Innab and Kerari BMC Primary Care (2024) 25:274 BMC Primary Care

[Link]

RESEARCH Open Access

Validation of the Arabic version

of the diabetes self-management questionnaire
in patients with type 2 diabetes mellitus:
a cross-sectional study
Adnan Innab1*   and Ali Kerari1   

Abstract
Background The number of instruments available for measuring diabetes self-management activities in Arabic
countries has been limited to date. To our knowledge, no multidimensional instrument suitable for measuring
diabetes self-management is currently available in Arabic. This study assessed the validation of the Arabic version
of the Diabetes Self-Management Questionnaire (A-DSMQ) in patients with type 2 diabetes mellitus (T2DM).
Methods This cross-sectional study was conducted from May to August 2022 at primary healthcare cent-
ers within the Riyadh region of Saudi Arabia. Four steps were followed during the translation and adaptation
of the DSMQ: forward translation, consulting an expert panel, backward translation, and pilot testing on the target
population. The data were collected using a convenience sample of 154 patients with T2DM. Cronbach’s α coefficient,
criterion validity, and known-group validity were determined.
Results Cronbach’s α coefficient for internal consistency was 0.76. The A-DMSQ “sum scale” scores were nega-
tively correlated with glycosylated hemoglobin (HbA1c) levels (Pearson’s r =  − 0.48, p < 0.01) and body mass indices
(r =  − 0.29, p < 0.01) and positively correlated with Self-Rated Health Scale scores (r = 0.41, p < 0.01). Mean A-DSMQ
“sum scale” scores differed significantly among groups with adequate, partially adequate, and inadequate glycemic
control (F = 23.193, p < 0.001).
Conclusions These results indicate that the A-DSMQ is a reliable and valid tool for measuring diabetes self-manage-
ment in patients with T2DM. The A-DSMQ can be used by researchers and healthcare providers interested in assessing
diabetes self-management in this population. Healthcare providers should remain alert for suboptimal diabetes self-
management, which may lead to significant economic costs in emergency and healthcare utilization.

Highlights
What do we already know about this topic?
• Adequate diabetes self-management is essential for maintaining better glycemic control and achieving optimal
health outcomes. However, evidence supports that many individuals living with diabetes report improvable self-
management behaviors.

*Correspondence:
Adnan Innab
ainnab@[Link]
Full list of author information is available at the end of the article

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Innab and Kerari BMC Primary Care (2024) 25:274 Page 2 of 8

• The DSMQ is a widely used measure of self-management skills in areas of diabetes, which has been validated
among individuals with T2DM in many countries.
How does your research contribute to the field?
• Our results provide additional evidence on the reliability and validity of the A-DSMQ in patients with T2DM.
• The A-DSMQ had appropriate structural and construct validity and acceptable internal consistency and reliability.
What are your research’s implications toward theory, practice, or policy?
• The A-DSMQ provides primary care nurses and other healthcare professionals with an easily administered tool
for assessing the diabetes self-management skills of Arabic-speaking patients with T2DM.
Keywords DSMQ, Diabetes, Self-management, Reliability, Validation

