Diabetes Treatment Satisfaction Questionnaire – An Arabic adaptation for Qatar

Diabetes Treatment Satisfaction Questionnaire – An Arabic adaptation for Qatar

diabetes research and clinical practice 99 (2013) e24–e26 Contents available at Sciverse ScienceDirect Diabetes Research and Clinical Practice jou r...

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diabetes research and clinical practice 99 (2013) e24–e26

Contents available at Sciverse ScienceDirect

Diabetes Research and Clinical Practice jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es

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Diabetes Treatment Satisfaction Questionnaire – An Arabic adaptation for Qatar§ Kerry Wilbur * College of Pharmacy, Qatar University, PO Box 2713, Doha, Qatar

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Article history:

The Diabetes Treatment Satisfaction Questionnaire is recommended by the World Health

Received 17 July 2012

Organization and the International Diabetes Federation for assessing diabetes care. We

Accepted 12 November 2012

conducted a systematic linguistic adaptation of the three existing Arabic versions to arrive

Published on line 11 December 2012

at a questionnaire suitable for administration of Arabic-speaking patients with diabetes in Qatar. # 2012 Elsevier Ireland Ltd. All rights reserved.

Keywords: Diabetes treatment satisfaction Linguistic adaptation Questionnaire Arabic



An individual’s perception of their health is one of the most significant qualitative health indicators studied today [1]. A number of tools exist to assess diabetes-specific measures of patient health-related quality of life [2]. The Diabetes Treatment Satisfaction Questionnaires (DTSQ standard and DTSQ change) are two such instruments, each consisting of eight items assessing treatment satisfaction, scored on a scale of 0–6, with six representing the greatest satisfaction and the DTSQs is recommended by the World Health Organization (WHO) and the International Diabetes Federation (IDF) for assessing outcomes of diabetes care [3,4]. While the DTSQ instruments have been translated into more than 40 languages, it is imperative that such questionnaires undergo a process to ensure cultural relevance. A well-translated survey instrument should have semantic §

equivalence across languages, conceptual equivalence across cultures and normative equivalence to the source survey [5]. This study’s aim is to conduct a systematic linguistic adaptation of the existing Arabic translations of the DTSQs and DTSQc for administration of Arabic-speaking patients with diabetes in Qatar.



Three existing Arabic versions of the DTSQs and DTSQc (Kingdom of Saudi Arabia (KSA), United Arab Emirates (UAE), Egypt) were obtained under an agreement with the copyright holder. These were reviewed by two native Qatar Arabic speakers and a sociologist expertise in designing Arabic questionnaires for administration in Qatar to arrive at one proposed version suitable for domestic use (draft version 1). This intermediate linguistic adaptation was then reviewed for

This publication was made possible by a grant from the Qatar University Internal Student Research Program. Results have been presented at the European Society of Clinical Pharmacy 40th Symposium on Clinical Pharmacy in Dublin, Ireland, October 2011. * Tel.: +974 4403 5581; fax: +974 4403 5551. E-mail addresses: [email protected], [email protected] 0168-8227/$ – see front matter # 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2012.11.007

diabetes research and clinical practice 99 (2013) e24–e26


any further modification by two physician clinicians practicing at the Qatar Diabetes Association (draft version 2). Following each draft review, a formal report was submitted to the copyright holder for documentation and quality assurance purposes. Cognitive debriefing interviews were then conducted following these reviews (using draft version 2) to test the applicability, comprehension, and relevance of the revised scales with diabetes patients [6,7]. Respondents complete the questionnaire in the presence of the interviewer and are then asked to comment on the questionnaire instructions, items, and response format. Respondents are asked to explain what was asked in each question and described when they misunderstood the original concept of a question, had difficulty in understanding a question, and when a question was vague or poorly worded. Researchers summarized and organized these results for review. After exchange of feedback, the Qatar DTSQs and DTSQc version 3 was completed and submitted to the copyright holder for final proof reading. In addition, basic demographic and diabetesrelated details were obtained for each respondent, as well as their actual scores for each DTSQs and DTSQc item. The study was approved by the Qatar University Research Ethics Board.

