Translation, Cross-Cultural Adaptation, and Validation of Self-Care Measurement of Diabetes Scale in Urdu

doi:10.21203/rs.3.rs-4898887/v1

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Translation, Cross-Cultural Adaptation, and Validation of Self-Care Measurement of Diabetes Scale in Urdu

https://doi.org/10.21203/rs.3.rs-4898887/v1

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Objective: The Cross-sectional study was conducted to validate the Urdu version of the self-care measurement of diabetes scale at Mercy Teaching Hospital, Peshawar from January to March 2024 on 506 diabetic patients.

Methods: The average age of the participants was 48.37 + 12.96 years. The majority were females (n=283, 55.9%), married (n=475, 93.9%) uneducated (n=362, 71.5%) unemployed (n=381, 75.3%), and lived in joint family systems (n=241, 47.6%) respectively.

Results: The study found that 96.6% of patients were diabetic, with 58.5% managing the disease for under 10 years; 38.9% used both insulin and oral medications, while 38.1% used only tablets. Additionally, 71.7% of patients had no other medical comorbidities. The three bilingual experts used forward-backward translation methods to translate the Self-Care Measurement of Diabetes Scale from English to Urdu. The Urdu translation was administered to the patients to evaluate their confirmatory and exploratory factor analysis, construct validity, and Cronbach’s alpha reliability. Factorial validity indicated that the scale conforms to a five-factor model, with items showing significant inter-correlation (p < .01). Item-total correlation showed a significant correlation coefficient (p < .001) to find the construct validity. The Cronbach’s alpha reliability of the Urdu version was 0.704. Confirmatory factor analysis (CFA) demonstrated a goodness of fit model with a Comparative Fit Index (0.970) and a Root Mean Square Error of Approximation (RMSEA) of 0.088.

Conclusion: These findings suggest that the Self-Care Measurement of Diabetes Scale, Urdu translation is a reliable scale with robust validity, suitable for assessing self-care in clinical settings.

Self-care measurement of diabetes scale

Urdu

Translation

Validation

A metabolic disorder, type 2 Diabetes Mellitus (DM) resulting from either defects in insulin function or pancreatic insufficiency in insulin secretion, or both, primarily due to obesity and physical inactivity [1, 2]. Over the last twenty years, Diabetes Mellitus gathered significant consideration in literature search, being known as a major global development risk [3, 4]. It is the most prevalent metabolic disorder and foremost cause of death in eastern populations [5]. Its occurrence reached epidemically a two decades ago [6, 7], reducing life expectancy by five to ten years [8]. In 2016, according to WHO, Diabetes is a 7th leading cause of deaths because around 1.6 million people died due to diabetes. Many individuals with diabetes experience emotional difficulties, linked to treatment complications such as poor quality of life, depression, negligence towards self-care, negative perceptions of insulin therapy, decreased sugar levels, and even mortality due to adverse cardiovascular outcomes [9, 10]. Given that the majority of diabetes care is managed by diabetic patients and their care-givers [11, 12], there is an urgent requirement for dependable and valid tools to measure self-management of diabetes [13–16].

Type 2 diabetes mellitus patients require measurement of self-care activities, and the Summary of Diabetes Self-Care Activities (SDSCA) scale has demonstrated adequate convergent validity, proving to be a reliable tool. The inter-construct correlations were highest between general and specific diet measures [17]. A simple, effective, reliable, and accessible self-care measurement scale is crucial for reducing complications and regression of Type 2 DM. Farsi version of the Diabetes Foot Self-Care Behavior Scale has shown a good validity and reliability through exploratory and confirmatory factor analysis [18]. Factorial and convergent validity analyses, along with comparisons to HbA1c and the SDSCA, provided preliminary evidence that the DSMQ has sound psychometric properties and suitable for both scientific and clinical purposes [19].