Background and healthcare professionals who want to examine mul-

Diabetes is a significant health problem worldwide, tiple dimensions of diabetes self-management.
and its rate of diagnosis is currently soaring. Since Several instruments have been used to assess self-man-
2015, diabetes has affected an estimated 340–536 mil- agement behaviors in various areas related to managing
lion individuals worldwide [1]. Based on this estimate, diabetes [8–15]. The available instruments were used to
the number of adults with type 2 diabetes mellitus evaluate patients’ adherence to treatment plans or clarify
(T2DM) will reach 829 million by 2040 [1]. While dia- their misconceptions about treatment plans [8, 13]. To
betes is considered widespread, only a third of patients our knowledge, no multidimensional instrument suit-
achieve the ideal glycosylated hemoglobin (HbA1c) tar- able for measuring diabetes self-management is currently
get, reflecting a controlled state. Uncontrolled diabetes available in Arabic.
contributes to morbidity and mortality, placing a heavy A systematic review of measures for assessing patients’
burden on healthcare systems worldwide [2, 3]. adherence to diabetes self-management tasks identified
In Saudi Arabia, affluent lifestyles have increased 30 unique instruments [13], of which 21 addressed mul-
among the population, with corresponding increases tiple dimensions of diabetes self-management behaviors
in obesity and related chronic diseases [4]. Diabetes [13]. However, only two instruments have been translated
affects about four million Saudi adults. Moreover, 1 and validated in Arabic: the Summary of Diabetes Self-
in 10 of the remaining Saudi adults has a higher like- Care Activities Measure (SDSCA) and the Morisky Med-
lihood of developing diabetes, specifically prediabetes ication Adherence Scale. While the SDSCA and Morisky
[3, 5]. Previous researchers have argued that the high Medication Adherence Scale are reliable, valid, and
prevalence of diabetes indicates poor self-management available in Arabic, neither fully captures the self-man-
of a chronic illness by patients [6]. Therefore, the Min- agement construct. To assess diabetes self-management
istry of Health and other government health agencies in behaviors among diverse groups of patients, researchers
Saudi Arabia have taken responsibility for implement- and healthcare providers must adapt and apply appro-
ing the diabetes management standards recommended priate instruments after retesting and confirming their
by the American Diabetes Association. Accordingly, the psychometric properties. Transcultural adaptation of
role of Saudi hospitals and primary healthcare centers existing validated tools can prove valuable for comparing
has been to systematically assess patients’ self-manage- studies on diabetes self-management.
ment practices related to diabetes. Few instruments measuring diabetes self-management
HbA1c has been widely identified as a marker for activities have been available in Arabic countries to date.
predicting late-stage diabetes-related complications For example, the Arabic version of the SDSCA is com-
[7]. Glycemic control can minimize the risks of such monly used to assess diabetes self-management in Saudi
complications. Moreover, adherence to diabetes self- Arabia. Several authors have stated that the SDSCA can-
management behaviors such as healthy dietary choices, not robustly measure the association between self-man-
regular physical activity, and blood glucose self-moni- agement and glycemic control [16]. In addition, its short
toring are imperative in establishing euglycemia. There- timeframe, considering only self-care activities reported
fore, patients’ self-management behaviors should be by patients in the previous week, may influence its reli-
assessed to identify factors contributing to poor glyce- ability in assessing proper adherence to diabetes self-
mic control. For this purpose, a validated self-manage- management activities.
ment assessment instrument is valuable to researchers Compared to the SDSCA, the Diabetes Self-Man-
agement Questionnaire (DSMQ) is a relatively new
Innab and Kerari BMC Primary Care (2024) 25:274 Page 3 of 8

