and 21.3%, respectively. Two items (23,26) were loaded on one component. The extracted perceived norms sub-constructs were labelled Factor 1, "intrinsic" and Factor 2, "extrinsic". For the intention, behaviour, and barriers constructs, only one factor with an eigenvalue of >1 and 65.4%, 86.2%, and 63.6% CPV, respectively, was extracted. The scree plot test revealed seven factors with eigenvalues of >1 (Figure 3). Table 5 shows that each construct extracted demonstrated different Cronbach's alpha values: 0.855 for "perception implementation strategies of the AED" (five items), 0.637 for "community's perception of the importance of CPR and AED" (three items), 0.637 for "community's perception of AED handling training" (two items), 0.755 for "fearful of CPR and AED" (four items), 0.693 for "courage for CPR and AED" (three items), 0.633 for "perceived norms by relatives" (three items), 0.895 for "self-efficacy intrinsic" (three items), 0.878 for "intention" (six items), 0.945 for "behaviour" (four items), and 0.903 for "barriers" (seven items).   Table 5 shows that each construct extracted demonstrated different Cronbach's alpha values: 0.855 for "perception implementation strategies of the AED" (five items), 0.637 for "community's perception of the importance of CPR and AED" (three items), 0.637 for "community's perception of AED handling training" (two items), 0.755 for "fearful of CPR and AED" (four items), 0.693 for "courage for CPR and AED" (three items), 0.633 for "perceived norms by relatives" (three items), 0.895 for "self-efficacy intrinsic" (three items), 0.878 for "intention" (six items), 0.945 for "behaviour" (four items), and 0.903 for "barriers" (seven items). Examination of the construct "self-efficacy extrinsic" (two items) revealed that it had a corrected item-total correlation of <0.32 and Cronbach's alpha of 0.111; therefore, it was eliminated [43]. The "attitude importance of CPR and AED" and "perceived norms community" components, which only had one item each, were also eliminated. This brought the total number of items deleted to four. After arrangement and deletion, there were a total of 40 items in the seven constructs. The corrected item-total correlation of all items was 0.378-0.897 and the overall Cronbach's alpha, calculated at 0.849, indicated high reliability of the FIXED instrument. All constructs and sub-constructs yielded values of >0.60. According to DeVellis [42] and Straub et al. [47], Cronbach's alpha reliability should be ≥0.60. This indicated that the FIXED instrument is reliable.

Perception (Implementation Strategies of the AED)
The signage that shows the location of the AED is clear The AED is located in a location that is easily accessible at all times (including after office hours)

0.835
The steps in the AED instructional poster on how to use the AED are easy to follow 0.790 The AED is clearly visible 0.713 The AED is located at a secure site 0.748

Attitude (Importance of CPR and AED)
Knowing the importance of starting a resuscitation before EMS arrival Component eliminated (one item) Examination of the construct "self-efficacy extrinsic" (two items) revealed that it had a corrected item-total correlation of <0.32 and Cronbach's alpha of 0.111; therefore, it was eliminated [43]. The "attitude importance of CPR and AED" and "perceived norms community" components, which only had one item each, were also eliminated. This brought the total number of items deleted to four. After arrangement and deletion, there were a total of 40 items in the seven constructs. The corrected item-total correlation of all items was 0.378-0.897 and the overall Cronbach's alpha, calculated at 0.849, indicated high reliability of the FIXED instrument. All constructs and sub-constructs yielded values of >0.60. According to DeVellis [42] and Straub et al. [47], Cronbach's alpha reliability should be ≥0.60. This indicated that the FIXED instrument is reliable.
Data were collected from 45 participants using the same scale four weeks later ( Table 6). The ICC values for the constructs and sub-constructs were as follows: AED perception implementation strategies, 0.932; community's perception of the importance of CPR and AED, 0.643; community's perception of AED handling training, 0.502; fearful of CPR and AED, 0.729; courage for CPR and AED, 0.746; perceived norms, 0.760; self-efficacy, 0.911; intention, 0.875; behaviours, 0.922; and barriers, 0.896. The overall ICC value was 0.723 with a 95% confidence interval of 0.614-0.819, indicating moderate to good reliability retests. The overall Cronbach's alpha of 0.849 indicated that the FIXED questionnaire had high reliability.