The Portuguese version has been evaluated for its psychometric properties, focusing on patients of Type 2 diabetes mellitus for therapeutic self-care. This scale is a promising for measuring therapeutic self-care abilities among adult patients with Type 2 diabetes mellitus when applied in primary healthcare settings [20]. German translation of SDSCA-G demonstrated it to be a reliable and valid tool, utilizing Cronbach's alpha, confirmatory and exploratory factor analyses, and a multivariate linear regression to identify the influence of predictor variables [21]. In Pakistan, a qualitative study exploring perspectives, experiences, and obstacles to diabetes self-care reported that economic restraints, physical restrictions, life-threatening climate settings, community get-togethers, preference for certain foods, and hectic routines hinder adherence to diabetes self-care practices [22]. Systematic review & meta-analysis, demonstrated the efficacy of patient-centered self-management care interventions in cultivating glycemic control [23].

A randomized controlled trial in Pakistan evaluating the self-care education on diabetes by the pharmacist-led, and concluded that pharmacist-led educational interventions significantly improved glycemic control, disease awareness, and self-care activities in patients with type 2 DM following face-to-face educational sessions on self-care activities [24]. Additionally, the effectiveness of chronic care among diabetes patients, including disease-related knowledge, self-management aspects, and opinions on educational support groups and self-care guidance, was assessed. The findings indicated that lifestyle modification and self-care guidance required attendance at nurse-led diabetic education sessions [25]. A qualitative analysis examining the perspectives of healthcare professionals on the experiences of patients self-managing type 2 diabetes in rural Pakistan highlighted the importance of doctor-patient relationships, patient non-adherence to exercise and diet, and the influence of cultural factors on self-management activities. Health care professionals face the challenges in rural Pakistan in providing lifestyle modification and self-care management for type 2 diabetes mellitus [26].

The Urdu version of the SDSCA demonstrated its strong reliability and validity. The study concluded that the SDSCA-U is suitable for assessing self-management activities in patients with type 2 diabetes in Urdu-speaking regions of the country [27]. Additionally, the Urdu version of DSMQ, and its psychometric properties were also examined. Reliability was determined using Cronbach's alpha coefficient, while validity was assessed through confirmatory factor analysis and criterion-related correlations, showed strong psychometric properties [28].

Above mentioned studies underscore the high prevalence of type 2 DM in Pakistan and the significant challenges faced by healthcare professionals and patients in handling the illness efficiently. This highlights the need for self-care measurement tools that are not only translated but also culturally adapted and validated in the local language, as these tools are crucial for improving disease management and patient outcomes. Cultural adaptation and translation ensure that the tools are relevant and accurate, enhancing data reliability and improving patient-provider communication, which leads to better education and adherence to treatment plans. Moreover, culturally adapted tools foster trust and compliance, vital for chronic disease management. For a self-care measurement tool to be effective, it must demonstrate high reliability by providing consistent results across various populations, accurately measuring intended outcomes, and comprehensively assessing all aspects of diabetes self-care, such as diet, exercise, medication adherence, and blood glucose monitoring. By addressing these factors, culturally adapted and translated self-care measurement tools can significantly enhance the managing of diabetes, type II in Pakistan and more Asian nations, ultimately improving health outcomes and patients' quality of life. Unfortunately, there are no validated and culturally appropriate instruments available in Urdu for measuring diabetes. Consequently, so the objective of the study is to validate, culturally adapt and translate the self-care measurement of diabetes scale in Urdu, the widely vocal language in the area, to assess diabetes-related self-care among Urdu-speaking Population of Pakistan.

A cross-sectional survey was conducted on Urdu speaking population visiting to the out-patient unit of Endocrinology of Mercy teaching hospital, Peshawar. The purposive sampling technique was used and the study period spanned from January to March 2024.

