**2. Measurement of attitude towards palliative care**

#### **2.1 Understanding about attitude**

Social-cultural knowledge is important in the understanding of palliative care [3–5]. Attitude, which referred to a force or quality of mind, seemed much more appropriate [6, 7]. Traditionally, attitudes have been considered to have three fundamental components: affective (feeling and emotional reaction) behavioral (individual intention that self-concept), and cognitive (beliefs, knowledge, thought, experience) components to the attitude object [6–9] (as shown **Figure 1**).

**Figure 1.** *Response of attitude model by Gelegjamts [10].*

Attitudes refer to the positive or negative attitude evaluations that people make about any aspect of reality [11]. Attitudes are directly related to the thoughts and beliefs one has towards object of attitude [6] these beliefs and attitudes can also impact the level of palliative education [12].

Cultural factors of attitudes such as race, religion, ethnicity may also have a perspective effect on a patient's suffering and recovery.

The attitude of healthcare professionals towards dying patients may vary based on their cultural structure, religious thought, social environment, family structure the technology used in their unit, communication methods, palliative care training, and previous experience of encountering death [13].

A supportive care attitude has recognized the psychosocial features and problems that make every patient a unique individual and these unique characteristics can greatly influence suffering and need to be considered when planning caring service [14].

#### **2.2 Measurement of attitude towards object**

In 1928 Louis Leon Thurston said, "attitude can be measured" [8] and "attitude can be learned" [6]. Humans are not born with attitudes, and they acquire attitudes during their lifestyle and course of socialization [6]. Attitudes measurements have followed the explicit attitude (acquired consciousness) and the implicit attitude (subconsciously) dichotomy, attitude can be examined through direct and indirect measures [15].

The Implicit attitude measures are more valid and reliable. This has important implications are implicit attitude measures (such as self-reports). The implicit measures help account for attitudes that a person may be aware of or want to show [16] and usually rely on an indirect measure of attitude. The implicit attitudes measurement tests, include the implicit association test, evaluative and semantic priming tasks, the Extrinsic Affective Simon Task, Go/No-Go Association Task, and the Affect Misattribution Procedure. The explicit attitude measures are direct measurement and attitude-related acquired knowledge. The explicit measure is lower valid and more reliable than the implicit measure because people are often unwilling to provide responses perceived as socially undesirable and therefore tend to report what they think their attitude should be rather than what they know them to be [17]. Explicit and Implicit attitudes did not correlate: the model of dual attitudes [18].

The following points highlight the top five techniques used to measure the attitude of an individual. The techniques are [19]:


#### Method of summated rating

Likert developed this method of summated rating and is famous for constructing several attitude scales to measure attitudes towards various complex issues.

Liker's scale is presented in five categories such, on a 5-point (Strongly Agree, Somewhat Agree, Neutral, Somewhat Disagree, Strongly Disagree) scale, for example, researchers assume that the psychological difference between Strongly Agree to strongly disagree [6].

The total score for each individual subject for all the statements is calculated by summing up each individual response. The use of 'Item Analysis' in the construction of attitude scale is the most important feature of Likert's scale. In this scale, the individual scores are interpreted in terms of the scores obtained by a group of individuals which is commonly done in psychological test construction.

#### **2.3 Measurement of attitudes towards end of life**

Many tools have been developed to measure the attitude for health care professionals such as physicians, nurses, and medical students and the tools usually measure with their knowledge, attitude, and practice (KAP).

It is important to have tools that allow us to know the attitudes of health care professionals towards the care of patients who is under Palliative care [9]. Attitudes towards palliative care were defined as feelings, thoughts, attitudes, and comfort level towards care of the patients and their family [5, 20] and most of the available tools are in attitude and competence in dealing with death and dying tools that are Frommel's attitudes towards care of the dying (FATCOD—A for nurses, FATCOD-B for students) scale by 1991 [21]. FATCOD tool has been used with physicians and nurses form different countries and a few countries' reports have been using for psychologists and social workers [5, 9, 13, 22–24]. This tool is specifically designed for evaluating nurses and has an equal number of positively and negatively worded items and responding rate is 5 point on the Liker scale, ranging from 30 to 150. Higher scores reflected more positive attitudes towards the end of life. It is necessary for health care professionals to better understand death, accept, and prepare for it with a mature attitude [25, 26]. Death attitude profile revised (created by Wong, Reker and Gesser in 1994 [27]) tool is reliable and valid assessment instrument used to identify attitudes about care at the end of life among clinicians [9]. DAP-R reliability values were high and the five domains of attitude towards death i.e., fear of death, death avoidance, natural acceptance, approach acceptance, and escape acceptance, respectively [26, 28].

Additionally, many study has used attitude related tools and scales such as the cancer attitudes questionnaire, the attitude assessment questionnaire, the cancer attitude inventory, and attitudes towards pain.
