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Translation and its Psychometric Characteristic of the Diabetes Strengths and Resilience Measure among Chinese Adolescents with type 1 Diabetes
YJPDN-02060; No of Pages 6 Journal of Pediatric Nursing xxx (xxxx) xxx
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Translation and its psychometric characteristic of the diabetes strengths and resilience measure among Chinese adolescents with type 1 diabetes Jingjing Xu, MSN, RN a,1, Dan Luo, PhD, RN b,1, Min Zhu, BA, RN a, Hong Wang, BA, RN a, Yun Shi, CD, PhD a, Dan Ya, BA, RN a, Zheng Lin, MSN, RN c,d,⁎, Zejuan Gu, MSN, RN c,d,⁎ a
Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, Jiangsu, China School of Nursing, Peking University, Beijing, China School of Nursing, Nanjing Medical University, Nanjing, Jiangsu, China d Department of Nursing, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, Jiangsu, China b c
a r t i c l e
i n f o
Article history: Received 4 June 2019 Revised 27 August 2019 Accepted 27 August 2019 Available online xxxx Keywords: Type 1 diabetes mellitus Adolescent Resilience Instrument adaptation Psychometric analysis
a b s t r a c t Purpose: This study is designed to develop a Chinese version of the Diabetes Strengths and Resilience Measure for Adolescents (DSTAR-Teen) and evaluate its psychometric characteristics. Design and methods: One hundred and twenty adolescents with type 1 diabetes (Mean age = 16.3 ± 5.1, 51.7% male, Mean HbA1c = 7.6 ± 2.2%) were enrolled from one national endocrine center in China. Participants were administered with the DSTAR-Teen and the related psychosocial instruments to evaluate the reliability and validity. The DSTAR-Teen was adapted into Chinese version prior to data collection. Results: The Chinese DSTAR-Teen demonstrated adequate reliability (Cronbach's α coefficients = 0.90, intraclass correlation coefficient = 0.98). A minimum detectable change at the 95% confidence level was 5.8 points. In exploratory and confirmatory factorial analyses, a three-factor structure emerged with a variance of 67.4%, demonstrating construct validity. Moreover, resilience was significantly associated with glycated hemoglobin, diabetes distress and self-care behavior as hypothesized, further supporting validity. Conclusion: The Chinese version of the DSTAR-Teen is a psychometrically sound instrument that may capture the adaptive attitudes and behaviors associated with diabetes management. Practice implications: This scale can be used in both clinical and research settings with the aim of identifying diabetes specific strengths and improving the health outcomes in adolescents with type 1 diabetes. © 2019 Elsevier Inc. All rights reserved.
Introduction Type 1 diabetes (T1D) is a chronic metabolism disorder mainly caused by the absolute deficiency of insulin (DiMeglio, Evans-Molina, & Oram, 2018), which requires lifelong management. The incidence of T1D in China has been increasing rapidly, especially among adolescents. According to the International Diabetes Federation (IDF), N47.000 children and adolescents are diagnosed with T1D in China, which ranks fourth highest in the world (Q&A: Key Points for IDF Diabetes Atlas 2017, 2018). In addition to the developmental challenges during adolescent, those with T1D also have to undertake burdensome self-care tasks, which can be a significant hurdle. Deteriorating glycemic control is
⁎ Corresponding authors at: Department of Nursing, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Nanjing, Jiangsu 210000, China. E-mail addresses: [email protected] (Z. Lin), [email protected] (Z. Gu). 1 Jingjing Xu and Dan Luo contributed equally to this work and should be regarded as co-first authors.
common in adolescence, which is associated with more complications and higher mortality in adulthood. In mainland China, studies indicate an average glycosylated hemoglobin (HbA1c) of 9.4% among adolescents and the incidence of diabetic ketoacidosis to be 14.4 events/100 patient years (McGuire et al., 2017). Moreover, adolescents with T1D are also at risk for mental health disorders including depression and diabetes distress) (Buchberger et al., 2016). Researchers have been making elaborate efforts on identifying potential protective factors in adolescents with T1D so as to improve their health outcomes. A potential factor that can help adolescents adopt the challenges of T1D is resilience, which is defined as the capacity to achieve positive outcomes despite exposure to significant challenges (Richardson, 2002). Among patients with T1D, resilience has been shown to positively impact health outcomes including high engagement in self-care, better glycemic control, and fewer negative emotions (Hilliard et al., 2017; Hilliard, Iturralde, Weissberg-Benchell, & Hood, 2017; Lo et al., 2016; Wang et al., 2017). Although there are many articles about resilience advantages, nurses tend to focus on identifying and eliminating risk factors rather than assessing and promoting resilience in China.
https://doi.org/10.1016/j.pedn.2019.08.020 0882-5963/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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This is largely owing to the inadequacy of appropriate instruments. Although some resilience measures are available, most of them are designed for general populations, which could not explicitly assess adaptive aspects associated with diabetes management. Professor Hilliard and her colleagues (Hilliard, Iturralde, et al., 2017) proposed the Diabetes Strengths and Resilience Measure (DSTAR-Teen) for adolescents with T1D. This self-report instrument possesses two dimensions, one is to measure patients' perception of their ability to manage diabetes and the other is to measure their ability of seeking help from close others. The 12-item DSTAR-Teen exhibits excellent psychometric properties in the West and has applicability for use in clinical care. However, resilience functions differently depending on the specific culture and environment around people (Ungar, 2011). Chinese adolescents adapt to challenges of T1D in manners that are sometimes different from those of Western patients. For example, many Chinese adolescents are inclined to conceal the disease and suppress their desires in the process of T1D management, whereas Western patients tend to share their feelings and seek help from parents or physicians (Ye et al., 2017). Therefore, the structure of the English version of DSTAR-Teen may not be appropriate for Chinese adolescents with T1D. The aims of this study are to adapt the English DSTAR-Teen into Chinese and evaluate its reliability and validity among Chinese adolescents with T1D. Indicators of reliability included internal consistency reliability, test-retest reliability, and item homogeneity. Validity was tested by implementing factor analysis and verifying known relationships between resilience and related variables. Based on the findings of empirical studies, we hypothesized that higher resilience scores would be associated with better self-care behavior and glycemic control. Lower resilience scores would predict more severe diabetes distress.
Methods Study design, setting, and sample This was a prospective observational study. One hundred and twenty adolescents with T1D were enrolled from the outpatient and inpatient services of a national endocrine center by convenience sampling technique. Inclusion criteria were as follows: 1) T1D diagnosis ≥ 6 months, 2) age 12–19 years, 3) Chinese fluency. Adolescents were excluded if they had any of the following conditions: 1) other serious organic diseases, 2) cognitive impairment or psychiatric disorder, and 3) inability to understand study instruments. The sample size was calculated on the basis of ensuring the psychometric quality of the factor analysis. Both exploratory factor analysis and confirmatory factor analysis require at least 100 participants (Boomsma, 1985; Kaiser, 1960). A total of 125 adolescents with T1D were recruited, and the data from five participants were not included in this study due to the existence of missing data.
Procedures All participants completed the study instruments under the guidance of the primary investigator and one research assistant (a diabetes specialist nurse). Participants' socio-demographic and disease characteristics were collected simultaneously. The latest HbA1c value within three months was acquired from the participants' medical files. The time each participant spent to complete the study instruments were approximately 20 min. In test-retest reliability analysis, 18 patients were selected by convenience sampling technique from the 120 participants. They were reassessed the Chinese DSTAR-Teen within two weeks. This sample size was determined on Fleiss's (1999) suggestion that 15–20 subjects were enough to verify testretest reliability.
