Translation and Validation of the Diabetes Empowerment Scale

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					           Translation and Validation of the
            Diabetes Empowerment Scale
May 2002                                                HCPF Report # 212901
The translation and validation of the Chinese version of the
Diabetes Empowerment Scale
Shiu TYA1, Wong YMR2
    The Nethersole School of Nursing, The Chinese University of Hong Kong
    Diabetes & Endocrine Centre, Prince of Wales Hospital

INTRODUCTION                                    version consists of 28 items (DES-28)
                                                with 3 subscales. Both scales have
Diabetes has become a major public health       demonstrated     good    validity and
problem in Hong Kong. Diabetologists            reliability.
have advocated the use of patient
empowerment as a theoretical model to           AIMS and OBJECTIVES
guide diabetes care and education.1 To
develop educational interventions using         The aim of this study was to translate the
this model, one of the pre-requisites is to     DES-37 into Chinese and to establish the
conduct baseline assessments of the             psychometric properties of the Chinese
patients’ perceived psychosocial self-          measure among Hong Kong Chinese
efficacy levels. This information is            people with diabetes.
essential for the design of interventions to
overcome psychosocial constraints to            METHODS
diabetes self-management.
It is suggested that the lack of a reliable     A two-stage study design incorporating
and valid Chinese measure of diabetes-          qualitative and quantitative components
related psychosocial self-efficacy is one of    was adopted. The first stage of the study
the major drawbacks in the development          included: (1) back translation of the
of diabetes education and related research      scale, (2) 2 focus group interviews (n=5
in Hong Kong. A diabetes-related                & 7 respectively) to determine the
psychosocial      self-efficacy    measure,     cultural equivalency of the translated
Diabetes Empowerment Scale (DES), has           scale, and (3) the assessment of the
been developed and psychometrically             content validity by a panel of Hong
tested among Caucasians.2,3,4 There are         Kong Chinese diabetologists (n=3) and
two versions of the DES3,4, one with 37         diabetes nurses (n=5). The second stage
items (DES-37) (8 sub-scales) and a brief       established the psychometric properties

of the Chinese scale by applying it to a        content experts (N=8) in Hong Kong to
sample of patients with diabetes (N=207).       assess the content validity. The overall
                                                CVR of the Chinese DES-37 was high
Data analysis and psychometric tests
                                                Stage two
Items identified as culturally unsuitable by    Demographic and clinical data
the focus groups were modified. Content
validity was assessed by the content            A total of 207 patients (response rate =
validity ratio (CVR). Each expert panel         70%) completed the questionniare. The
member rated their agreement for each           majority of respondents were above 45
item as a valid measure of the construct        years of age (Table 1).
using a 5-point Likert scale from ‘1’
(strongly disagree) to ‘5’ (strongly agree).    Psychometric tests and scale statistics
Descriptive statistics were used to
establish the frequency, range, mean and        After a principal components factor
standard deviation of the demographic and       analysis, a 20-item Chinese DES
clinical characteristics of the respondents.    (CDES-20, α=0.86) with 5 subscales
Factor analysis was used to determine the       was identified (Table 2) accounting for
underlying construct of the scale to test the   63.3% of the total variance. Factor 1,
construct validity of the scale. Cronbach’s
                                                “Overcoming        barriers”     (α=0.89),
alpha coefficient was calculated for each
                                                assesses patients’ ability to identify and
sub-scale and the overall Chinese DES to
                                                apply strategies to overcome barriers to
determine the internal consistency. Test-
                                                achieving diabetes goals. Factor 2,
retest    reliability    using     Spearman
                                                “Determining suitable methods for self-
correlation coefficients between the 20
                                                management”        (α=0.79),      describes
patients’ test and retest scores over 2
                                                patients’ perceived knowledge about
weeks were calculated.
                                                diabetes and self, and the ability to
Pearson correlation coefficients between
                                                assess the need for making changes in
metabolic control (HbA1c) and the Chinese
                                                their diabetes care. Factor 3, “Achieving
DES were calculated to establish the
criterion validity of the scale. Metabolic      diabetes goals” (α=0.78), assesses the
control was selected as a criterion measure     patients’ perceived ability to identify and
on the assumption that people with high         achieve realistic diabetes goals. Factor 4,
diabetes-specific      psychosocial     self-   “Obtaining support to self-management”
efficacy would exhibit better self-             (α=0.78), describes patients’ perceived
management resulting in better HbA1c2.          ability to identify and obtain support
The lack of valid and reliable Chinese          when required. Factor 5, “Coping with
scales measuring similar concepts               diabetes-related      stress”    (α=0.76),
precluded the use of concurrent validity.       describes the patients’ perceived ability
                                                to identify sources of diabetes-related
RESULTS                                         stress and effective coping strategies.

