Development and Validation of Factors Affecting Telenutrition Adoption among Malaysian Dietitians Questionnaire
Abstract
This study aimed to determine the validity of a newly developed questionnaire to assess dietitians' understanding of the factors influencing telenutrition adoption in Malaysia. As such, a questionnaire was developed to assess dietitians’ professional changes, acceptability, barriers, and facilitators to telenutrition implementation. It was constructed based on published questionnaires and an extensive literature review. The questionnaire comprising 52 items, underwent content and face validity assessments. Eight dietetics experts with academic and clinical backgrounds and more than five years of experience in the field evaluated the questionnaire items for relevance, clarity, simplicity, ambiguity, readability, and practicality. The experts quantitatively assessed the questionnaire using a Likert scale rating and additional comments. The Content Validity Index (CVI) was determined using item and scale indices (I-CVI/S-CVI/Ave). The findings show that the I-CVI score ranged between 0.78 and 1.00, and the S-CVI/Ave was >0.87. Thirteen items with an I-CVI score of <0.83 were deleted. Based on the feedback, revisions were made to the instructions and questions regarding clarity, redundancy, ambiguity, or item length. Then, face validation was qualitatively conducted by cognitive review (n=7). This utilized think-aloud and verbal-probing techniques on participants with experience providing telenutrition services for >2 years. The interview was transcribed verbatim and analyzed using ATLAS.ti software. Twelve items were amended due to ambiguity and unclear meanings. The final questionnaire with thirty-nine items is valid to assess the factors influencing telenutrition adoption among Malaysian dietitians.
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References
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Bujang MA. 2021. A step-by-step process on sample size determination for medical research. Malays J Med Sci 28(2):15–27. https://doi.org/10.21315/MJMS2021.28.2.2
Buschle C, Reiter H, Bethmann A. 2022. The qualitative pretest interview for questionnaire development: outline of programme and practice. Qual Quant 56(2):823–842. https://doi.org/10.1007/s11135-021-01156-0
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Coşkun MG, Kolay E, Basaranoglu M. 2023. Telenutrition for the management of inflammatory bowel disease: Benefits, limits, and future perspectives. World J Clin Cases 11(2):308–308. https://doi.org/10.12998/WJCC.V11.I2.308
Davis LL. 1992. Instrument review: Getting the most from a panel of experts. Apple Nurs Res 5(4):194–197. https://doi.org/10.1016/S0897-1897(05)80008-4
de Yébenes MJG, Rodriguez-Salvanés P, Carmona L. 2009. Validation of questionnaires. Reumatol Clin 5(4):171–177. https://doi.org/10.1016/S2173-5743(09)70115-7.
Farid D. 2020. COVID-19 and telenutrition: Remote consultation in clinical nutrition practice. Curr Dev Nutr 4(12):1–4. https://doi.org/10.1093/CDN/NZAA124
Gentili A, Failla G, Melnyk A, Puleo V, Tanna G L D, Ricciardi W, Cascini F. 2022. The cost-effectiveness of digital health interventions: A systematic review of the literature. Front Public Health 10:787135. https://doi.org/10.3389/fpubh.2022.787135
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Thrisha P, Vijayaraghavan S, Wherton J, Shaw S, Byrne E, Campbell-Richards D, Bhattacharya S, Hanson P, Ramoutar S, Gutteridge C, et al. 2016. Virtual online consultations: advantages and limitations (VOCAL) study. BMJ Open 6(1):e009388. http://dx.doi.org/10.1136/bmjopen-2015-009388
Guntu M, Lin EJD, Sezgin E, Gregory ME, Huang Y, Linwood SL. 2022. Identifying the factors influencing patients' telehealth visit satisfaction: Survey validation through a Structural Equation Modeling approach. Telemed J E Health 28(9):1261–1269. https://doi.org/10.1089/TMJ.2021.0372
Güss CD. 2018. What is going through your mind? Thinking aloud as a method in cross-cultural psychology. Front Psychol 9:355159 https://doi.org/10.3389/fpsyg.2018.01292
Hibben KC, Jong JD. 2016. Title of cognitive interview. guidelines for best practice in cross-cultural surveys. Ann Arbor, MI: Survey research center, institute for social research, University of Michigan. http://ccsg.isr.umich.edu/ [Accessed 18th May 2023]
Izquierdo R, Lagua CT, Meyer S, Ploutz-Snyder RJ, Palmas W, Eimicke JP, Kong J, Teresi JA, Shea S, Weinstock RS. 2010. Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. Diabetes Technol Ther 12(3):213–220. https://doi.org/10.1089/DIA.2009.0102
Kishore K, Jaswal V, Kulkarni V, De D. 2021. Practical guidelines to develop and evaluate a questionnaire. Indian Dermatol Online J 12(2):266–266. https://doi.org/10.4103/IDOJ.IDOJ_674_20