psychometric tool with a broader time frame that may cross-cultural validation and adaptation of instruments
allow a more reliable assessment of self-management [24]. They followed four steps during the translation and
skills and an effective prediction of glycemic control [16, adaptation of the DSMQ: forward translation, consulting
17]. This instrument has been widely used to clinically an expert panel, backward translation, and pilot testing
evaluate patients presenting with inadequate diabetes on the target population.
self-management. In addition, it could be significant for In the first step, two professional bilingual translators
studies examining the factors contributing to poor self- translated the DSMQ from English into Arabic. In the
management and glycemic control in individuals with second step, the translated A-DSMQ was presented to
diabetes [16–18]. a panel of five experts knowledgeable about Arabic cul-
To our knowledge, while several researchers have ture, who were asked to focus on the clarity, accuracy,
translated the DSMQ into Arabic [19–23], none have and cultural relevance of the wording for each item,
tested its psychometric properties after translation or thereby establishing the foundation of the A-DSMQ. In
used it to assess self-management activities in patients the third step, an additional bilingual translator reverse-
with diabetes. Therefore, this study aimed to translate the translated the A-DSMQ into English; the back translation
DSMQ from English into Arabic and establish its valid- of this instrument appropriately resembled the original
ity in Middle Eastern populations using a sample of Saudi DSMQ. In the fourth and final step, 15 participants with
adults diagnosed with T2DM and currently visiting pri- diabetes from primary healthcare centers pilot-tested the
mary healthcare centers in Riyadh, Saudi Arabia. A-DSMQ. The selected participants provided feedback,
indicating the items were clear and informative and con-
Methods firming no misunderstandings when answering them.
Research design The final version of the A-DSMQ was established based
This cross-sectional study was conducted from May to on this translation process. Once this process was com-
August 2022 at primary healthcare centers in the Riyadh pleted, the instrument was ready to be validated for use
region of Saudi Arabia. These primary healthcare centers with Saudi individuals with diabetes.
provide healthcare services to patients with chronic dis-
eases at various locations throughout the Riyadh region. Measures
Demographic characteristics
Data collection procedure The participants’ demographic characteristics were
Saudi adults with T2DM were recruited from primary obtained by asking them six questions about their age,
healthcare centers in Riyadh, Saudi Arabia. Many adults sex, education, body mass index (BMI), HbA1c, and
with chronic diseases attend follow-up appointments at time elapsed since diabetes diagnosis (in years). The par-
primary healthcare centers. Among adults who visited ticipants’ demographic characteristics are presented in
the centers, only those with T2DM were approached and Table 1. The study sample comprised 154 patients with
recruited. The study’s inclusion criteria required partici- T2DM, with a response rate of 96.25%. Their mean age
pants to be (1) aged ≥ 18 years and (2) diagnosed with was 52 (standard deviation [SD]: ± 12.5), and their mean
T2DM. Potential participants were excluded if they were BMI was 26.8 (SD: ± 4.26). Slightly more participants
pregnant, had cancer, or presented with cognitive disor-
ders. Trained research assistants explained the study’s
purpose and confidentiality to participants.
Participants completed the Arabic version of the Table 1 Characteristics of participants (n = 154)
DSMQ (A-DSMQ) scale at one point during their visits Variable Mean ± SD or n (%)
to the primary healthcare centers. The G*Power software
Age (years) 52 ± 12.5
was used to determine the required sample size. Con-
Gender
sidering a significance level of 0.05, a power of 0.80, and
Male 80 (52)
an effect size of 0.30, the minimum sample size was 111.
Female 74 (48)
This study’s sample comprised 154 patients, indicating an
BMI 26.8 (4.26)
adequate sample size for the bivariate and multivariate
Time passed since diabetes diagnosis
analyses.
≤ 5 years 67 (42.5)
> 5 years 87 (57.5)
Translation process
HbA1c 8.23 ± 2.03
All study participants provided written informed con-
DSMQ Sum Scores 5.91 ± 1.29
sent. To develop a comprehensive and accepted trans-
Self-rated Health Scale 3.10 ± 0.70
lation, the researchers identified essential steps for the
Innab and Kerari BMC Primary Care (2024) 25:274 Page 4 of 8