Discussion
The FIXED questionnaire was developed to assess the factors that influence the community's willingness to perform CPR and use an AED. Apart from its importance in determining the community's willingness, this can empower the community by doing CPR and using an AED in emergency situations and can indirectly improve the survival of OHCA patients [48][49][50]. Although the questionnaire was developed with the community population as a primary target, the majority of items were not specifically related to the community, suggesting that the questionnaire may be useful in a variety of other populations upon further validation.
For the content validation, this study compared the I-CVI and the S-CVI, however, the majority of publications have reported either the I-CVI or the SCVI, but not both [51]. Both approaches can result in contradictory values, making it difficult to reach an accurate conclusion about content validity [25]. The content validity by five expert review panels achieved high content validity of I-CVI and high content validity of the overall questionnaire, whereby the items were appropriate for the study purpose. The proportion of agreement among the experts was considered to have excellent content validity (CVI = 0.98). This allows for easy interpretation of why the experts agreed that all original 59 items were appropriate and acceptable.
Following the review of the items by the expert panel, their responses were analysed using the FKI with the kappa value of 0.159, which indicated little agreement. This indicates the inability of the investigated measure or classification to clearly distinguish between subjects in a population where those distinctions are extremely rare or difficult to achieve [52,53]. Another possibility is that raters are unable to differentiate between adjacent categories [54]. The items were modified and improved in response to expert feedback, which included the use of simple words, revise medical terms to easy-to-understand terms, the avoidance of repetitive questions, and the rephrasing of sentences to the constructs' relevance, adequateness, and representativeness.
For the construct validity testing, the KMO value for all seven constructs (perceptions, attitudes, perceived norms, self-efficacy, intentions, behaviours, barriers) and 44 items was 0.777. These findings are consistent with the findings of the original validation study by Chew et al. [20], which was 0.79. This may be influenced by the use of a validated construct from the original study for perceptions (perception of AED placement strategies and perception of importance of CPR and AED), barriers (concerns of injuring victims during CPR and AED, and concerns of legality in performing CPR and AED), and behaviours (confidence and willingness to perform CPR and AED), even though different populations produce nearly identical results. The KMO value for this study was between 0.7 and 0.8, indicating a good correlation with each other, and factor analysis was appropriate for this dataset. The Bartlett test of sphericity values for all constructs was significant, which is line with the previous study indicating that there was appropriate correlation between the items based on the correlation matrix [20]. The communality values for all items had a value of >0.25 (0.296-0.853). One item had a communality value of 0.4, that is, "knowing the importance of starting a resuscitation before EMS arrival" (0.296), which was considered unrelated to other items. However, according to Beavers et al. [55], communalities between 0.25 and 0.4 have been suggested as acceptable cut-off values, with ideal communalities being 0.7 or above.
All of the components were considered internally consistent, as each earned a Cronbach's alpha value of >0.60, which coincides with the literature that the consistency of the construct using Cronbach's alpha for a newly developed tool should be 0.60 [42,47]. Compared with the previous validation study by Chew et al. [20], the factor for "perception of AED placement strategies" was 0.942 compared to 0.915, showing the same excellent reliability results. The factor for "confidence and willingness to perform CPR and AED" was 0.893 compared to 0.945, showing an increase from high to excellent reliability results. However, the "perception of importance of CPR and AED" showed a significant difference from 0.855 (high reliability) to 0.637 (moderate reliability). This may be influenced by the participation of respondents in this study, who were only allocated a shorter time to learn CPR and AED compared to the original study involving participation in workshops, thus influencing their perceptions of the importance of CPR and AED at a moderate level. The internal consistency of the overall FIXED instrument was high reliability and the ICC indicated moderate to good test-retest reliability. Overall, the goods requirement in each construction as a whole met the KMO (>0.60), Bartlett's test of sphericity (significant), factor loading exceeding the minimum threshold of 0.4, corrected item-total correlation >0.30, and the Cronbach's alpha exceeded the minimum limit of 0.6 for adoption in this study.
The FIXED questionnaire translation and validation processes were difficult to compare with the previous study. There have been some limited validation studies even though they were for other languages. Some of the constructs from previous studies that were used in the FIXED questionnaire were not fully validated.

Conclusions
The FIXED instrument is the first tool for assessing the knowledge, training, perceptions, attitudes, perceived norms, self-efficacy, intentions, behaviours, and barriers within the community toward performing CPR and using an AED. The overall findings indicate that the Malay version of the instrument demonstrated acceptable validity and reliability in its pilot testing. In this evaluation, the validity and reliability of the instrument displayed the appropriate and acceptable measurement performance needed to assess the influencing factors affecting community willingness to perform CPR and use an AED in the Malaysian context. This tool has potential applications in both the research setting and clinical practice. Investigators can use it to survey their population of interest and use the information to inform decision-making to derive an effective strategy by implementing CPR-and AED-related comprehensive programmes involving the community. The tool can be tested on a larger sample to further establish its reliability and validity. In the future, the FIXED instrument is ready to be used by health care workers and policymakers to evaluate the factors influencing the community's willingness to perform CPR and use an AED.   Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. The study's objectives and benefits through participant information leaflets were linked online. The respondents' confidentiality and anonymity were assured.

Data Availability Statement:
The data presented in this study are available within the article.