Kruse C, Heinemann K. 2022. Facilitators and barriers to the adoption of telemedicine during the first year of COVID-19: Systematic review. J Med Internet Res 24(1):e31752. https://doi.org/10.2196/31752
Said NAM, Bujang SM, Buang NA, Siraj@Ramli HH, Besar MNA. 2022. Critical thinking transfer practice instrument: A content validity calculation steps based on expert panel evaluation. Educ Med J 14(3):61–74. https://doi.org/10.21315/ eimj2022.14.3.5
Mahmoodi MR, Kazemian B, Asaadi S. 2023. Could telenutrition be applied interchangeably with the face-to-face interview for dietary intake assessment in patients with type 2 diabetes during the COVID-19 pandemic? J Kerman Univ Med Sci 30(2):100–105. https://doi.org/ 10.34172/jkmu.2023.16
McCabe BJ, Copeland NP, Shull CA, Dictson KD. 2001. Telehealth and telenutrition. J Nutr Elder 21(2):73–84. http://dx.doi.org/10.1300/J052v21n02_06
Meadows K. 2021. Cognitive interviewing methodologies. Clin Nurs Res 30(4):375–379. https://doi.org/10.1177/1054773821101409
Mehta P, Marisa, Monique, Nagle S, Guigli R, Thomas J, Shull M, Liu E. 2021. Telehealth and Nutrition Support During the COVID-19 Pandemic. Komp Nutr Diet 1(3):110−112. https://doi.org/10.1159/000519959
Nirmalan PK. 2021. The validation of questionnaires. Kerala J Ophthalmol 33(3):260–262. https://doi.org/10.4103/kjo.kjo_12_21
Polit DF, Beck CT. 2006. The content validity index: Are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 29(5):489–497. https://doi.org/10.1002/NUR.20147
Polit DF, Beck CT, Owen SV. 2007. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health 30(4):459–467. https://doi.org/10.1002/NUR.20199
Rozga M, Handu D, Kelley K, Jimenez EY, Martin H, Schofield M, Steiber A. 2021. Telehealth during the COVID-19 pandemic: A cross-sectional survey of registered dietitian nutritionists. J Acad Nutr Diet 121(12):2524–2535. https://doi.org/10.1016/J.JAND.2021.01.009
Ryan K, Gannon-Slater N, Culbertson MJ. 2012. Improving survey methods with cognitive interviews in small- and medium-scale evaluations. Am J Eval 33(3):414–430. https://doi.org/10.1177/1098214012441499
Tsang S, Royse CF, Terkawi AS. 2017. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth 11(Suppl 1):S80–S89. https://doi.org/10.4103/SJA.SJA_203_17
Willis GB, Miller K. 2011. Cross-cultural cognitive interviewing: Seeking comparability and enhancing understanding. Field Methods 23(4):331–341. https://doi.org/10.1177/1525822X11416092
Willis GB, Artino AR. 2013. What do our respondents think we're asking? Using cognitive interviewing to improve medical education surveys. J Grad Med Educ 5(3):353–356. https://doi.org/10.4300/JGME-D-13-00154.1
Yusoff MSB. 2019. ABC of content validation and content validity index calculation. Educ Med J 11(2):49–54. https://doi.org/10.21315/EIMJ2019.11.2.6
Zamanzadeh V, Ghahramanian A, Rassouli M, Abbaszadeh A, Alavi-Majd H, Nikanfar AR. 2015. Design and implementation content validity study: Development of an instrument for measuring patient-centered communication. J Caring Sci 4(2):165–178. https://doi.org/10.15171/jcs.2015.017
Almathami HKY, Win KT, Vlahu-Gjorgievska E. 2020. Barriers and facilitators that influence telemedicine-based, real-time, online consultation at patients' homes: Systematic literature review. J Med Internet Res 22(2). https://doi.org/10.2196/16407
Almojaibel AA, Munk N, Goodfellow LT, Fisher TF, Miller KK, Comer AR, Bakas T, Justiss MD. 2019. Development and validation of the tele-pulmonary rehabilitation acceptance scale. Respir Care 64(9):1057–1064. https://doi.org/10.4187/RESPCARE.06432
Benson GA, Sidebottom A, Hayes J, Miedema MD, Boucher J, Vacquier M, Illah A, Gamam S, VanWormer JJ. 2019. Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) telemedicine randomized controlled trial on diabetes optimal care outcomes in patients with type 2 diabetes. J Acad Nutr Diet 119(4):585–598. https://doi.org/10.1016/J.JAND.2018.11.013
Brunton C, Arensberg MB, Drawert S, Badaracco C, Everett W, McCauley SM. 2021. Perspectives of registered dietitian nutritionists on adoption of telehealth for nutrition care during the COVID-19 pandemic. Healthcare 9(2):235. https://doi.org/10.3390/healthcare9020235
Bujang MA. 2021. A step-by-step process on sample size determination for medical research. Malays J Med Sci 28(2):15–27. https://doi.org/10.21315/MJMS2021.28.2.2
Buschle C, Reiter H, Bethmann A. 2022. The qualitative pretest interview for questionnaire development: outline of programme and practice. Qual Quant 56(2):823–842. https://doi.org/10.1007/s11135-021-01156-0
Cabatan MCC, Grajo LC, Sana EA. 2020. Development and content validation of the adaptation process in academia questionnaire for occupational therapy educators. Acta Med Philipp 54(2):142–150. https://doi.org/10.47895/amp.v54i2.1537.