Prime Foundation’s Ethical Review Committee gave the ethical approval (approval number: 6, 10PRIME/ERC/2024-73). 506 patients were involved in the study. three bilingual experts facilitated the forward-backward translation method for the translation of the self-care measurement of diabetes scale questionnaire from English to Urdu following WHO guidelines [29]. Since no feedback from the sample indicated a need for changes, the translation remained unchanged. Patients were guaranteed of confidentiality and the anonymity of their responses and were given the Urdu translation to complete.

SPSS-25 and AMOS-26 were used for data analysis. The factorial validity of the Urdu translation of self-care measurement of diabetes questionnaire was assessed using the Varimax rotation for factor loading through exploratory factor analysis. Questionnaire reliability was measured by alpha reliability, and value of 0.7 or greater reflected as satisfactory. Construct validity was evaluated by calculating item-total correlation and examining Cronbach’s alpha if an item was deleted. Confirmatory Factor Analysis (CFA) employed to link the goodness of fit model by AMOS, with factor structure assessed by the Comparative Fit Index (CFI).

To explore the relationship between self-care measurement of diabetes and participants’ education and employment status, the Chi-Square test was utilized. Additionally, to study the association, the Pearson correlation coefficients were calculated between self-care measurement of diabetes and various factors including participant’s education, employment status, HbA1c, and medical comorbidities.

Total 506 participants participated in study. Mean age was 48.37 ± 12.96 years with the age range of 18–84 years. The reliability was 0.704 for self-care measurement of diabetes questionnaire. Majority were females (n = 283, 55.9%), were married (n = 475, 93.9%) uneducated (n = 362, 71.5%) and were unemployed housewives (n = 381, 75.3%) and lives in joint family system (n = 241, 47.6%) respectively.

The majority of patients in the study were diabetic, with 489 individuals (96.6%) diagnosed with diabetes. Of these, 296 patients (58.5%) had been managing their diabetes for less than 10 years. In terms of diabetes management, the largest group preferred a combination of insulin and oral medications, accounting for 197 patients (38.9%). This was closely followed by those who used only tablets, comprising 193 patients (38.1%). Furthermore, the majority of the patients (363 individuals, 71.7%) did not have any additional medical comorbidities. Detailed information is presented in Table 1.

Exploratory Factor analysis

“Exploratory Factor Analysis (EFA) with Varimax rotation was used. Factors were selected based on: (a) a simple structure where items load highly on a single factor; (b) an Eigenvalue of 1 or higher; (c) a minimum factor loading of 0.30; and (d) the factor's relevance to the underlying construct [30, 31]. Bartlett’s Test of Sphericity was conducted to assess the normal distribution of responses and was significant (p < 0.001), representing that the statistics were appropriate for factor analysis [32]. Additionally, the Kaiser-Meyer-Olkin test was applied to ensure sample adequacy. This method aims to robustly and meaningfully explore the underlying factors in the data, supported by statistical validation of data suitability”.

In current study findings according to EFA, five factor model described variance for 1st factor is 16.96%, and 15.87% for second factor and 15.57% for third factor and 14.89% for forth factor and 9.95% for fifth factor, indicated a significant association with the conforming factors. Additionally, Bartlett’s test yielded also significant results, signifying that the measures were inter-correlated and suitable for factorial validity. All items were retained as each had a factor loading greater than 0.3. All other aspect is displayed in Table 2.

Reliability and Construct Validity

The Urdu translation of the diabetes self-care measurement showed a Cronbach's Alpha reliability of 0.704. The study results confirmed a significant relationship with the total score, with an item-total correlation p-value of < 0.01, indicating significantly acceptable association. The high reliability values propose strong internal consistency. These results are detailed in Table 3.

Confirmatory Factor Analysis (CFA)

We used CFA through AMOS to evaluate the factor structure of diabetes self-care measurement. “The model fit was assessed using the “Comparative Fit Index (CFI; acceptable fit values > 0.90)”, “root mean square error of approximation (RMSEA; acceptable value < 0.08)”, and “Normed Fit Index (NFI; acceptable fit values > 0.90)”. Our CFA results indicated that the model fit the data well.