were male (53%). Over half (57.5%) of the study par- informed that their information would be kept confi-
ticipants had lived with T2DM for over five years. Their dential and that they had the right to withdraw from the
mean HbA1c level was 8.23 (SD: ± 2.03). Approximately study without any consequences. The completed consent
56% of the participants had HbA1c levels > 7.9%, indi- forms were obtained from those who met the inclusion
cating poor glycemic control according to the Ameri- criteria and decided to participate in this study.
can Diabetes Association’s target criterion. Almost half
of the study participants reported adequate diabetes Data analysis
self-management. The mean A-DSMQ score was 5.9 The data were managed and analyzed using the Statistical
(SD: ± 1.29), with higher scores indicating adequate dia- Package for the Social Sciences (version 28) and Analysis
betes self-management. of a Moment Structures (version 28) software. Descrip-
tive statistics are used to present the participants’ charac-
Diabetes self‑management questionnaire teristics, while means and standard deviations are used to
Developed by Schmitt et al. [17], the A-DSMQ was used present the continuous variables.
to assess the study participants’ self-management skills The internal consistency of the A-DSMQ was assessed
related to their diabetes control status during the eight by computing Cronbach’s alpha coefficient for each sub-
weeks preceding this study. A previous study reported scale and the sum scale. A Cronbach alpha of > 0.70 is
that the DSMQ demonstrated adequate reliability and considered acceptable. In addition, item-total correla-
validity in German individuals with diabetes, with a tions and the effect of item removal on the coefficient
Cronbach’s α of 0.84. The DSMQ comprises 16 items were examined.
assessing four areas: glucose management (GM), dietary The construct validity of the A-DSMQ was evaluated
control (DC), physical activity (PA), and healthcare use by criterion validity and known-group validity. For cri-
(HU). Each item is rated on a four-point Likert-like scale terion validity, Pearson’s product-moment correlation
from 0 (does not apply) to 3 (applies to me very much), coefficient was used to determine correlations between
giving a total DSMQ score between 0 (minimum) and 48 diabetes self-management and variables theoretically or
(maximum). In this study, the total DMSQ scores were empirically related to diabetes self-management, such as
transformed into a scale from 0 to 10, and adherence to self-rated health and HbA1c levels. A-DSMQ scores were
diabetes self-management behaviors was categorized into expected to correlate (1) positively with self-rated health
three levels: inadequate (score of < 5), partially adequate and (2) negatively with HbA1c levels. In addition, levels
(score of 5–8), and perfect (score of > 8). of diabetes self-management were expected to correlate
negatively with BMI.
Self‑rated health scale For known-group validity, a one-way analysis of vari-
The Self-Rated Health Scale was used to measure the ance was performed after categorizing the participants
health status of the study participants. It was adapted into three groups based on their HbA1c levels: HbA1c
from the U.S. National Health Survey and has been levels < 7% were classified as adequate glycemic control,
reported to be predictive of future health status [25]. The from 7%– < 8% were classified as partially adequate glyce-
Self-Rated Health Scale comprises a single item rated on mic control, and ≥ 8% were classified as inadequate glyce-
a five-point Likert-like scale from 1 (poor) to 5 (excel- mic control.
lent); lower scores indicate worse health. The reliability of
this scale was 0.92. Results
Validation process
Glycemic control Internal consistency reliability
The participants’ HbA1c levels were tracked to assess The Cronbach’s alpha for the A-DSMQ sum scale and
their glycemic control over three months. The research its subscales were determined. The reliability analysis
assistants recorded HbA1c levels from patients’ files con- was conducted on the A-DSMQ sum scale compris-
currently with the psychometric assessments. ing 16 items. It had a Cronbach’s alpha of 0.76, indicat-
ing acceptable internal consistency. The removal of any
Ethical considerations item did not increase Cronbach’s alpha. Correlation coef-
This study was approved by the Institutional Review ficients varied from 0.15 to 0.60 between items. Over-
Board of the Saudi Ministry of Health before data collec- all, the internal consistency results indicated that the
tion began (approval number: H-01-R-012, IRB00010471; A-DSMQ was reliable (Table 2).
February 2022). The researchers informed each partici- The GM subscale, consisting of five items, had ques-
pant of the study’s purpose, its risks and benefits, and tionable reliability (α = 0.65). Item 12 (“I tend to forget or
their rights to information privacy. The participants were skip my diabetes medication”) showed a low item-total
Innab and Kerari BMC Primary Care (2024) 25:274 Page 5 of 8