Chen YC, Tsao LI, Huang CH, Yu YY, Liu IIL, Jou HJ. 2013. An internet-based health management platform may effectively reduce the risk factors of metabolic syndrome among career women. Taiwan J Obstet Gyne 52(2):215–221. https://doi.org/10.1016/J.TJOG.2013.04.011
Coşkun MG, Kolay E, Basaranoglu M. 2023. Telenutrition for the management of inflammatory bowel disease: Benefits, limits, and future perspectives. World J Clin Cases 11(2):308–308. https://doi.org/10.12998/WJCC.V11.I2.308
Davis LL. 1992. Instrument review: Getting the most from a panel of experts. Apple Nurs Res 5(4):194–197. https://doi.org/10.1016/S0897-1897(05)80008-4
de Yébenes MJG, Rodriguez-Salvanés P, Carmona L. 2009. Validation of questionnaires. Reumatol Clin 5(4):171–177. https://doi.org/10.1016/S2173-5743(09)70115-7.
Farid D. 2020. COVID-19 and telenutrition: Remote consultation in clinical nutrition practice. Curr Dev Nutr 4(12):1–4. https://doi.org/10.1093/CDN/NZAA124
Gentili A, Failla G, Melnyk A, Puleo V, Tanna G L D, Ricciardi W, Cascini F. 2022. The cost-effectiveness of digital health interventions: A systematic review of the literature. Front Public Health 10:787135. https://doi.org/10.3389/fpubh.2022.787135
Gnagnarella P, Ferro Y, Monge T, Troiano E, Montalcini T, Pujia A, Mazza E. 2022. Telenutrition: Changes in professional practice and in the nutritional assessments of Italian dietitian nutritionists in the COVID-19 era. Nutrients 14(7):1359. https://doi.org/10.3390/nu14071359
Thrisha P, Vijayaraghavan S, Wherton J, Shaw S, Byrne E, Campbell-Richards D, Bhattacharya S, Hanson P, Ramoutar S, Gutteridge C, et al. 2016. Virtual online consultations: advantages and limitations (VOCAL) study. BMJ Open 6(1):e009388. http://dx.doi.org/10.1136/bmjopen-2015-009388
Guntu M, Lin EJD, Sezgin E, Gregory ME, Huang Y, Linwood SL. 2022. Identifying the factors influencing patients' telehealth visit satisfaction: Survey validation through a Structural Equation Modeling approach. Telemed J E Health 28(9):1261–1269. https://doi.org/10.1089/TMJ.2021.0372
Güss CD. 2018. What is going through your mind? Thinking aloud as a method in cross-cultural psychology. Front Psychol 9:355159 https://doi.org/10.3389/fpsyg.2018.01292
Hibben KC, Jong JD. 2016. Title of cognitive interview. guidelines for best practice in cross-cultural surveys. Ann Arbor, MI: Survey research center, institute for social research, University of Michigan. http://ccsg.isr.umich.edu/ [Accessed 18th May 2023]
Izquierdo R, Lagua CT, Meyer S, Ploutz-Snyder RJ, Palmas W, Eimicke JP, Kong J, Teresi JA, Shea S, Weinstock RS. 2010. Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. Diabetes Technol Ther 12(3):213–220. https://doi.org/10.1089/DIA.2009.0102
Kishore K, Jaswal V, Kulkarni V, De D. 2021. Practical guidelines to develop and evaluate a questionnaire. Indian Dermatol Online J 12(2):266–266. https://doi.org/10.4103/IDOJ.IDOJ_674_20
Kruse C, Heinemann K. 2022. Facilitators and barriers to the adoption of telemedicine during the first year of COVID-19: Systematic review. J Med Internet Res 24(1):e31752. https://doi.org/10.2196/31752
Said NAM, Bujang SM, Buang NA, Siraj@Ramli HH, Besar MNA. 2022. Critical thinking transfer practice instrument: A content validity calculation steps based on expert panel evaluation. Educ Med J 14(3):61–74. https://doi.org/10.21315/ eimj2022.14.3.5