cognitive debriefing interview (Table 1). When the instruments were administered, the questions posing most difficulty pertained to the word felt as in item, ‘‘How often have you felt that your blood sugars have been unacceptably high recently?’’. Respondents were unsure if they were meant to respond according to perceived symptoms (the intended concept) or whether they had too many documented high glucose values. When such misinterpretation arose, alternate item versions from the existing Arabic translations were offered in attempts to arrive at greater respondent comprehension. For this item, Egypt and KSA versions did not improve understanding, and so after further reconciliation, the final translation became akin to ‘‘sensed physically’’. Unlike those using insulin, the term flexibility as in ‘‘how flexible have you been finding your treatment to be recently’’ was often misunderstood by T2DM respondents as how easily they are able to adapt their daily life around their treatment and not the opposite, intended concept (how easily can the treatment be adapted to fit the person’s daily life). The phrasing of this item from KSA questionnaires was more clear and preferred by the respondents. Modifications to the linguistic adaptation (draft #2) arising from the cognitive interviews generated a third draft submitted and approved by the copyright holder as the final version of DTSQs and DTSQc for Qatar.




No singular existing Arabic DTSQ instrument was completely suitable for direct administration in Qatar. Draft version 1 combined questions items adopted from the other versions as follows: DTSQs: items 5 and 8 from KSA; items 1–4 and 6 from UAE; and item 7 from Egypt. DTSQc: items 5 and 6 from KSA; items 1–4 from UAE; and items 7 and 8 from Egypt. Title, introductions and instructions were all taken from the UAE Arabic translations. The diabetes clinicians did not offer any further recommendations to revise draft version 1 (draft versions 1 and 2 were identical). A convenient sample of 13 diabetes patients attending appointments at the Qatar Diabetes Association consented to

Table 1 – DTSQs and DTSQc cognitive debriefing interview respondent demographics. Characteristic

N = 13 (%)

Age (mean and range), in years Gender (female) Type 2 diabetes Time since diabetes diagnosis (mean and range), in years Duration of current treatment (mean and range), in years Type 1 diabetes using insulin Type 2 diabetes using insulin Type 2 diabetes using monotherapy (oral metformin) Type 2 diabetes using metformin and sulfonylurea Type 2 diabetes treated with diet and exercise alone

41.7 (21–66) 9 (69.2) 9 (69.2) 10 (1–22) 6 (0.2–22) 4 (30.8) 1 (7.7) 5 (38.5) 2 (15.4)


An Arabic adaptation of DTSQs and DTSQc for use in Qatar was completed adopting some items from all existing Arabic translations, but primarily the UAE. It is not surprising that four distinct versions for unique administration in these Arabic speaking-countries would be necessary; although UAE, Qatar and parts of KSA historically share a Khaliji dialect (associated with the Arabian Gulf), distinct idioms and cultural nuances abound [8]. Indeed, the linguistic adaptation process for the original UK English versions undertaken in at least 10 English-speaking countries has also yielded important observed differences, in both grammar and lexicon, influenced not only by the evolution of language in these countries but by local diabetes treatment as well [9]. Such systematic translation and adaptation processes underscore the importance of careful review to ensure all resulting language versions are conceptually equivalent to the original while being relevant and culturally acceptable to the target population [10,11]. This harmonization across countries also facilitates international comparisons and pooling of data [12,13]. Just as translated questionnaires cannot be immediately employed in another setting without linguistic adaptation, the translated version is also not automatically considered validated regardless of such status of the source instrument. The next step is to conduct psychometric testing to assess the reliability and validity of the Arabic linguistic adaptation of DTSQs and DTSQc instruments in Qatar.

Conflict of interest

1 (7.7)

The author declares that there is no conflict of interest.


diabetes research and clinical practice 99 (2013) e24–e26

Acknowledgments The author wishes to acknowledge: DTSQs and DTSQc reviewers and cognitive interviewers Noor Al Salimy and Sahar Nasser; sociologist reviewer Dr. Wessam Al-Otham, QU Social Sciences faculty; clinician reviewers Dr. Amal Adam and Ms. Ayah Matter, Qatar Diabetes Association; and members of the linguistic adaptation/validation team at Health Psychology Research Ltd., Rosalind Plowright, Alison Wilson, and Dr. Clare Bradley.



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