Table 2 Item analyses and reliability of the A-DSMQ

Item Mean (SD) Corrected item-total Cronbach’s
correlation alpha if item
deleted

1. Check blood sugar levels with care and attention 1.78 (0.86) 0.35 0.74
2. Choose food to easily achieve optimal blood sugar 1.70 (0.73) 0.31 0.75
3. Keep recommended doctors’ appointments 1.85 (0.90) 0.55 0.72
4. Take diabetes medication as prescribed 1.73 (1.02) 0.52 0.73
5. Occasionally eat lots of sweets/ high-carb foods 1.90 (0.90) 0.15 0.76
6. Record blood sugar levels regularly 1.22 (0.98) 0.25 0.75
7. Avoid diabetes-related doctors’ appointments 2.21 (0.92) 0.32 0.75
8. Do physical activity to achieve optimal sugar levels 1.37 (0.92) 0.16 0.76
9. Follow specialist’s dietary recommendations 1.38 (0.76) 0.17 0.76
10. Do not check blood sugar levels frequently enough 2.08 (0.87) 0.46 0.73
11. Avoid physical activity, although good for diabetes 1.94 (0.95) 0.46 0.73
12. Forget to take/ skip diabetes medication 2.03 (0.86) 0.60 0.72
13. Sometimes have real ‘food binges’ 1.93 (0.81) 0.44 0.73
14. Should see medical practitioner(s) more often 1.50 (0.89) 0.20 0.76
15. Skip planned physical activity 1.74 (0.78) 0.36 0.74
16. Diabetes self-care is poor 2.01 (0.88) 0.54 0.72
Total 0.76
A-DSMQ Arabic Version of Diabetes Self-Management Questionnaire

Table 3 Correlations of DSMQ ‘Sum Scale’ and HbA1c, Self-rated Known‑groups validity
Health Scale, and BMI A-DSMQ scores differed significantly among partici-
Sum Scale
pant groups stratified according to adequate, partially
adequate, and inadequate glycemic control (F = 23.193,
HbA1c − 0.48** p < 0.001). These findings indicated that participants
Self-rated Health Scale 0.41** with adequate glycemic control (HbA1c < 7%) scored
BMI − 0.29** significantly higher on the A-DSMQ (6.97 ± 0.97) than
DSMQ Diabetes Self-Management Questionnaire, HbA1c glycated hemoglobin, those with partially adequate glycemic control (HbA1c
BMI Body Mass Index of 7%– < 8%) and inadequate glycemic control (HbA1c
**
p < .01
of ≥ 8%). Notably, A-DSMQ scores did not differ signifi-
cantly between the inadequate and partially adequate gly-
cemic control groups (Table 4).
correlation (r = 0.18), and its removal increased Cron-
bach’s alpha (α = 0.69). The DC subscale, consisting of
four items, had acceptable reliability (α = 0.71). The PA
Discussion
subscale, consisting of three items, had acceptable relia-
The primary aim of this study was to create and validate
bility (α = 0.72). Its three items appeared worthy of reten-
the A-DSMQ using a convenience sample of patients
tion since their removal decreased Cronbach’s alpha. The
with T2DM in Saudi Arabia. The A-DSMQ was created
HU subscale, consisting of three items, had poor reliabil-
to provide a reliable and valid measure of diabetes self-
ity (α = 0.51).
management across medical settings. Since patients with
poor diabetes self-management may constitute a high-
Criterion validity
risk group, a proper instrument may also prove valuable
The correlations between A-DSMQ scores and variables
for clinical practice.
of interest are shown in Table 3. A-DSMQ scores were
The original study recruited participants from a dia-
significantly positively correlated with better self-rated
betes care center, with equal numbers of individuals
health (r = 0.41, p < 0.01) and negatively correlated with
with type 1 and 2 diabetes mellitus. In contrast, our
HbA1c levels (r =  − 0.48, p < 0.01) and BMI (r =  − 0.29,
study’s design may influence its generalizability since it
p < 0.01). In other words, participants with normal body
only recruited participants with T2DM from primary
weight performed better in diabetes self-management.
Innab and Kerari BMC Primary Care (2024) 25:274 Page 6 of 8

Table 4 Comparison of the DSMQ ‘sum scale’ in patients with HbA1c < 7%, from 7 to 8% and > 8%
DSMQ HbA1c < 7% Sign.a HbA1c 7–8% Sign.b HbA1c > 8% Sign.c ANOVA
(n = 49) (n = 29) (n = 76) P-value