Mahmoodi MR, Kazemian B, Asaadi S. 2023. Could telenutrition be applied interchangeably with the face-to-face interview for dietary intake assessment in patients with type 2 diabetes during the COVID-19 pandemic? J Kerman Univ Med Sci 30(2):100–105. https://doi.org/ 10.34172/jkmu.2023.16
McCabe BJ, Copeland NP, Shull CA, Dictson KD. 2001. Telehealth and telenutrition. J Nutr Elder 21(2):73–84. http://dx.doi.org/10.1300/J052v21n02_06
Meadows K. 2021. Cognitive interviewing methodologies. Clin Nurs Res 30(4):375–379. https://doi.org/10.1177/1054773821101409
Mehta P, Marisa, Monique, Nagle S, Guigli R, Thomas J, Shull M, Liu E. 2021. Telehealth and Nutrition Support During the COVID-19 Pandemic. Komp Nutr Diet 1(3):110−112. https://doi.org/10.1159/000519959
Nirmalan PK. 2021. The validation of questionnaires. Kerala J Ophthalmol 33(3):260–262. https://doi.org/10.4103/kjo.kjo_12_21
Polit DF, Beck CT. 2006. The content validity index: Are you sure you know what's being reported? Critique and recommendations. Res Nurs Health 29(5):489–497. https://doi.org/10.1002/NUR.20147
Polit DF, Beck CT, Owen SV. 2007. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health 30(4):459–467. https://doi.org/10.1002/NUR.20199
Rozga M, Handu D, Kelley K, Jimenez EY, Martin H, Schofield M, Steiber A. 2021. Telehealth during the COVID-19 pandemic: A cross-sectional survey of registered dietitian nutritionists. J Acad Nutr Diet 121(12):2524–2535. https://doi.org/10.1016/J.JAND.2021.01.009
Ryan K, Gannon-Slater N, Culbertson MJ. 2012. Improving survey methods with cognitive interviews in small- and medium-scale evaluations. Am J Eval 33(3):414–430. https://doi.org/10.1177/1098214012441499
Tsang S, Royse CF, Terkawi AS. 2017. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi J Anaesth 11(Suppl 1):S80–S89. https://doi.org/10.4103/SJA.SJA_203_17
Willis GB, Miller K. 2011. Cross-cultural cognitive interviewing: Seeking comparability and enhancing understanding. Field Methods 23(4):331–341. https://doi.org/10.1177/1525822X11416092
Willis GB, Artino AR. 2013. What do our respondents think we're asking? Using cognitive interviewing to improve medical education surveys. J Grad Med Educ 5(3):353–356. https://doi.org/10.4300/JGME-D-13-00154.1
Yusoff MSB. 2019. ABC of content validation and content validity index calculation. Educ Med J 11(2):49–54. https://doi.org/10.21315/EIMJ2019.11.2.6
Zamanzadeh V, Ghahramanian A, Rassouli M, Abbaszadeh A, Alavi-Majd H, Nikanfar AR. 2015. Design and implementation content validity study: Development of an instrument for measuring patient-centered communication. J Caring Sci 4(2):165–178. https://doi.org/10.15171/jcs.2015.017
Authors
Mohd Daud, N. L. H., Mohamed Nor, N., Jaafar, N. H., Abu Bakar, W. A. M. A. B., & Mohd Shukri, N. A. (2025). Development and Validation of Factors Affecting Telenutrition Adoption among Malaysian Dietitians Questionnaire. Jurnal Gizi Dan Pangan, 20(Supp.1), 71-78. https://doi.org/10.25182/jgp.2025.20.Supp.1.71-78
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Mohd Daud, N. L. H., Mohamed Nor, N., Jaafar, N. H., Abu Bakar, W. A. M. A. B., & Mohd Shukri, N. A. (2025). Development and Validation of Factors Affecting Telenutrition Adoption among Malaysian Dietitians Questionnaire. Jurnal Gizi Dan Pangan, 20(Supp.1), 71-78. https://doi.org/10.25182/jgp.2025.20.Supp.1.71-78