Complete results are given in Table 4 and Fig. 1.

Table 1

Simple demographic facts of current study (n = 506)
S. N	Measures		N (%)
1	Gender	Male	223 (44.1%)
1	Gender	Female	283 (55.9%)
2	Marital Status	Married	475 (93.9%)
2	Marital Status	Unmarried	31 (6.1%)
3	Family Structure	Nuclear	240 (47.4%)
3	Family Structure	Joint	266 (52.6%)
4	Education	Uneducated	362 (71.5%)
4	Education	Educated	144 (28.5%)
5	Occupation	Employed	125 (24.7%)
5	Occupation	Unemployed	381 (75.3%)
6	HbA1c	Non-Diabetic	2 (0.4%)
		Pre- Diabetic	15 (3.0%)
		Diabetic	489 (96.6%)
7	Duration of Diabetes	Less than 10 years	296 (58.5%)
7	Duration of Diabetes	10 and more years	210 (41.5%)
8	Type of Treatment	Tablets only	193 (38.1%)
		Insulin only	116 (22.9%)
		Both tablets & Insulin	197 (38.9%)
9	Other Medical Comorbidities	Hypertension	111 (21.9%)
		Heart Disease	19 (3.8%)
		Kidney Problem	8 (1.6%)
		Depression	18 (3.6%)
		Liver Problem	1 (0.2%)
		Parkinson	2 (0.4%)
		Retinopathy	1 (0.2%)
		Neuropathy	1 (0.2%)
		No Other Co-morbidities	363 (71.7%)

Table 2

Factor Loadings of the Urdu version of self-care measurement of diabetes using Varimax rotation for factor loading (n = 506)
S. No	Items	Factor I	Factor II	Factor III	Factor IV	Factor V
1	آپ نے پچھلے سات دن میں سے کتنےدن ڈاکٹر کی ہدایات کے مطابق خوراک پر عمل کیا؟				.839
2	پچھلے مہینے میں اوسط ایک ہفتے میں کتنے دن آپ نے اپنے کھانے کے پلان پر عمل کیا؟				.781
3	پچھلے سات دنوں میں کتنے دن آپ نے پھل یا سبزیاں کھائیں؟					.672
4	پچھلے سات دنوں میں کتنے دن آپ نے مرغن غذائیں جیسے بڑا یا چھوٹا گوشت یا دودھ کی بنی ہوئی غذائیں کھائیں؟				.523
5	پچھلے سات دنوں میں کتنےدن آپ نے کم از کم 30 منٹ کی جسمانی سرگرمی مثلا ورزش وغیرہ میں حصہ لیا؟		.877
6	آپ نے گذشتہ سات دنوں میں کتنے دن گھر کے کام کے علاوہ مخصوص ورزش جیسے تیراکی ، تیز تیز چلنا ، سائیکل چلانا وغیرہ میں حصہ لیا؟		.876
7	پچھلےسات دنوں میں آپ نے کتنےدن شوگر کا ٹیسٹ کروایا ہے	.902
8	پچھلے سات دنوں میں اپنے معالج کے مطابق مشورے اور اس کی تجویز کے مطابق کتنے دن آپ نے ایک دفعہ یا اس سے زیادہ دفعہ شوگر کو چیک کیا ہے	.894
9	پچھلے سات دنوں میں آپ نےکتنےدن اپنے پاؤں چیک کیے؟			.920
10	پچھلے سات دنوں میں کتنے دن آپ نےاپنے جوتوں کا اندر سے معائنہ کیا ہے؟			.899
11	کیا آپ نے پچھلے سات دنوں کے دوران سگریٹ پیا ہے؟					.770
Eigen Values		1.86	1.74	1.71	1.63	1.09
Percentage of variance		16.96	15.87	15.57	14.89	9.95
Kaiser-Myer Olkin Measure of Sampling Adequacy		.594
Bartlett’s Test of Sphericity, Approximate Chi-Square		1749.904***

Bold: greater values of factor loadings in every item (> 0.3).

