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The Development of the Thai Version of the Diabetes Management Self-efficacy Scale for Older Adults with Ty

The Development of the Thai Version of the Diabetes Management Self-efficacy Scale for Older Adults with Type 2 Diabetes. Dissertation Defense Wipa Iamsumang , RN, MSN, GCNS, PhD-c March 27 th , 2009. Acknowledgement. Dissertation Committee

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The Development of the Thai Version of the Diabetes Management Self-efficacy Scale for Older Adults with Ty

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  1. The Development of the Thai Version of the Diabetes Management Self-efficacy Scale for Older Adults with Type 2 Diabetes Dissertation Defense WipaIamsumang, RN, MSN, GCNS, PhD-c March 27th , 2009

  2. Acknowledgement • Dissertation Committee • Dr. Sherry Pomeroy, Dissertation Co-Chair • Dr. Yvonne K. Scherer, Dissertation Co-Chair • Dr. Yow-Wu Bill Wu, Committee member • Participants • Sigma Theta Tua International (Gamma Kappa Chapter) • Mark Diamond Research Foundation • Translation team • Dr. Timothy Harigan Dr. VilipornRunkawatt • Carolyn Montgomery PhD-c. Diane Ryan PhD-c. • William Drischler PhD-s Mr. NakarateRunkawatt • Expert team • Dr. SutatanaChomson Dr. DuagrudeeLasuka • Dr. ThawornLorga Ms. JaruwonSrithong • Mrs. SukunyaKumwan

  3. Contents of Presentation • Background • Purpose of the Study • Research Questions • Sample • Data Collection • Data Analysis • Results • Limitations • Implications

  4. Background • In 2008, 11 % of the older adults in the total Thai population • Life expectancy 73 yr. : • 70 yr. for males • 77yr. for females • Aging Index (elders/100 children) • 23 in 2003 to50in 2008 • Aging Dependency Ratio (elders/100 adults) • 14 in 2003 to 16 in 2008 (National Statistic Office of Thailand , 2008)

  5. Background: Epidemiologic Data • In 2005, 50% of the older adults had chronic illness • Diabetes was the 2nd cause of their chronic illness • Known to reduce life expectancy in the older adults. • Associated with increased mortality & morbidity • In 2004, the 3rdcause of disability for female , the 8th for male. • In 2007, the 2nd leading cause of death for older females (Diabetic nephropathy) (National Statistics Office of Thailand, 2008)

  6. Background : Diabetes Management • Two main goals of diabetes education (Funnell, et al., 2008; Plodnaimuang, 1999). • Support Patients with diabetes: • Decision-making • Self-care behaviors • Problem-solving • Active collaboration with the health care team • Improve their diabetes outcomes: • Clinical outcomes • Health status • Quality of life

  7. Background: Diabetes Management • Empirical evidences support factors to improve the education outcomes • Involving patients in their own care • Guiding them in actively learning about the disease • Exploring their feeling about having behavior to control their own health outcomes • Thus, one of the goals for diabetes education is to improve their individual’s self-efficacy , accordingly, their self-management behavior.

  8. Background : Self-efficacy • A major construct of the Social Cognitive Theory • “ People’s judgments of their capacities to do something” • When individuals’ perceptions of their abilities to perform health behaviors are high, they likely will be more successful in changing health behaviors to decrease their risk of illness

  9. Background: Self-Efficacy & Diabetes management • A strong predictor of self-care behaviors (Hurley & Shea, 1992 ; Sigurardottir, 2005) • Associated with self-managements (e.g. diet, exercise, SMBG, and foot care) • Thailand: • Among older adults : positive self-efficacy & general self-care behavior • Type 2 diabetes: • Self-efficacy has been shown not only to be important in managing diabetes, but also to predict their self-care behaviors

  10. Person The older adults with type 2 diabetes Behaviors *Diet *Exercise *Medication *Monitoring complications • Outcome • *Normal Blood glucose • Lower HbA1c Perceived Self-efficacy “I think I’m able to select the right food” Outcome expectations “If I have the right food, my blood sugar will improve.” Sources of Self-efficacy *Performance accomplishments *Vicarious experiences *Verbal persuasion *Physiological feedback Theoretical Framework

  11. Significance • A necessary step was to develop a valid &reliable diabetes management self-efficacy instrument for Thai older adults with type 2 diabetes • The Thai Version of the Diabetes Management Self-Efficacy Scale (T-DMSES) • This instrument can be used to: • Guide behavioral & educational interventions aimed at improving older adults’ diabetes self-management

  12. Purpose of the Study

  13. Research Questions 1. How was the content validity of this instrument established by the judgment of a panel of experts? 2. How much did the data support the desired validity of this instrument, including factor analysis, convergent validity & concurrent validity? 3. How much did the data support the desired reliability of this instrument, including internal consistency & test-retest reliability?