Stage one

After back translation and the two focus
group interviews, the authors developed a
Chinese DES-37. Both the Chinese and
original versions were sent to a panel of

Table 1 Respondents’ demographic data (N=207)
                              Frequency (%)
Age (years)
                      16-25             3 (1.4%)
                      26-35            15 (7.3%)
                      36-45           40(19.3%)
                      46-55            60 (29%)
                      56-65          55 (26.6%)
                       ≥66           34 (16.4%)
                      Male           99 (47.8%)
                    Female          108 (52.2%)
Type of diabetes
                     Type I          36 (17.4%)
                 Type II            171 (82.6%)
*Mean=52.98, SD=12.44

Table 2 Descriptive statistics for CDES-20 subscales (N=207)
Scale name                         n Means + SD (range)        Standardized    Variance    Eigen
                                                               item α          (%)         value
1 Overcoming barriers           4 3.33+0.86 (1-5)              0.89            27.2        5.4
2 Determining suitable          5 3.81+0.49 (2-5)              0.79            12.5        2.5
methods for self-management
3 Achieving diabetes goals      4 3.75+0.59 (2-5)              0.78            9.4         1.9
4 Obtaining support to self-    3 3.77+0.60 (1-5)              0.78            7.5         1.5
5 Coping with diabetes-related 4 3.58+0.67 (1.75-5)            0.76            6.7         1.3
Global scale: α=0.86, mean=3.65, SD=0.4, range, 2.3-5
                                                        cultural equivalency. A panel of Hong
The CDES-20 subscales test and retest                   Kong diabetes workers who were
reliability coefficients (N=20) ranged                  content experts also assessed the cultural
from 0.61 to 0.81. A significant                        equivalency and content validity of the
correlation was found between the                       translated scale.
global scale and HbA1c of Type 2                        The analysis also supports the construct
respondents (-0.17, p=0.03). Higher the                 validity and test-retest reliability of the
CDES scores are associated with lower                   CDES-20. Each coefficient alpha for the
the HbA1c values.                                       5 subscales and the global CDES-20 was
                                                        above 0.70. The test-retest reliability of
DISCUSSION                                              the CDES-20 was supported by the good
                                                        test-retest correlation.
The cultural equivalency of the CDES-                   However, criterion validity was only
20 was supported by this analysis.                      supported by the correlation between the
Participants of the two focus groups,                   global scale and HbA1c of respondents
who were council members of two                         with Type 2. While metabolic control as
diabetes self-help groups, examined and                 a physical marker has been used as an
modified the translated scale for its                   important objective outcome indicator of

       diabetes control, it’s function in                       2. Anderson RM, Arnold MS, Funnell
       discriminating whether subjects engage                      MM, Fitzgerald JT, Bulter PM, Feste
       in good self-management as a result of                      C Patient Empowerment: Results of
       high psychosocial self-efficacy may be                      a randomized controlled trial. Diabet
       questionable.                                               Care 1995;18(7):943-949.
                                                                3. Anderson RM, Arnold Ms, Funnell
       CONCLUSION                                                  MM. Diabetes Empowerment Scale:
                                                                   A measure of psychosocial self-
       The CDES-20 has good reliability and                        efficacy. Paper presented in the
       satisfactory validity and can serve as an                   American Diabetes Association
       outcome measure for future patient                          Meeting, USA, 1997.
       education     and     health   promotion                 4. Anderson RM, Funnell MM,
       interventions for people with diabetes.                     Fitzgerald JT, Marrero DG. Diabetes
                                                                   empowerment scale: A measure of
       REFERENCES                                                  psychosocial self-efficacy. Diabet
                                                                   Care 2000;23(6):739-743.
       1. Chan JCN, Yeung VTF, Chow CC,
          Ko GTC, Cockram CS. A manual for                      ACKNOWLEDGEMENTS
          management of diabetes mellitus: A
          Hong Kong Chinese perspective.                        The authors would like to thank the
          Hong Kong: Chinese University                         Health Care and Promotion Fund for
          Press, 1998.                                          supporting this research project (HCPF #

                                               Key Messages
       1. The Chinese version of DES with 20 items (CDES-20) demonstrates acceptable
          reliability and validity.

       2. Type 2 patients with high CDES scores demonstrate lower HbA1c than those with low
          CDES scores.

       3. The CDES-20 can serve as an outcome measure for patient education interventions
          for people with diabetes.

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Tel 852 23006311 Fax 852 2895 2167, Email Editor Jan Johnston


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