*** p < .001

Table 3

Item total score correlation and Cronbach’s alpha, if item deleted, for the Urdu version of self-care measurement of diabetes (n = 506)
S. No	Items	Correlation with total score	Cronbach’s alpha, if deleted
1	آپ نے پچھلے سات دن میں سے کتنےدن ڈاکٹر کی ہدایات کے مطابق خوراک پر عمل کیا؟	.422***	.671
2	پچھلے مہینے میں اوسط ایک ہفتے میں کتنے دن آپ نے اپنے کھانے کے پلان پر عمل کیا؟	.479***	.662
3	پچھلے سات دنوں میں کتنے دن آپ نے پھل یا سبزیاں کھائیں؟	.074**	.721
4	پچھلے سات دنوں میں کتنے دن آپ نے مرغن غذائیں جیسے بڑا یا چھوٹا گوشت یا دودھ کی بنی ہوئی غذائیں کھائیں؟	− .015	.732
5	پچھلے سات دنوں میں کتنےدن آپ نے کم از کم 30 منٹ کی جسمانی سرگرمی مثلا ورزش وغیرہ میں حصہ لیا؟	.454***	.664
6	آپ نے گذشتہ سات دنوں میں کتنے دن گھر کے کام کے علاوہ مخصوص ورزش جیسے تیراکی ، تیز تیز چلنا ، سائیکل چلانا وغیرہ میں حصہ لیا؟	.415***	.672
7	پچھلےسات دنوں میں آپ نے کتنےدن شوگر کا ٹیسٹ کروایا ہے	.510***	.654
8	پچھلے سات دنوں میں اپنے معالج کے مطابق مشورے اور اس کی تجویز کے مطابق کتنے دن آپ نے ایک دفعہ یا اس سے زیادہ دفعہ شوگر کو چیک کیا ہے	.497***	.656
9	پچھلے سات دنوں میں آپ نےکتنےدن اپنے پاؤں چیک کیے؟	.356***	.683
10	پچھلے سات دنوں میں کتنے دن آپ نےاپنے جوتوں کا اندر سے معائنہ کیا ہے؟	.379***	.679

*** = p < 0.01 level; ** = p < 0.05 level.

Table 4

Confirmatory Factor Analysis for Indices of Model Fit (n = 506)
Measure	Model	X²	Df	GFI	CFI	NFI	RMSEA
Self-care measurement of diabetes (Urdu)	Default Model	83.586***	17	.970	.961	.952	.088

Table 5

Pearson correlation coefficient among participant’s employment status, education, HbA1c and medical comorbidities with self-care measurement of diabetes (n = 506)
S. No	Items	I	II	III	IV	V
I	Self-care measurement of diabetes	1
II	Participants’ Education	.028 (.527)	1
III	Participant’s Employment	− .075 (.093)	− .451** (.000)	1
IV	Other Medical Comorbidities	− .081 (.068)	− .057 (.199)	.020 (.646)	1
V	HbA1c	− .132** (.003)	− .075 (.092)	.181** (.000)	− .066 (.136)	1

Similar to numerous other research domains, diabetes has been extensively studied in Western countries, leading to a paucity of translated and validated instruments for measuring diabetes self-care in non-Western contexts. This study constitutes the inaugural effort to translate and validate a pivotal tool for assessing diabetes self-care into Urdu. Recent advancements in the field emphasize the critical need for culturally adapted tools, as emerging evidence underscores substantial variations in diabetes management practices and outcomes across different populations. Moreover, the escalating prevalence of type 2 diabetes in South Asia, especially in Pakistan, has heightened the demand for reliable, culturally relevant self-care measurement instruments. This study not only addresses a significant void in diabetes research but also establishes a solid foundation for future investigations aimed at enhancing diabetes self-management and patient education within Urdu-speaking communities. The findings affirm that the Urdu version of the diabetes self-care measurement scale possesses excellent psychometric properties, with a Cronbach's alpha reliability of 0.704. This reliability is greater than those described in Chinese (0.630) [33] and German (0.682) [21] translations but slightly lower than the Farsi (0.83) [17], Hungarian (0.845) [34], and Portuguese (0.884) versions [20].