Measures Diabetes related resilience The Diabetes Strengths and Resilience Measure for Adolescents (DSTAR-Teen) was developed to measure adaptive attitudes and behaviors associated with diabetes management and control (Hilliard, Hagger, et al., 2017; Hilliard, Iturralde, et al., 2017). The total score of 12-item DSTAR-Teen ranged from 12 to 60 points, with each item rating on a 5-point scale according to frequency (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = almost always). The higher score indicated higher resilience level. Above all, we obtained the permission from Professor Hilliard to translate the English DSTAR into Chinese. The process of translation was carried out in four stages based on the methodology proposed by Beaton, Bombardier, Guillemin, and Ferraz (2000): 1) forwardtranslation, 2) back-translation, 3) committee discussion, and 4) pilot test. In the first stage, two bilingual experts who are proficient in different areas (one was an endocrinologist who was familiar with the concept of resilience and the other was a professional translator who had an administrative job within the university) translated the original English DSTAR-Teen into Chinese respectively. On the premise of ensuring the semantics and original conceptualization of the DSTAR-Teen, the culture-related modifications were made. After the discussion between the two bilingual experts, the two translated versions were synthesized into one Chinese version. In the second stage, another bilingual expert who had lived in English-speaking country and was blinded to the original English DSTAR-Teen translated the Chinese version back to English. Subsequently, members of expert committee (three translators and research team members) compared the back-translation version with the original English version of DSTAR-Teen to ensure good agreement between them. In the last stage, 17 Chinese adolescents with T1D were invited to pretest the translated version. Brief interviews were conducted to collect comments of 17 participants on single item and the general scale (clarity of words, meaning of items, etc.). All suggestions from them were evaluated and discussed by the expert committee and further modifications of the translated version were made. At this point, the Chinese version of the DSTAR-Teen was obtained. The process of translation and adaptation ensured the content validity of the Chinese DSTAR-Teen. Self-care behavior Self-care behavior was assessed by using the Diabetes Behavior Rating Scale (DBRS) (Iannotti et al., 2006). The DBRS had insulin injection version (37 items) and insulin pump version (38 items). The total score was transformed to a score ranging from 0 to 1, with a higher score suggesting better self-care behavior. The reliability and validity of the DBRS were demonstrated in Chinese adolescents with T1D (Zhu et al., 2018). The Cronbach's α in this sample were 0.937 and 0.818 for the insulin injection and insulin pump version respectively. Diabetes distress Diabetes-related psychological distress was assessed by using the Problem Areas in Diabetes Scale-5 (PAID-5) (McGuire et al., 2010). The total score of the 5-item PAID-5 ranged from 0 to 20, with the higher scores indicating more severe diabetes distress. A cut-off point of 8 was used to distinguish those had mild distress or severe distress. The PAID-5 was widely used in mainland China and the reliability and validity were supported (Nicolucci et al., 2013). The Cronbach's α in this sample was 0.874. General characteristics Socio-demographic (gender, age, education level, medical payment method, living status, family income) and disease characteristics (disease duration, insulin regimen, HbA1c) were acquired from the medical
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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file and general information questionnaire which was developed by the research team.
Table 1 Sample characteristics (n = 120). Classification
Characteristic
Classification Number (n)
Percent (%)
Demographic factors
Gender
Female Male 10–14 15–20 Elementary school Middle school High school College or higher Without medical insurance With medical insurance Live with family Live with classmates Live alone b5000 5000–8000 N8000
58 62 43 77 25
48.3 51.7 35.8 64.2 20.8
33
27.5
22 40
18.3 33.3
38
31.7
82
68.3
91
75.8
25
20.8
4 26 33 61
3.3 4 21.7 27.5 50.8
b1 1–5 5–10 N10 MDI CSII ≤7.5 N7.5
14 66 20 20 80 40 76 44
11.7 55.0 16.7 16.6 66.7 33.3 63.3 36.7
Ethical considerations This study was approved by the Institutional Review Boards of the hospital where the study was conducted, and the required permissions were obtained from the hospital. All Participants provided verbal permission and signed informed consent forms voluntarily after knowing the purpose and privacy of this study. Their personal information and responses were recorded confidentially. In addition, prior to the study, we obtained Professor Hilliard's permission to use the DSTAR-Teen.
Age (years) Education level
Medical insurance
Statistic analysis All data analyses were performed by SPSS (version 22.0; SPSS Inc., Chicago, Ill) except the confirmatory factor analysis which was analyzed by AMOS (version 22.0; Amos Development Corporation, Meadville, PA, USA). p values b 0.05 indicated statistical significance. Descriptive statistics (percentages, means, central tendency) were used to describe characteristics of the sample. Indicators of reliability included internal consistency reliability and test-retest reliability. The Cronbach's alpha coefficient and intraclass correlation coefficient (ICC) were used to evaluate the internal consistency reliability and testretest reliability respectively. The minimum detectable change with 95% confidence level (MDC95) was calculated to show the smallest change in DSTAR-Teen score that reflects true change rather than measurement error. In this study, the value of Cronbach's alpha coefficient and ICC should exceed 0.70 and 0.90 respectively to ensure sufficient reliability. Indicators of validity included construct validity as well as convergent and discriminant validity. Construct validity was assessed through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). As this was the first time that the DSTAR-Teen was evaluated under the eastern culture and context, we conducted an EFA using principal axis factoring extraction with direct oblimin rotation to determine the underlying structure of Chinese version of the DSTAR-Teen. The Kaiser-Meyer-Olkin (KMO) test and Bartlett's test of sphericity were performed before EFA to ensure psychometric quality. The eigenvalues ≥1 and factor loading coefficients ≥0.4 were used as the standard for factor extraction and item retention respectively (Kaiser, 1960). The CFA was implemented to verify the factor structure acquired from the EFA. Following criteria were used to assess the model fit: the ratio of the χ2 value and the degrees of freedom (χ2/df) b 5, goodness-of-fit index (GFI) ≥ 0.85, adjusted goodness-of-fit index (AGFI) ≥ 0.80, comparative fit index (CFI) N 0.90, and standardized root mean square residual (SRMR) b 0.10 (Byrne, 2009). Convergent and discriminant validity were tested by verifying known relationships between resilience and related variables. It was assumed that correlation validity would be supported if the bivariate correlations between measures of resilience and related variables (self-care behavior, diabetes distress, and glycemic control) were in hypothesized directions. Results Descriptive characteristics Participants' socio-demographic and disease characteristics are summarized in Table 1. One hundred and twenty adolescents with T1D participated in this study. The mean age of them was 16.3 (SD: 5.1) and sixty-two of them (51.7%) were male. Ninety-one of the participants lived at home (75.8%) and 25 of them lived with classmates. Eighty-two of them (68.3%) had medical insurance. Sixty-one of them (50.8%) reported family monthly income N8000 Yuan. The median diabetes duration of participants was 4.6 years (SD: 2.1) and the mean level
3
Living status
Disease factors
Family monthly income (Yuan) Diabetes duration (year) Insulin regimen HbA1c, %
Mean ± SD
16.3 ± 5.1
4.6 ± 2.1
7.9 ± 2.2
Note. DSTAR-Teen = Diabetes Strengths and Resilience measure for Adolescents; SD = standard deviation; CSII = continuous subcutaneous insulin infusion; MDI = multiple daily injections.
of HbA1 was 7.6% (SD: 2.2) with 44 of them (36.7%) failing to achieve the goal of glycemic control. Eighty of them (66.7%) were treated with continuous subcutaneous insulin infusion (CSII) and the rest were given multiple daily injections. The mean score of the DSTAR-Teen was 42.4 (SD: 10.3) in this sample. As is shown in Table 2, participants endorsed the full range of responses on every item, yet on some items, the majority of participants endorsed “Sometimes/3”, “Often/4” or “Almost Always/5”. The ratings were evenly distributed. Item skewness ranged from −1.16 to 0.24 with one item greater than |1| (Item 6), and kurtosis ranged from −1.39 to 0.09 with four items greater than |1| (Items 4, 7, 9, 10). Total score skewness was −0.12, kurtosis was −0.87.
Reliability Internal consistency reliability The internal consistency reliability of the Chinese DSTAR-Teen was indicated by the Cronbach's alpha coefficient. In this sample, the Cronbach's alpha coefficient was 0.90 which confirmed acceptable and sufficient internal consistency reliability.
Test-retest reliability The mean time between completion of the two test occasions was 8.0 (SD: 3.0) days (ranged from 4 to 14 days). The Chinese DSTARTeen proved adequate test-retest reliability with a high ICC of 0.98 (95% CI: 0.95 to 0.99). In addition, the minimum detectable change at the 95% confidence level (MDC95) was 5.8 points.
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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Table 2 Items and response options statistics for the Chinese version of the DSTAR-Teen (n = 120).
Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12
1 Never (%)
2 Rarely (%)
3 Sometimes (%)
4 Often (%)
5 Almost always (%)
Mean ± SD
Skewness
Kurtosis
2.5 29.2 2.5 9.2 5.0 1.7 15.8 6.7 24.2 8.3 6.7 5.8
5.8 22.5 9.2 18.3 12.5 10.0 13.3 8.3 25.8 17.5 13.3 15.0
25.0 23.3 27.5 25.0 30.0 11.7 15.0 14.2 14.2 24.2 18.3 20.0
35.8 15.8 31.7 22.5 23.3 21.7 19.2 34.2 14.2 20.0 20.0 23.3
30.8 9.2 29.2 25.0 29.2 55.0 36.7 36.7 21.7 30.0 41.7 35.8
3.9 ± 1.0 2.5 ± 0.8 3.8 ± 1.1 3.4 ± 1.3 3.6 ± 1.8 4.2 ± 1.1 3.5 ± 1.5 3.9 ± 1.5 2.8 ± 0.9 3.5 ± 1.3 3.8 ± 1.3 3.7 ± 1.3
−0.69 0.37 −0.51 −0.24 −0.38 −1.16 −0.47 −0.98 0.24 −0.31 −0.67 −0.55
0.11 −0.99 −0.40 −1.03 −0.77 0.24 −1.23 0.09 −1.39 −1.07 −0.77 −0.85
Note. DSTAR-Teen = Diabetes Strengths and Resilience measure for Adolescents.
Validity Construct validity The results of the KMO test and Bartlett's test of sphericity (KMO = 0.87, Chi-square = 700.13; p = 0.000) indicated that this sample was suitable for EFA. The EFA identified a greater variance (67.4%) explained by a threefactor structure, inconsistent with the two-factor structure of the original English version. All of 12 items met the retention criteria with factors loading coefficients ranging from 0.59 to 0.72. Taken content and meaning of three factors into consideration, we labeled factor 1 to 3 as ‘help-seeking’, ‘self-care related confidence’ and ‘family resources’ respectively (Table 3). To further verify the three-factor structure acquired from the EFA, we performed the CFA with the same sample. The good model fit indexes were found with the three-factor structure: c2/df = 2.29, GFI = 0.87, AGFI = 0.80, CFI = 0.90, SRMR = 0.07 (Fig. 1) which supported acceptable construct validity.
Convergent and discriminant validity The Chinese DSTAR-Teen significantly negatively correlated with HbA1c (r = −0.21, p = 0.002) and established instruments of diabetes distress (r = −0.36, p = 0.000). Inversely, it was positively correlated
with self-care behavior (r = 0.61, p = 0.000). Above results supported the hypothesis for known relationships (Table 4). Discussion To our knowledge, this was the first study to adapt the English DSTAR-Teen to the Chinese version cross-culturally. Findings confirmed the psychometric properties of the Chinese DSTAR-Teen. The Chinese DSTAR-Teen demonstrated adequate validity. The content validity of the Chinese DSTAR-Teen was ensured by the process of adaptation, which was conducted in accordance with guidelines (Beaton et al., 2000). The back-translation technique, bilingual translation method, and committee discussion approach were employed to maintain the equivalence between the original and translated version. In addition, we revised the translated version based on comments and suggestions from adolescents who had participated in the preliminary experiment, which further decreased unintelligibility and supported appropriateness of the Chinese DSTAR-Teen. In construct validity testing, factor analysis revealed a three-factor structure which was inconsistent with the bidimensional factor structure of the original version. Considering that we had adopted a variety of methods to maintain original context and meaning of the scale in the adaptation stage, we suggest that the inconsistency may be caused by the different cultural and environment between Eastern and Western countries. Three factors
Table 3 Three-factor structure of the Chinese version of the DSTAR-Teen (n = 120). Factor 1 Item 3 I am good at responding to high or low blood sugars 我可以很好的应对高血糖和低血糖的发生 Item 5 I am good at figuring out what to do for my diabetes care when problems come up 当出现问题时，我很擅长找到管理糖尿病的方法 Item 10 I can figure out ways to take care of my diabetes even when I am busy or other things make diabetes hard to manage 当我很忙碌或者因为其他事情导致糖尿病管理面临困难时，我可以想出办法来管理糖尿病 Item 7 I can ask for help with my diabetes management when I need to 当我需要时，我可以向我的糖尿病管理团队寻求帮助 Item 6 My parent(s) help me take care of my diabetes 父母帮助我一起管理糖尿病 Item 11 There is someone I can always ask for help with my diabetes 关于糖尿病，随时有个人可以让我求助 Item 12 I talk to my parent(s) calmly about diabetes, like talking about my A1c or remembering to do blood sugar checks 我和父母平静地讨论糖尿病，比如讨论我的糖化血红蛋白或要记得做血糖监测 Item 9 I can count on my friends to help me take care of diabetes if I need help 如果我需要的话，我会寻求朋友帮助我管理糖尿病 Item 8 If I try hard to do everything I need to do for my diabetes, it makes a difference 如果我努力的去做一切我能做的事情，将会对我的病情有很大的帮助 Item 1 I am able to take care of my diabetes pretty well 我可以很好的管理我的糖尿病 Item 2 I tell my friends about diabetes 我可以和我的朋友讨论关于糖尿病的事 Item 4 I am able to ask my nurse or doctor questions about how to manage my diabetes 我可以询问熟悉的护士或医生关于如何管理好糖尿病的问题
Factor 2
Factor 3
0.88 0.79 0.62 0.76 0.81 0.68 0.69 0.76 0.57 0.68 0.72 0.68
Note. Items are listed from the highest to lowest loadings; DSTAR-Teen = Diabetes Strengths and Resilience measure for Adolescents.
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Fig. 1. Factor structure of the Chinese version of the DSTAR-Teen. Note. Standardized estimates. All ps b 0.001.
of the Chinese DSTAR-Teen (help-seeking, self-care related confidence and family resources) are consistent with Hilliard, Harris, and Weissberg-Benchell's (2012) diabetes resilience model, in which strengths from individual and family are supposed to improve patients' health outcomes. In convergent and discriminant validity testing, the correlations between the Chinese DSTAR-Teen and related instruments were all in the predicted directions. The inclusion of objective indicator (e.g., HbA1c) and comprehensive related constructs (behavior and psychology aspects) in this study reduced the risk of bias and ensure representativeness. The Chinese DSTAR-Teen also demonstrated suitable reliability. The Cronbach's alpha coefficient of the Chinese DSTAR-Teen was 0.898, showing relative high internal consistency reliability. In a previous study (Hilliard, Iturralde, et al., 2017), the test-retest reliability of the original English DSTAR-Teen had not been assessed due to the crosssectional design. Our study remedied this deficiency by calculating the ICC with a perspective and longitudinal sample. The stability of the Chinese DSTAR-Teen was excellent and the minimum detectable change at the 95% confidence level (MDC95) in this study was 5.821 points, which indicated that a change of N5.821 points after a given resilience-related intervention represented a ‘real change’. The psychometric properties of the original English DSTAR-Teen were supported in adolescents with T1D without major depressive Table 4 Associations among DSTAR-Teen Total Score and measures of convergent and discriminant validity (n = 120). Variable
1
2
3
4
1. DSTAR-Teen 2. HbA1c 3. DBRS 4. PAID-5
– −0.28 0.61 −0.36
– −0.45 0.02
– 0.16
–
Note. Bold correlation coefficients indicate p b 0.01; DSTAR-Teen = Diabetes Strengths and Resilience Measure for Adolescents; HbA1c = glycosylated hemoglobin; DBRS = Diabetes Behavior Rating Scale; PAID-5 = Problem Areas in Diabetes Scale-5.