  14. Methodology • Two phases derived from procedures of DeVellis (2003) • Phase I : Instrument development • Phase II: Instrument psychometric properties • Validity • Reliability

  15. Phase I: Instrument development • Two steps • Instrument formation • Define the concept • Perceived Self-efficacy of Type 2 diabetes • Review the existing instruments • Blindly back translation

  16. Instrument Formation:Definition of Perceived Self-efficacy of Type 2 diabetes • Judgments of the older adults with type 2 diabetes on their own capacities related to situational behaviors, and their confidence to perform the diabetes management activities. • Three domains based on diabetes self-care activities (Pennings-van der Eerden, 1992) • Performing essential activities for treatment of diabetes • Self-monitoring • Self-regulation

  17. Review the Existing Instruments

  18. Diabetes Management Self-Efficacy Scale: DMSES(van derBijl, van Poelgeest-Eeltink & Shortridge-Baggett, 1999) • A domain-specific instrument • Diabetes self-care activities with a central place in self-efficacy • Three domains with 20 items • All items are objective & easy to understand • Well established psychometrics • (CVI = .78; Cronbach’sα = .81; test-retest = .79) • Has been well used cross culturally • Australia/Turkey/Taiwan

  19. 1. Initial translation by first 2 bilinguals, independently 2. Synthesis of translation Panel discussion Semantic Testing by 3 native speakers 3. Blindly back translation by a bilingual The 2nd draft of T-DMSES Back Translation Method The original English version of DMSES The 1st draft of T-DMSES The English back- translated version of DMSES

  20. Back Translation Method (cont.) 4. Expert Consulting For content validity The 3rd draft of T-DMSES The 2nd draft of T-DMSES 5. Pilot Study 10 Thai older adults with type 2 diabetes The Final T-DMSES Psychometric testing With 209 Thai older adults with type 2 diabetes

  21. Phase II :Instrument psychometric properties • Survey Study • To evaluate psychometrics of the T-DMSES • Validity • Reliability

  22. Sample • Participants from 8 hospitals in 4 parts of Thailand selected from 2 provinces in each part • Convenient sampling • Inclusion Criteria • Type 2 diabetes • Age ≥ 60 years old • Attendance in out-patient diabetic clinics during October-December 2007 • Exclusion Criteria • Cognitive impairment (Thai Mental State Exam < 24)

  23. Data Collection Procedure

  24. Data Analysis

  25. Results

  26. Semantic Equivalence of the T-DMSES

  27. Participant Characteristics • n = 209 • North 26 % • Lampang 27 • Phayao 28 • Northeast 26 % • Lopburi 28 • Ayuthaya 27 • Central 26 % • KhonKaen 27 • SiSaket 27 • South 22 % • SuratThani 17 • Phangnga 28

  28. Demographic Characteristics

  29. Demographic Characteristics

  30. Duration of Diagnosis, Co-morbidity, & Health Problem

  31. Content Validity of T-DMSES (20 items) • Eliminating one item • Item 13 (follow diet) & 14 (adjust diet) : same word in Thai language “control” • Adding one item • Vision Problem : : the most chronic complication of diabetes in older adults • Item-level Content Validity Index (I-CVI) I-CVI = .80 – 1 • Scale-level Content Validity Index (S-CVI) S-CVI = .96

  32. Exploratory Factor Analysis • Kaiser-Meyer-Olkin (KMO) measure was .92. • Bartlett’s test of Sphericity was highly significant • (χ2 [190], n=209) =3544.75, p < .0001 • EFA after extraction • A three factor solution explained 69% of the variance. • Item Analysis: • From the R-matrix: inter-item correlation • Item 4 (choose the right food) & item 5 (choose variation in nutrition) redundancy • Item 4 more meaning & understandable • 19 items remained in the T-DMSES

  33. Names & Descriptions of Factors Fator1: Diet & exercise (10 items)

  34. Factor 2: Self-monitoring/regulating(6 items)

  35. Factor 3 : Essential activities for medical treatment(3 items)

  36. Confirmatory Factor Analysis • 19 items were structured into a three factor model • To confirm the hypothesized factor structure of the T-DMSES • CFA • Modifying the model by adding parameter relationship based on the modification indexes (MI)