Using CFA via AMOS, the study compared the factor model of the self-care measurement scale, yielding a CFI (0.970) and an RMSEA (0.088) with a five-factor model. This contrasts with the German study, which used a four-factor model but reported similar goodness of fit [21]. The Portuguese version produced a three-factor model, enlightening 75% of the whole variance, surpassing the variance explained in our study [20]. Similarly, the Chinese version demonstrated a good fit with a three-factor structure [33], while the Farsi version exhibited an excellent fit, accounting for 56.22% of the variance [17]. Another scale, the Diabetes Self-Management Questionnaire (DSMQ), indicated an appropriate fit for a four-factor model [19].

The self-care measurement scale for diabetes was negatively correlated with HbA1c scores, consistent with findings from other studies [35, 36]. DSMQ-R scale also showed correlations with HbA1c levels, though generally weaker than those found by Schmitt and colleagues [19]. The known group analysis revealed that greater levels of DSMQ-R corresponded with better HbA1c levels, demonstrating that improved self-care is linked with better diabetes control [34], aligning with our current study's findings.

The majority of participants were female, married, housewives residing in joint family systems and had managed their diabetes for less than ten years, predominantly using a combination of insulin and oral medications. Also the study concluded that the Urdu version of the diabetes self-care measurement scale exhibited strong internal consistency and reliability. Factor analysis validated the scale's structure, while CFA showed a good model fit, so the Urdu version of the diabetes self-care measurement scale has showed a sound psychometric properties for evaluating self-care activities in diabetic patients of Asian population.

LIMITATION

Study's limitations included that the results cannot be generalized as population consisted of uneducated, unemployed housewives, potentially unrepresentative of the broader Type 2 diabetes population. Also, the focus on Urdu-speaking individuals may limit the generalizability to other linguistic and cultural groups. Furthermore, the self-care measurement scale may not fully encompass all aspects of diabetes self-care, possibly overlooking critical areas.

RECOMMANDATIONS

Future studies should strive to include a more diverse sample that reflects various education levels, employment statuses, and cultural backgrounds to enhance generalizability. Expanding the scope of the self-care measurement scale to cover a broader range of relevant activities and behaviors is recommended. Also, integrating validated self-care measurement tools into routine clinical practice can improve patient monitoring and allow for tailored interventions.

The authors report no competing interests to declare.

ACKNOWLEDGEMENT

Acknowledge all the participants who cooperated and took part in this study.

FUNDING:

None

Authors Contribution:

MRS: Planned the overall study, helped in the write up of the manuscript, and also helped in data analysis and final production of results and supervised the whole process of the study from the conception to finalization and critically reviewed the manuscript.

MHW: helped in the data collection process and data entry, also critically reviewed the whole manuscript.

SS: Helped in Data Acquisition

MU, SHQ, MH: Helped in data collection, data entry in the software.

DECLARATION OF INTEREST

Ethical Approval and consent to participate: Ethical Approval was taken from the Prime Foundation’s Ethical Review Committee (approval number: 6, 10PRIME/ERC/2024-73).

Consent to Publication: All the authors made significant intellectual contribution to the study and gave the consent for publication.

Data Availability statement: The data supporting the findings of this study are available within the article, and detailed files (like SPSS Files) will be provided on request.

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No competing interests reported.

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Translation, Cross-Cultural Adaptation, and Validation of Self-Care Measurement of Diabetes Scale in Urdu

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INTRODUCTION

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RESULTS

*** p < .001

DISCUSSION

CONCLUSION

LIMITATION

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