disorder in the United States (Hilliard, Iturralde, et al., 2017). Our study expanded the usage of the DSTAR-Teen not only to Chinesespeaking adolescents with T1D but also to those with the major depressive disorder. Therefore, the distributions of scores in this study were more even than those in Hilliard's study, with less skew toward the top of the scale. The generalizability and utility of the DSTAR-Teen were strengthened. Notably, the mean score of resilience (42.4) in this study was just over a medium level, which was lower than that observed in Hilliard's study. Although the inclusion of TID adolescents with major depression partly contributed to the lower resilience score, the special social environment in China may also account for this. The incidence of T1D in China is among the lowest in the world (Patterson et al., 2013) and the disease stigmatization is common. Chinese adolescents with T1D have difficulty in being accepted by peers and families. What's worse, one government regulation of China states that individuals with ‘severe endocrine and metabolic diseases’ should not be admitted to universities (Jaacks, Liu, Ji, & Mayer-Davis, 2014). In order to avoid discrimination and be admitted by schools, adolescents have to hide their T1D. This coping strategy may make self-care more difficult and prevent patients from seeking help around them, which in turn, negatively affects their resilience. Our findings showed that higher resilience was associated with higher engagement in self-care, better glycemic control, and less diabetes distress, which emphasize the importance of incorporating regular resilience assessment into clinical care for adolescents with T1D. Using Chinese DSTAR-Teen, nurses can measure adolescents' adaptive behaviors and attitudes toward diabetes management and identify diabetes-related strengths of them, and then make more specific psychological intervention to improve adolescents' health outcomes. This study had some limitations. First, although the psychometric properties of the Chinese DSTAR-Teen were evaluated in accordance with guidelines, criterion validity was unable to be assessed since there is no gold standard instrument of resilience in China. Yet we explored the correlations between measures of resilience and related variables as alternatives, more efforts are needed in further study. Second,
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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due to the limits of research resources, we could not perform the confirmatory factor analysis with a second sample. The robustness of the findings would be enhanced by replicating the confirmatory factor analysis in the different samples. Third, we calculated MDC95 in this study using the distribution-based approach. Because of the inconsistent measurement error across different samples, more studies with external criterion are needed to confirm whether the MDC95 achieved in this study has clinical meaning. Fourth, this study was conducted with a convenience sample from one diabetes center. Although this center was responsible for diabetes patients across the country, more multicenter studies are needed to verify the findings and improve the generalizability of the Chinese DSTAR-Teen. Conclusion This study developed the semantically equivalent Chinese version of the DSTAR-Teen which has adequate reliability and validity. The Chinese DSTAR-Teen may have applicability in both research and clinical care for its short-form. Researchers and nurses can use this instrument to assess strengths and adaptive aspects associated with diabetes management and examine the unique effects of resilience on self-care behavior, glycemic control, and mental health of adolescents with T1D. Funding This work was supported by the Innovative Team of Jiangsu Province (from: Jiangsu Commision of Health, grant number (2016)22). Submission declaration This article has not previously been peer-reviewed or published, is not under consideration for publication elsewhere, has approval for publication by all authors, and if accepted, will not be published elsewhere. CRediT authorship contribution statement Jingjing Xu: Conceptualization, Investigation, Data curation, Resources, Writing - review & editing. Dan Luo: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft. Min Zhu: Investigation, Data curation. Hong Wang: Investigation, Data curation. Yun Shi: Methodology, Investigation. Dan Ya: Investigation. Zheng Lin: Conceptualization, Project administration. Zejuan Gu: Conceptualization, Funding acquisition, Validation, Supervision. Declaration of competing interest None. Acknowledgments We express our thanks to Professors Hilliard M E, who provided the resilience scale for this study and all participants of this study for their dedication and time.
References Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2000). Guidelines for the process of cross-cultural adaptation of self-report measures. Spine, 25(24), 3186–3191. Boomsma, A. (1985). Nonconvergence, improper solutions, and starting values in Lisrel maximum-likelihood estimation. Psychometrika, 50(2), 229–242. Buchberger, B., Huppertz, H., Krabbe, L., Lux, B., Mattivi, J. T., & Siafarikas, A. (2016). Symptoms of depression and anxiety in youth with type I diabetes: A systematic review and meta-analysis. Psychoneuroendocrinology, 70, 70–84. Byrne, B. M. (2009). Structural equation modeling with AMOS: Basic concepts, applications, and programming (2nd ed.). New York: Routledge. Q&A: Key Points for IDF Diabetes Atlas 2017 (2018). Diabetes research and clinical practice135. (pp. 235–236), 235–236. DiMeglio, L. A., Evans-Molina, C., & Oram, R. A. (2018). Type 1 diabetes. The Lancet, 391 (10138), 2449–2462. Fleiss, J. L. (1999). Design and analysis of clinical experiments. Hoboken: John Wiley & Sons, Incorporated. Hilliard, M. E., Hagger, V., Hendrieckx, C., Anderson, B. J., Trawley, S., Jack, M. M., ... Speight, J. (2017). Strengths, risk factors, and resilient outcomes in adolescents with type 1 diabetes: Results from Diabetes MILES Youth-Australia. Diabetes Care, 40(7), 849–855. Hilliard, M. E., Harris, M. A., & Weissberg-Benchell, J. (2012). Diabetes resilience: A model of risk and protection in type 1 diabetes. Current Diabetes Reports, 12(6), 739–748. Hilliard, M. E., Iturralde, E., Weissberg-Benchell, J., & Hood, K. K. (2017). The diabetes strengths and resilience measure for adolescents with type 1 diabetes (DSTARteen): Validation of a new, brief self-report measure. Journal of Pediatric Psychology, 42(9), 995–1005. Iannotti, R. J., Nansel, T. R., Schneider, S., Haynie, D. L., Simons-Morton, B., Sobel, D. O., ... Clark, L. (2006). Assessing regimen adherence of adolescents with type 1 diabetes. Diabetes Care, 29(10), 2263–2267. Jaacks, L. M., Liu, W., Ji, L., & Mayer-Davis, E. J. (2014). Type 1 diabetes stigma in China: A call to end the devaluation of individuals living with a manageable chronic disease. Diabetes Research and Clinical Practice, 107(2), 306–307. Kaiser, H. F. (1960). The application of electronic computers to factor analysis. Educational and Psychological Measurement, 20(1), 141–151. Lo, F. -S., Hsu, H. -Y., Chen, B. -H., Lee, Y. -J., Chen, Y. -T., & Wang, R. -H. (2016). Factors affecting health adaptation of Chinese adolescents with type 1 diabetes: A path model testing. Journal of Child Health Care, 20(1), 5–16. McGuire, H. C., Ji, L., Kissimova-Skarbek, K., Whiting, D., Aguirre, F., Zhang, P., ... Zhou, Z. (2017). Type 1 diabetes mellitus care and education in China: The 3C study of coverage, cost, and care in Beijing and Shantou. Diabetes Research and Clinical Practice, 129, 32–42. McGuire, B. E., Morrison, T. G., Hermanns, N., Skovlund, S., Elup, E., Gagliardino, J., ... Snoek, F. J. (2010). Short-form measures of diabetes-related emotional distress: The Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia, 53(1), 66–69. Nicolucci, A., Kovacs Burns, K., Holt, R. I. G., Comaschi, M., Hermanns, N., Ishii, H., ... the, D. S. G (2013). Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Crossnational benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabetic Medicine: Journal of Diabetes UK, 30(7), 767–777. Patterson, C., Guariguata, L., Dahlquist, G., Soltész, G., Ogle, G., Silink, M., ... Umeå, U. (2013). Diabetes in the young — A global view and worldwide estimates of numbers of children with type 1 diabetes. Diabetes Research and Clinical Practice, 103(2), 161–175. Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58(3), 307–321. Ungar, M. (2011). The social ecology of resilience: Addressing contextual and cultural ambiguity of a nascent construct. American Journal of Orthopsychiatry, 81(1), 1–17. Wang, R. H., Hsu, H. C., Kao, C. C., Yang, Y. M., Lee, Y. J., & Shin, S. J. (2017). Associations of changes in psychosocial factors and their interactions with diabetes distress in patients with type 2 diabetes: A longitudinal study. Journal of Advanced Nursing, 73 (5), 1137–1146. Ye, Z. J., Qiu, H. Z., Li, P. F., Chen, P., Liang, M. Z., Liu, M. L., ... Quan, X. M. (2017). Validation and application of the Chinese version of the 10-item Connor-Davidson Resilience Scale (CD-RISC-10) among parents of children with cancer diagnosis. European Journal of Oncology Nursing, 27, 36–44. Zhu, J., Xu, J., Chen, Y., Gu, Y., Ji, L., Zhou, Y., ... He, W. (2018). Cross-cultural adaption and psychometric properties of the Chinese version of the Diabetes Behavior Rating Scale: A pilot study. Science China Life Sciences, 61(3), 310–317.