  37. Confirmatory Factor Analysis

  38. Results: Validity & reliability

  39. Discussion The T-DMSES • EFA suggested a three factor model • diet and exercise, self-monitoring/regulating , and essential activities for medical treatment • Comparisons • The original DMSES with 4 factors (venderBijl, et al., 1999) • The Turkish version of the DMSES with 3 factors (Kara, van derBijl, Shortridge-Baggett, Asti, & Erguney, 2006) • The Chinese version of the DMSES with 4 factors (Wu, 2008)

  40. Discussion: EFA (cont.) • The 3- factor model of the T-DMSES differed from others. • Modified by changing, eliminating, and adding • The T-DMSES has clear three clusters of self-care activities which patients with type 2 diabetes have to perform to prevent short & long term complications.

  41. Discussion: Convergent validity • A significantly positive correlation between the T-DMSES (specific self-efficacy) & the T-GSES (global self-efficacy): Same construct but differ in the scope • The result was similar to the previous studies: • The Australian/English version of the DMSES & GSE scale with r = .52, p < .01(McDowell, et al, 2005) • The Chinese version of the DMSES & the Chinese version of GSE scale with r = .55, p < .01 (Wu, 2008)

  42. Discussion:Concurrent Validity • This result provided the evidence of the positive correlation between T-DMSES (judgment of capability) & T-RSES (judgment of self-worth): different construct but same phenomenon • Evidences from meta-analysis (75 studies) supported the positive correlation between self-efficacy & self-esteem with ρ = .85 (Judge, et al., 2002). • Among diabetes, there was a positive relationship between self-efficacy & self-esteem (Crabtree, 1986; Grossman, Brink, & Hauser, 1987). • Among older adults, there were positive correlations among perceived self-efficacy, self-esteem, and self-care behavior (Homnan, 1996).

  43. Discussion : Test-retest reliability • ICC was at acceptable level for a new instrument (ICC = .69; p< .01, 95% CI: .54-.80). • Possible reasons: • Aging is one of the common sources of bias & error in test-retest situations (Strauss, Sherman, & Spreen, 2006). • Participants had to do retest by themselves or with family, lack of understanding. • Retested by mail • Typical of the experience with older adult populations (Andresen, Bowley, Rotheenberg, Panzer, & Katz, 1996) • One’s sense of self-efficacy is determined by an array of personal, social and environmental factors (Bandura, 1986).

  44. Conclusion • The T-DMSES with 3 subscales has acceptable validity and reliability. • The T-DMSES can be used to identify self-efficacy of Thai older adults with type 2 diabetes.

  45. Limitations • Generalization was limited: • Majority of the participants were educated. • 30 % of Thai older adults have never attended school • Older adults with a short-DM • Most of Thai older adults with type 2 diabetes were diagnosed as a long-DM • Using the same data to conduct the CFA

  46. Implications Nursing Practice • The T-DMSES with 3 subscales can be used to: • Help HCP in assessingpatients’ self-efficacy in the management of their diabetes • Guide interventions to improve knowledge and skills in areas where self-efficacy is low. • Evaluate the effectiveness of interventions targeted at improving self-efficacy among the older adults with type 2 diabetes.

  47. Future research • Closer examination of the individual items & some modifications of the model is likely needed to improve its ‘goodness-of-fit.’ • Larger sample size to conduct factor analysis both EFA & CFA in separate group of data • Using to predict performance of diabetic self-care behaviors • (e.g. diet, exercise, and medication-taking behavior). • Testing the instrument in older adults with long -DM, less education

  48. KhopKhunMakKha (Thank you so much)

  49. Supplemental Information • ICC • Limitations of Pearson’s Product-Moment correlation • Why did I choose the SCT? • Why did I choose type 2 diabetes? • Related concepts • Power Analysis to determine SS • Bilingual participant • General Self-efficacy Scale (GSES) • Rosenberg’s Self-esteem Scale

  50. ICC • Model 1 • One-way random effect model. • The sources of errors cannot be separated & are pooled. • Rater is viewed as measurement error. • Model 2 • Two-way random effect model • Sources of errors can be separated • Rater & subject as random effects • Model 3 • Two-way mixed model • Rater are seem as fixed effect • Subject/targets are a random effect

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