Sum Scale 6.97 ± 0.97 * 5.96 ± 1.18 ns 5.43 ± 1.09 *** < 0.001
Data are M ± SD. One-way ANOVA and Scheffé Test for post-hoc group comparisons were addressed. Scheffé Test significance is expressed
DSMQ Diabetes Self-Management Questionnaire, HbA1c glycated hemoglobin, ANOVA Analysis of Variance
*
p < 0.05
***
p < 0.001; ns, not significant
a
regards comparison between the first and second group
b
regards comparison between the second and third group
c
regards comparison between the third and first group

healthcare centers. Indeed, there were noticeable differ- lower disease-related complications were reported
ences in the populations between the original and our among those who scored higher on the DSMQ [27].
study. The HbA1c levels of primary care patients were
lower in our study than in the original study (8.23 ± 2.03 Implications and recommendations for research
vs. 8.6 ± 1.5). However, their DSMQ scores were also and practice
lower (5.91 ± 1.29 vs. 6.8 ± 1.7). Despite these differ- The results revealed that A-DSMQ had very good psy-
ences, our study’s findings support the reliability and chometric properties. Thus, the Arabic version of this
validity of the A-DSMQ. instrument can be used among Arab adults with type 2
In the context of Saudi patients with diabetes, the diabetes. Future researchers are recommended to re-
overall internal consistency (Cronbach’s alpha) of the test the A-DSMQ across a wide-nation of Arab adults
A-DSMQ was found to be acceptable, albeit lower than to determine the generalizability of the findings to other
in the study by Schmitt et al. Accordingly, the com- settings. It is also recommended to use a probability sam-
parative analysis of the known groups supports the pling method to assure that the results are unbiased and
A-DSMQ as a valid tool for measuring self-manage- generalizable to other settings. Other essential variables,
ment activities related to glycemic control. Further- such as health literacy, should be taken into considera-
more, it was able to differentiate patients with varying tion to better understand the applicability of using the
levels of glycemic control. Arabic version of the instrument for patients with type 2
The observed correlations between diabetes self-man- diabetes.
agement and the variables expected to be associated
with diabetes self-management (e.g., self-rated health Limitations
and HbA1c level) were consistent with the study’s This study is the first to validate the DSMQ in Arabic.
hypotheses, indicating criterion validity. A-DSMQ sum However, it had several limitations. Firstly, it used a
scores correlated significantly with glycemic control, cross-sectional design, so it could not infer causality. Sec-
assessed by HbA1c levels, and health status, assessed ondly, it used a convenience sampling method, so its find-
by the Self-Rated Health Scale. In addition, higher ings might be less applicable to the primary care setting.
A-DSMQ sum scores were significantly associated with Thirdly, it did not include patients with type 1 diabetes,
optimal glycemic control (HbA1c ≤ 7.5%) and excellent so its results are limited to patients with T2DM. Fourthly,
health status. These findings support the notion that it only registered HbA1c levels over three months, but
assisting patients in adopting self-management tasks individuals’ behavior can change within a shorter period.
(e.g., dietary control, physical activity, and glucose A more appropriate method would have involved per-
management) may lead to proper glycemic control, forming HbA1c blood sampling concurrently with
optimal health status, and reduced diabetes-related administering psychometric assessments, which was not
complications [6, 26]. These correlations were generally implemented due to financial limitations.
stronger than those found in a Hungarian study of the
DSMQ, in which a minimal association (r = 0.25) was Conclusions
reported between DSMQ sum scores and HbA1c lev- The A-DSMQ was found to be a reliable and valid instru-
els [18]. In another study that evaluated diabetes self- ment for measuring self-management behaviors in
management skills among Iranian patients with T2DM, patients with T2DM in Saudi Arabia. Our findings for the
Innab and Kerari BMC Primary Care (2024) 25:274 Page 7 of 8

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