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Journal of Pediatric Nursing journal homepage: www.pediatricnursing.org
Translation and its psychometric characteristic of the diabetes strengths and resilience measure among Chinese adolescents with type 1 diabetes Jingjing Xu, MSN, RN a,1, Dan Luo, PhD, RN b,1, Min Zhu, BA, RN a, Hong Wang, BA, RN a, Yun Shi, CD, PhD a, Dan Ya, BA, RN a, Zheng Lin, MSN, RN c,d,⁎, Zejuan Gu, MSN, RN c,d,⁎ a
Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, Jiangsu, China School of Nursing, Peking University, Beijing, China School of Nursing, Nanjing Medical University, Nanjing, Jiangsu, China d Department of Nursing, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, Jiangsu, China b c
a r t i c l e
i n f o
Article history: Received 4 June 2019 Revised 27 August 2019 Accepted 27 August 2019 Available online xxxx Keywords: Type 1 diabetes mellitus Adolescent Resilience Instrument adaptation Psychometric analysis
a b s t r a c t Purpose: This study is designed to develop a Chinese version of the Diabetes Strengths and Resilience Measure for Adolescents (DSTAR-Teen) and evaluate its psychometric characteristics. Design and methods: One hundred and twenty adolescents with type 1 diabetes (Mean age = 16.3 ± 5.1, 51.7% male, Mean HbA1c = 7.6 ± 2.2%) were enrolled from one national endocrine center in China. Participants were administered with the DSTAR-Teen and the related psychosocial instruments to evaluate the reliability and validity. The DSTAR-Teen was adapted into Chinese version prior to data collection. Results: The Chinese DSTAR-Teen demonstrated adequate reliability (Cronbach's α coefficients = 0.90, intraclass correlation coefficient = 0.98). A minimum detectable change at the 95% confidence level was 5.8 points. In exploratory and confirmatory factorial analyses, a three-factor structure emerged with a variance of 67.4%, demonstrating construct validity. Moreover, resilience was significantly associated with glycated hemoglobin, diabetes distress and self-care behavior as hypothesized, further supporting validity. Conclusion: The Chinese version of the DSTAR-Teen is a psychometrically sound instrument that may capture the adaptive attitudes and behaviors associated with diabetes management. Practice implications: This scale can be used in both clinical and research settings with the aim of identifying diabetes specific strengths and improving the health outcomes in adolescents with type 1 diabetes. © 2019 Elsevier Inc. All rights reserved.
Introduction Type 1 diabetes (T1D) is a chronic metabolism disorder mainly caused by the absolute deficiency of insulin (DiMeglio, Evans-Molina, & Oram, 2018), which requires lifelong management. The incidence of T1D in China has been increasing rapidly, especially among adolescents. According to the International Diabetes Federation (IDF), N47.000 children and adolescents are diagnosed with T1D in China, which ranks fourth highest in the world (Q&A: Key Points for IDF Diabetes Atlas 2017, 2018). In addition to the developmental challenges during adolescent, those with T1D also have to undertake burdensome self-care tasks, which can be a significant hurdle. Deteriorating glycemic control is
⁎ Corresponding authors at: Department of Nursing, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), 300 Guangzhou Road, Nanjing, Jiangsu 210000, China. E-mail addresses: [email protected] (Z. Lin), [email protected] (Z. Gu). 1 Jingjing Xu and Dan Luo contributed equally to this work and should be regarded as co-first authors.
common in adolescence, which is associated with more complications and higher mortality in adulthood. In mainland China, studies indicate an average glycosylated hemoglobin (HbA1c) of 9.4% among adolescents and the incidence of diabetic ketoacidosis to be 14.4 events/100 patient years (McGuire et al., 2017). Moreover, adolescents with T1D are also at risk for mental health disorders including depression and diabetes distress) (Buchberger et al., 2016). Researchers have been making elaborate efforts on identifying potential protective factors in adolescents with T1D so as to improve their health outcomes. A potential factor that can help adolescents adopt the challenges of T1D is resilience, which is defined as the capacity to achieve positive outcomes despite exposure to significant challenges (Richardson, 2002). Among patients with T1D, resilience has been shown to positively impact health outcomes including high engagement in self-care, better glycemic control, and fewer negative emotions (Hilliard et al., 2017; Hilliard, Iturralde, Weissberg-Benchell, & Hood, 2017; Lo et al., 2016; Wang et al., 2017). Although there are many articles about resilience advantages, nurses tend to focus on identifying and eliminating risk factors rather than assessing and promoting resilience in China.
https://doi.org/10.1016/j.pedn.2019.08.020 0882-5963/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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This is largely owing to the inadequacy of appropriate instruments. Although some resilience measures are available, most of them are designed for general populations, which could not explicitly assess adaptive aspects associated with diabetes management. Professor Hilliard and her colleagues (Hilliard, Iturralde, et al., 2017) proposed the Diabetes Strengths and Resilience Measure (DSTAR-Teen) for adolescents with T1D. This self-report instrument possesses two dimensions, one is to measure patients' perception of their ability to manage diabetes and the other is to measure their ability of seeking help from close others. The 12-item DSTAR-Teen exhibits excellent psychometric properties in the West and has applicability for use in clinical care. However, resilience functions differently depending on the specific culture and environment around people (Ungar, 2011). Chinese adolescents adapt to challenges of T1D in manners that are sometimes different from those of Western patients. For example, many Chinese adolescents are inclined to conceal the disease and suppress their desires in the process of T1D management, whereas Western patients tend to share their feelings and seek help from parents or physicians (Ye et al., 2017). Therefore, the structure of the English version of DSTAR-Teen may not be appropriate for Chinese adolescents with T1D. The aims of this study are to adapt the English DSTAR-Teen into Chinese and evaluate its reliability and validity among Chinese adolescents with T1D. Indicators of reliability included internal consistency reliability, test-retest reliability, and item homogeneity. Validity was tested by implementing factor analysis and verifying known relationships between resilience and related variables. Based on the findings of empirical studies, we hypothesized that higher resilience scores would be associated with better self-care behavior and glycemic control. Lower resilience scores would predict more severe diabetes distress.
Methods Study design, setting, and sample This was a prospective observational study. One hundred and twenty adolescents with T1D were enrolled from the outpatient and inpatient services of a national endocrine center by convenience sampling technique. Inclusion criteria were as follows: 1) T1D diagnosis ≥ 6 months, 2) age 12–19 years, 3) Chinese fluency. Adolescents were excluded if they had any of the following conditions: 1) other serious organic diseases, 2) cognitive impairment or psychiatric disorder, and 3) inability to understand study instruments. The sample size was calculated on the basis of ensuring the psychometric quality of the factor analysis. Both exploratory factor analysis and confirmatory factor analysis require at least 100 participants (Boomsma, 1985; Kaiser, 1960). A total of 125 adolescents with T1D were recruited, and the data from five participants were not included in this study due to the existence of missing data.
Procedures All participants completed the study instruments under the guidance of the primary investigator and one research assistant (a diabetes specialist nurse). Participants' socio-demographic and disease characteristics were collected simultaneously. The latest HbA1c value within three months was acquired from the participants' medical files. The time each participant spent to complete the study instruments were approximately 20 min. In test-retest reliability analysis, 18 patients were selected by convenience sampling technique from the 120 participants. They were reassessed the Chinese DSTAR-Teen within two weeks. This sample size was determined on Fleiss's (1999) suggestion that 15–20 subjects were enough to verify testretest reliability.
Measures Diabetes related resilience The Diabetes Strengths and Resilience Measure for Adolescents (DSTAR-Teen) was developed to measure adaptive attitudes and behaviors associated with diabetes management and control (Hilliard, Hagger, et al., 2017; Hilliard, Iturralde, et al., 2017). The total score of 12-item DSTAR-Teen ranged from 12 to 60 points, with each item rating on a 5-point scale according to frequency (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = almost always). The higher score indicated higher resilience level. Above all, we obtained the permission from Professor Hilliard to translate the English DSTAR into Chinese. The process of translation was carried out in four stages based on the methodology proposed by Beaton, Bombardier, Guillemin, and Ferraz (2000): 1) forwardtranslation, 2) back-translation, 3) committee discussion, and 4) pilot test. In the first stage, two bilingual experts who are proficient in different areas (one was an endocrinologist who was familiar with the concept of resilience and the other was a professional translator who had an administrative job within the university) translated the original English DSTAR-Teen into Chinese respectively. On the premise of ensuring the semantics and original conceptualization of the DSTAR-Teen, the culture-related modifications were made. After the discussion between the two bilingual experts, the two translated versions were synthesized into one Chinese version. In the second stage, another bilingual expert who had lived in English-speaking country and was blinded to the original English DSTAR-Teen translated the Chinese version back to English. Subsequently, members of expert committee (three translators and research team members) compared the back-translation version with the original English version of DSTAR-Teen to ensure good agreement between them. In the last stage, 17 Chinese adolescents with T1D were invited to pretest the translated version. Brief interviews were conducted to collect comments of 17 participants on single item and the general scale (clarity of words, meaning of items, etc.). All suggestions from them were evaluated and discussed by the expert committee and further modifications of the translated version were made. At this point, the Chinese version of the DSTAR-Teen was obtained. The process of translation and adaptation ensured the content validity of the Chinese DSTAR-Teen. Self-care behavior Self-care behavior was assessed by using the Diabetes Behavior Rating Scale (DBRS) (Iannotti et al., 2006). The DBRS had insulin injection version (37 items) and insulin pump version (38 items). The total score was transformed to a score ranging from 0 to 1, with a higher score suggesting better self-care behavior. The reliability and validity of the DBRS were demonstrated in Chinese adolescents with T1D (Zhu et al., 2018). The Cronbach's α in this sample were 0.937 and 0.818 for the insulin injection and insulin pump version respectively. Diabetes distress Diabetes-related psychological distress was assessed by using the Problem Areas in Diabetes Scale-5 (PAID-5) (McGuire et al., 2010). The total score of the 5-item PAID-5 ranged from 0 to 20, with the higher scores indicating more severe diabetes distress. A cut-off point of 8 was used to distinguish those had mild distress or severe distress. The PAID-5 was widely used in mainland China and the reliability and validity were supported (Nicolucci et al., 2013). The Cronbach's α in this sample was 0.874. General characteristics Socio-demographic (gender, age, education level, medical payment method, living status, family income) and disease characteristics (disease duration, insulin regimen, HbA1c) were acquired from the medical
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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file and general information questionnaire which was developed by the research team.
Table 1 Sample characteristics (n = 120). Classification
Characteristic
Classification Number (n)
Percent (%)
Demographic factors
Gender
Female Male 10–14 15–20 Elementary school Middle school High school College or higher Without medical insurance With medical insurance Live with family Live with classmates Live alone b5000 5000–8000 N8000
58 62 43 77 25
48.3 51.7 35.8 64.2 20.8
33
27.5
22 40
18.3 33.3
38
31.7
82
68.3
91
75.8
25
20.8
4 26 33 61
3.3 4 21.7 27.5 50.8
b1 1–5 5–10 N10 MDI CSII ≤7.5 N7.5
14 66 20 20 80 40 76 44
11.7 55.0 16.7 16.6 66.7 33.3 63.3 36.7
Ethical considerations This study was approved by the Institutional Review Boards of the hospital where the study was conducted, and the required permissions were obtained from the hospital. All Participants provided verbal permission and signed informed consent forms voluntarily after knowing the purpose and privacy of this study. Their personal information and responses were recorded confidentially. In addition, prior to the study, we obtained Professor Hilliard's permission to use the DSTAR-Teen.
Age (years) Education level
Medical insurance
Statistic analysis All data analyses were performed by SPSS (version 22.0; SPSS Inc., Chicago, Ill) except the confirmatory factor analysis which was analyzed by AMOS (version 22.0; Amos Development Corporation, Meadville, PA, USA). p values b 0.05 indicated statistical significance. Descriptive statistics (percentages, means, central tendency) were used to describe characteristics of the sample. Indicators of reliability included internal consistency reliability and test-retest reliability. The Cronbach's alpha coefficient and intraclass correlation coefficient (ICC) were used to evaluate the internal consistency reliability and testretest reliability respectively. The minimum detectable change with 95% confidence level (MDC95) was calculated to show the smallest change in DSTAR-Teen score that reflects true change rather than measurement error. In this study, the value of Cronbach's alpha coefficient and ICC should exceed 0.70 and 0.90 respectively to ensure sufficient reliability. Indicators of validity included construct validity as well as convergent and discriminant validity. Construct validity was assessed through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). As this was the first time that the DSTAR-Teen was evaluated under the eastern culture and context, we conducted an EFA using principal axis factoring extraction with direct oblimin rotation to determine the underlying structure of Chinese version of the DSTAR-Teen. The Kaiser-Meyer-Olkin (KMO) test and Bartlett's test of sphericity were performed before EFA to ensure psychometric quality. The eigenvalues ≥1 and factor loading coefficients ≥0.4 were used as the standard for factor extraction and item retention respectively (Kaiser, 1960). The CFA was implemented to verify the factor structure acquired from the EFA. Following criteria were used to assess the model fit: the ratio of the χ2 value and the degrees of freedom (χ2/df) b 5, goodness-of-fit index (GFI) ≥ 0.85, adjusted goodness-of-fit index (AGFI) ≥ 0.80, comparative fit index (CFI) N 0.90, and standardized root mean square residual (SRMR) b 0.10 (Byrne, 2009). Convergent and discriminant validity were tested by verifying known relationships between resilience and related variables. It was assumed that correlation validity would be supported if the bivariate correlations between measures of resilience and related variables (self-care behavior, diabetes distress, and glycemic control) were in hypothesized directions. Results Descriptive characteristics Participants' socio-demographic and disease characteristics are summarized in Table 1. One hundred and twenty adolescents with T1D participated in this study. The mean age of them was 16.3 (SD: 5.1) and sixty-two of them (51.7%) were male. Ninety-one of the participants lived at home (75.8%) and 25 of them lived with classmates. Eighty-two of them (68.3%) had medical insurance. Sixty-one of them (50.8%) reported family monthly income N8000 Yuan. The median diabetes duration of participants was 4.6 years (SD: 2.1) and the mean level
3
Living status
Disease factors
Family monthly income (Yuan) Diabetes duration (year) Insulin regimen HbA1c, %
Mean ± SD
16.3 ± 5.1
4.6 ± 2.1
7.9 ± 2.2
Note. DSTAR-Teen = Diabetes Strengths and Resilience measure for Adolescents; SD = standard deviation; CSII = continuous subcutaneous insulin infusion; MDI = multiple daily injections.
of HbA1 was 7.6% (SD: 2.2) with 44 of them (36.7%) failing to achieve the goal of glycemic control. Eighty of them (66.7%) were treated with continuous subcutaneous insulin infusion (CSII) and the rest were given multiple daily injections. The mean score of the DSTAR-Teen was 42.4 (SD: 10.3) in this sample. As is shown in Table 2, participants endorsed the full range of responses on every item, yet on some items, the majority of participants endorsed “Sometimes/3”, “Often/4” or “Almost Always/5”. The ratings were evenly distributed. Item skewness ranged from −1.16 to 0.24 with one item greater than |1| (Item 6), and kurtosis ranged from −1.39 to 0.09 with four items greater than |1| (Items 4, 7, 9, 10). Total score skewness was −0.12, kurtosis was −0.87.
Reliability Internal consistency reliability The internal consistency reliability of the Chinese DSTAR-Teen was indicated by the Cronbach's alpha coefficient. In this sample, the Cronbach's alpha coefficient was 0.90 which confirmed acceptable and sufficient internal consistency reliability.
Test-retest reliability The mean time between completion of the two test occasions was 8.0 (SD: 3.0) days (ranged from 4 to 14 days). The Chinese DSTARTeen proved adequate test-retest reliability with a high ICC of 0.98 (95% CI: 0.95 to 0.99). In addition, the minimum detectable change at the 95% confidence level (MDC95) was 5.8 points.
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Table 2 Items and response options statistics for the Chinese version of the DSTAR-Teen (n = 120).
Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12
1 Never (%)
2 Rarely (%)
3 Sometimes (%)
4 Often (%)
5 Almost always (%)
Mean ± SD
Skewness
Kurtosis
2.5 29.2 2.5 9.2 5.0 1.7 15.8 6.7 24.2 8.3 6.7 5.8
5.8 22.5 9.2 18.3 12.5 10.0 13.3 8.3 25.8 17.5 13.3 15.0
25.0 23.3 27.5 25.0 30.0 11.7 15.0 14.2 14.2 24.2 18.3 20.0
35.8 15.8 31.7 22.5 23.3 21.7 19.2 34.2 14.2 20.0 20.0 23.3
30.8 9.2 29.2 25.0 29.2 55.0 36.7 36.7 21.7 30.0 41.7 35.8
3.9 ± 1.0 2.5 ± 0.8 3.8 ± 1.1 3.4 ± 1.3 3.6 ± 1.8 4.2 ± 1.1 3.5 ± 1.5 3.9 ± 1.5 2.8 ± 0.9 3.5 ± 1.3 3.8 ± 1.3 3.7 ± 1.3
−0.69 0.37 −0.51 −0.24 −0.38 −1.16 −0.47 −0.98 0.24 −0.31 −0.67 −0.55
0.11 −0.99 −0.40 −1.03 −0.77 0.24 −1.23 0.09 −1.39 −1.07 −0.77 −0.85
Note. DSTAR-Teen = Diabetes Strengths and Resilience measure for Adolescents.
Validity Construct validity The results of the KMO test and Bartlett's test of sphericity (KMO = 0.87, Chi-square = 700.13; p = 0.000) indicated that this sample was suitable for EFA. The EFA identified a greater variance (67.4%) explained by a threefactor structure, inconsistent with the two-factor structure of the original English version. All of 12 items met the retention criteria with factors loading coefficients ranging from 0.59 to 0.72. Taken content and meaning of three factors into consideration, we labeled factor 1 to 3 as ‘help-seeking’, ‘self-care related confidence’ and ‘family resources’ respectively (Table 3). To further verify the three-factor structure acquired from the EFA, we performed the CFA with the same sample. The good model fit indexes were found with the three-factor structure: c2/df = 2.29, GFI = 0.87, AGFI = 0.80, CFI = 0.90, SRMR = 0.07 (Fig. 1) which supported acceptable construct validity.
Convergent and discriminant validity The Chinese DSTAR-Teen significantly negatively correlated with HbA1c (r = −0.21, p = 0.002) and established instruments of diabetes distress (r = −0.36, p = 0.000). Inversely, it was positively correlated
with self-care behavior (r = 0.61, p = 0.000). Above results supported the hypothesis for known relationships (Table 4). Discussion To our knowledge, this was the first study to adapt the English DSTAR-Teen to the Chinese version cross-culturally. Findings confirmed the psychometric properties of the Chinese DSTAR-Teen. The Chinese DSTAR-Teen demonstrated adequate validity. The content validity of the Chinese DSTAR-Teen was ensured by the process of adaptation, which was conducted in accordance with guidelines (Beaton et al., 2000). The back-translation technique, bilingual translation method, and committee discussion approach were employed to maintain the equivalence between the original and translated version. In addition, we revised the translated version based on comments and suggestions from adolescents who had participated in the preliminary experiment, which further decreased unintelligibility and supported appropriateness of the Chinese DSTAR-Teen. In construct validity testing, factor analysis revealed a three-factor structure which was inconsistent with the bidimensional factor structure of the original version. Considering that we had adopted a variety of methods to maintain original context and meaning of the scale in the adaptation stage, we suggest that the inconsistency may be caused by the different cultural and environment between Eastern and Western countries. Three factors
Table 3 Three-factor structure of the Chinese version of the DSTAR-Teen (n = 120). Factor 1 Item 3 I am good at responding to high or low blood sugars 我可以很好的应对高血糖和低血糖的发生 Item 5 I am good at figuring out what to do for my diabetes care when problems come up 当出现问题时，我很擅长找到管理糖尿病的方法 Item 10 I can figure out ways to take care of my diabetes even when I am busy or other things make diabetes hard to manage 当我很忙碌或者因为其他事情导致糖尿病管理面临困难时，我可以想出办法来管理糖尿病 Item 7 I can ask for help with my diabetes management when I need to 当我需要时，我可以向我的糖尿病管理团队寻求帮助 Item 6 My parent(s) help me take care of my diabetes 父母帮助我一起管理糖尿病 Item 11 There is someone I can always ask for help with my diabetes 关于糖尿病，随时有个人可以让我求助 Item 12 I talk to my parent(s) calmly about diabetes, like talking about my A1c or remembering to do blood sugar checks 我和父母平静地讨论糖尿病，比如讨论我的糖化血红蛋白或要记得做血糖监测 Item 9 I can count on my friends to help me take care of diabetes if I need help 如果我需要的话，我会寻求朋友帮助我管理糖尿病 Item 8 If I try hard to do everything I need to do for my diabetes, it makes a difference 如果我努力的去做一切我能做的事情，将会对我的病情有很大的帮助 Item 1 I am able to take care of my diabetes pretty well 我可以很好的管理我的糖尿病 Item 2 I tell my friends about diabetes 我可以和我的朋友讨论关于糖尿病的事 Item 4 I am able to ask my nurse or doctor questions about how to manage my diabetes 我可以询问熟悉的护士或医生关于如何管理好糖尿病的问题
Factor 2
Factor 3
0.88 0.79 0.62 0.76 0.81 0.68 0.69 0.76 0.57 0.68 0.72 0.68
Note. Items are listed from the highest to lowest loadings; DSTAR-Teen = Diabetes Strengths and Resilience measure for Adolescents.
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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Fig. 1. Factor structure of the Chinese version of the DSTAR-Teen. Note. Standardized estimates. All ps b 0.001.
of the Chinese DSTAR-Teen (help-seeking, self-care related confidence and family resources) are consistent with Hilliard, Harris, and Weissberg-Benchell's (2012) diabetes resilience model, in which strengths from individual and family are supposed to improve patients' health outcomes. In convergent and discriminant validity testing, the correlations between the Chinese DSTAR-Teen and related instruments were all in the predicted directions. The inclusion of objective indicator (e.g., HbA1c) and comprehensive related constructs (behavior and psychology aspects) in this study reduced the risk of bias and ensure representativeness. The Chinese DSTAR-Teen also demonstrated suitable reliability. The Cronbach's alpha coefficient of the Chinese DSTAR-Teen was 0.898, showing relative high internal consistency reliability. In a previous study (Hilliard, Iturralde, et al., 2017), the test-retest reliability of the original English DSTAR-Teen had not been assessed due to the crosssectional design. Our study remedied this deficiency by calculating the ICC with a perspective and longitudinal sample. The stability of the Chinese DSTAR-Teen was excellent and the minimum detectable change at the 95% confidence level (MDC95) in this study was 5.821 points, which indicated that a change of N5.821 points after a given resilience-related intervention represented a ‘real change’. The psychometric properties of the original English DSTAR-Teen were supported in adolescents with T1D without major depressive Table 4 Associations among DSTAR-Teen Total Score and measures of convergent and discriminant validity (n = 120). Variable
1
2
3
4
1. DSTAR-Teen 2. HbA1c 3. DBRS 4. PAID-5
– −0.28 0.61 −0.36
– −0.45 0.02
– 0.16
–
Note. Bold correlation coefficients indicate p b 0.01; DSTAR-Teen = Diabetes Strengths and Resilience Measure for Adolescents; HbA1c = glycosylated hemoglobin; DBRS = Diabetes Behavior Rating Scale; PAID-5 = Problem Areas in Diabetes Scale-5.
disorder in the United States (Hilliard, Iturralde, et al., 2017). Our study expanded the usage of the DSTAR-Teen not only to Chinesespeaking adolescents with T1D but also to those with the major depressive disorder. Therefore, the distributions of scores in this study were more even than those in Hilliard's study, with less skew toward the top of the scale. The generalizability and utility of the DSTAR-Teen were strengthened. Notably, the mean score of resilience (42.4) in this study was just over a medium level, which was lower than that observed in Hilliard's study. Although the inclusion of TID adolescents with major depression partly contributed to the lower resilience score, the special social environment in China may also account for this. The incidence of T1D in China is among the lowest in the world (Patterson et al., 2013) and the disease stigmatization is common. Chinese adolescents with T1D have difficulty in being accepted by peers and families. What's worse, one government regulation of China states that individuals with ‘severe endocrine and metabolic diseases’ should not be admitted to universities (Jaacks, Liu, Ji, & Mayer-Davis, 2014). In order to avoid discrimination and be admitted by schools, adolescents have to hide their T1D. This coping strategy may make self-care more difficult and prevent patients from seeking help around them, which in turn, negatively affects their resilience. Our findings showed that higher resilience was associated with higher engagement in self-care, better glycemic control, and less diabetes distress, which emphasize the importance of incorporating regular resilience assessment into clinical care for adolescents with T1D. Using Chinese DSTAR-Teen, nurses can measure adolescents' adaptive behaviors and attitudes toward diabetes management and identify diabetes-related strengths of them, and then make more specific psychological intervention to improve adolescents' health outcomes. This study had some limitations. First, although the psychometric properties of the Chinese DSTAR-Teen were evaluated in accordance with guidelines, criterion validity was unable to be assessed since there is no gold standard instrument of resilience in China. Yet we explored the correlations between measures of resilience and related variables as alternatives, more efforts are needed in further study. Second,
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020
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due to the limits of research resources, we could not perform the confirmatory factor analysis with a second sample. The robustness of the findings would be enhanced by replicating the confirmatory factor analysis in the different samples. Third, we calculated MDC95 in this study using the distribution-based approach. Because of the inconsistent measurement error across different samples, more studies with external criterion are needed to confirm whether the MDC95 achieved in this study has clinical meaning. Fourth, this study was conducted with a convenience sample from one diabetes center. Although this center was responsible for diabetes patients across the country, more multicenter studies are needed to verify the findings and improve the generalizability of the Chinese DSTAR-Teen. Conclusion This study developed the semantically equivalent Chinese version of the DSTAR-Teen which has adequate reliability and validity. The Chinese DSTAR-Teen may have applicability in both research and clinical care for its short-form. Researchers and nurses can use this instrument to assess strengths and adaptive aspects associated with diabetes management and examine the unique effects of resilience on self-care behavior, glycemic control, and mental health of adolescents with T1D. Funding This work was supported by the Innovative Team of Jiangsu Province (from: Jiangsu Commision of Health, grant number (2016)22). Submission declaration This article has not previously been peer-reviewed or published, is not under consideration for publication elsewhere, has approval for publication by all authors, and if accepted, will not be published elsewhere. CRediT authorship contribution statement Jingjing Xu: Conceptualization, Investigation, Data curation, Resources, Writing - review & editing. Dan Luo: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft. Min Zhu: Investigation, Data curation. Hong Wang: Investigation, Data curation. Yun Shi: Methodology, Investigation. Dan Ya: Investigation. Zheng Lin: Conceptualization, Project administration. Zejuan Gu: Conceptualization, Funding acquisition, Validation, Supervision. Declaration of competing interest None. Acknowledgments We express our thanks to Professors Hilliard M E, who provided the resilience scale for this study and all participants of this study for their dedication and time.
References Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2000). Guidelines for the process of cross-cultural adaptation of self-report measures. Spine, 25(24), 3186–3191. Boomsma, A. (1985). Nonconvergence, improper solutions, and starting values in Lisrel maximum-likelihood estimation. Psychometrika, 50(2), 229–242. Buchberger, B., Huppertz, H., Krabbe, L., Lux, B., Mattivi, J. T., & Siafarikas, A. (2016). Symptoms of depression and anxiety in youth with type I diabetes: A systematic review and meta-analysis. Psychoneuroendocrinology, 70, 70–84. Byrne, B. M. (2009). Structural equation modeling with AMOS: Basic concepts, applications, and programming (2nd ed.). New York: Routledge. Q&A: Key Points for IDF Diabetes Atlas 2017 (2018). Diabetes research and clinical practice135. (pp. 235–236), 235–236. DiMeglio, L. A., Evans-Molina, C., & Oram, R. A. (2018). Type 1 diabetes. The Lancet, 391 (10138), 2449–2462. Fleiss, J. L. (1999). Design and analysis of clinical experiments. Hoboken: John Wiley & Sons, Incorporated. Hilliard, M. E., Hagger, V., Hendrieckx, C., Anderson, B. J., Trawley, S., Jack, M. M., ... Speight, J. (2017). Strengths, risk factors, and resilient outcomes in adolescents with type 1 diabetes: Results from Diabetes MILES Youth-Australia. Diabetes Care, 40(7), 849–855. Hilliard, M. E., Harris, M. A., & Weissberg-Benchell, J. (2012). Diabetes resilience: A model of risk and protection in type 1 diabetes. Current Diabetes Reports, 12(6), 739–748. Hilliard, M. E., Iturralde, E., Weissberg-Benchell, J., & Hood, K. K. (2017). The diabetes strengths and resilience measure for adolescents with type 1 diabetes (DSTARteen): Validation of a new, brief self-report measure. Journal of Pediatric Psychology, 42(9), 995–1005. Iannotti, R. J., Nansel, T. R., Schneider, S., Haynie, D. L., Simons-Morton, B., Sobel, D. O., ... Clark, L. (2006). Assessing regimen adherence of adolescents with type 1 diabetes. Diabetes Care, 29(10), 2263–2267. Jaacks, L. M., Liu, W., Ji, L., & Mayer-Davis, E. J. (2014). Type 1 diabetes stigma in China: A call to end the devaluation of individuals living with a manageable chronic disease. Diabetes Research and Clinical Practice, 107(2), 306–307. Kaiser, H. F. (1960). The application of electronic computers to factor analysis. Educational and Psychological Measurement, 20(1), 141–151. Lo, F. -S., Hsu, H. -Y., Chen, B. -H., Lee, Y. -J., Chen, Y. -T., & Wang, R. -H. (2016). Factors affecting health adaptation of Chinese adolescents with type 1 diabetes: A path model testing. Journal of Child Health Care, 20(1), 5–16. McGuire, H. C., Ji, L., Kissimova-Skarbek, K., Whiting, D., Aguirre, F., Zhang, P., ... Zhou, Z. (2017). Type 1 diabetes mellitus care and education in China: The 3C study of coverage, cost, and care in Beijing and Shantou. Diabetes Research and Clinical Practice, 129, 32–42. McGuire, B. E., Morrison, T. G., Hermanns, N., Skovlund, S., Elup, E., Gagliardino, J., ... Snoek, F. J. (2010). Short-form measures of diabetes-related emotional distress: The Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia, 53(1), 66–69. Nicolucci, A., Kovacs Burns, K., Holt, R. I. G., Comaschi, M., Hermanns, N., Ishii, H., ... the, D. S. G (2013). Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Crossnational benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabetic Medicine: Journal of Diabetes UK, 30(7), 767–777. Patterson, C., Guariguata, L., Dahlquist, G., Soltész, G., Ogle, G., Silink, M., ... Umeå, U. (2013). Diabetes in the young — A global view and worldwide estimates of numbers of children with type 1 diabetes. Diabetes Research and Clinical Practice, 103(2), 161–175. Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58(3), 307–321. Ungar, M. (2011). The social ecology of resilience: Addressing contextual and cultural ambiguity of a nascent construct. American Journal of Orthopsychiatry, 81(1), 1–17. Wang, R. H., Hsu, H. C., Kao, C. C., Yang, Y. M., Lee, Y. J., & Shin, S. J. (2017). Associations of changes in psychosocial factors and their interactions with diabetes distress in patients with type 2 diabetes: A longitudinal study. Journal of Advanced Nursing, 73 (5), 1137–1146. Ye, Z. J., Qiu, H. Z., Li, P. F., Chen, P., Liang, M. Z., Liu, M. L., ... Quan, X. M. (2017). Validation and application of the Chinese version of the 10-item Connor-Davidson Resilience Scale (CD-RISC-10) among parents of children with cancer diagnosis. European Journal of Oncology Nursing, 27, 36–44. Zhu, J., Xu, J., Chen, Y., Gu, Y., Ji, L., Zhou, Y., ... He, W. (2018). Cross-cultural adaption and psychometric properties of the Chinese version of the Diabetes Behavior Rating Scale: A pilot study. Science China Life Sciences, 61(3), 310–317.
Please cite this article as: J. Xu, D. Luo, M. Zhu, et al., Translation and its psychometric characteristic of the diabetes strengths and resilience measure amo..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.08.020