Abstract
BACKGROUND:
During the last two decades, several reports have indicated an increase in the number of type-2 diabetes among adolescents. Therefore, an assessment of adolescents' awareness of this disease deserves serious consideration. This study aims at designing a psychometric tool for assessing adolescents' awareness of type-2 diabetes.
METHODS AND MATERIAL:
In this methodological research, 770 students attending 10 middle schools (five girls “schools and five boys” schools) from Tehran participated in the study. The questionnaire was designed by examining the relevant literature and the existing questionnaires, as well as considering the research team's comments, and the initial pool of items with 57 questions was designed. Face validity, content validity, and construct validity were calculated to determine the validity of the instrument. Reliability was measured via internal consistency coefficient (ICC) and internal consistency reliability was measured with Cronbach Alpha. SPSS 16 was used for data analysis.
RESULTS:
The questionnaire was initially designed with 57 items. Based on the results of CVR and CVI, five questions were removed. The average CVR and CVI were 0.75 and 0.82, respectively. Following exploratory factor analysis, the 30 questions in the questionnaire were categorized into five dimensions: public awareness, symptoms, behavioral risk factors, long-term effects, and medium-term effects. The internal reliability was calculated for the whole questionnaire—ICC = 0.87 with a Cronbach alpha coefficient of 0.80.
CONCLUSIONS:
The resulting questionnaire on adolescents' awareness of type-2 diabetes, with 30 questions in five dimensions, can be employed by researchers for its high factor loading in factor analysis and its standard psychometric properties.
Keywords: Adolescents, awareness, designing, diabetes mellitus, evaluation, psychometrics
Introduction
Type-2 diabetes is a chronic disease similar to a pandemic and constitutes 90% of all cases of diabetes.[1] According to a report by the World Health Organization (WHO), about 422 million people in the world suffer from diabetes mellitus (DM), with Eastern Mediterranean countries accounting for the highest prevalence (43 million people). DM is among the 10 highest lethal diseases worldwide and caused 1.6 million deaths in 2016.[2] In addition, this serious disease is witnessed as a new clinical condition among children. There has been a surge in the number of type-2 diabetics among children.[3] Evidence is accumulating that young-onset type-2 diabetes has a more aggressive disease phenotype, leading to premature development of complications, with adverse effects on quality of life and unfavorable effects on long-term outcomes, raising the possibility of a future public health catastrophe.[4] Experts expect more cases of this malady to appear among children in the coming decades.[5] The age of type-2 diabetes diagnosis is reported to be between 12 and 14 years, which co-occurs with the age of puberty.[6] The prevalence of type-2 diabetes was almost 1% among Iranian youth in 2011.[7] This disease can cause several complications in different parts of the body.[8] Nearly 5 million diabetics in the 20 to 79 years age range died in 2015. This appalling figure equals one death per 6 s. In 2016, type-2 diabetes was the seventh major cause of death in the world. In Iran, 10.8% of all mortalities (3,7075 cases) were associated with diabetes.[8] Sufferers not only incur enormous expenses but they have to deal with other dire consequences such as pain, anxiety, headache, discomfort, disability, stress, depression, infection, amputation, and digestive disorders.[9] Type-2 diabetes can be caused by a multitude of factors such as sociocultural, geographical, and environmental ones.[10] What WHO has adopted as a strategic measure to combat and curb diabetes is education.[11] Education or awareness raising seems essential[12] to the point that it can transform people's attitudes and lifestyles.[13]
Raising awareness among adolescents of non-infectious diseases and their risk factors is an integral part of preventive strategies. One such strategy is the evaluation, as well as the dissemination of information, regarding reversible risk factors.[14] Adolescents comprise a large portion of the population of countries, especially our country, and play a vital role in the dynamism and continuity of the social life of a nation and its comprehensive development.[15] Assessing adolescents' awareness of type-2 diabetes requires a valid instrument.[16] Most of the existing instruments measure diabetics' quality of life (DQOL),[17] diabetes self-care,[18] diabetes knowledge,[19] diabetics' awareness, attitude, and behavior,[20] and other instruments in the field of type-2 diabetes prevention are not designed to be comprehensive and most of them only deal with factors such as nutrition and physical activity and do not include all the risk factors of type-2 diabetes.[21]
Therefore, this study aimed at designing a comprehensive instrument with acceptable reliability and validity.
Materials and Methods
Study design and setting
This research is a methodological investigation performed in Tehran.
Inclusion and exclusion criteria
The entry criteria for research were junior high school students, students' willingness to participate, and not suffering from type-1 or type-2 diabetes. Also, the exclusion criteria from the study were reluctance to participate in the study at any stage.
Study participants and sampling
In this research, 770 male and female adolescents (between 13 and 15) participated. Initially, Tehran was divided into five sections. From each section, one area was selected. Then, a girl's school and a boy's school were randomly selected from each area—totally 10 schools. Finally, following the participation criteria, students were randomly selected from each grade to meet the study's criteria.
Data collection tool and technique: The design of the instrument took place in four stages:
Systematic review of the literature and the relevant instruments
Designing the items of the instrument employing the existing documents, papers, and questionnaires in Iran and other countries
Reliability of the instrument
Validity of the instrument.
Stage 1. In this stage, the relevant questionnaires and the review of literature were carefully studied.
Stage 2. Relevant questions were extracted from various instruments and some questions were designed by virtue of papers and documents. Then, after negotiation with research team members, the final items were added to the pool of questions. The first draft of the questionnaire with 57 questions was designed.
Stage 3. Face validity, content validity, and construct validity were used to determine the validity of the instrument.
Determination of content validity
Both quantitative and qualitative methods were employed to determine content validity. In quantitative analysis of content validity, content validity ratio (CVR), as well as content validity index (CVI), was calculated. To determine the content validity ratio, 11 experts (7 health education experts and 4 endocrinologists) were purposefully selected and asked to evaluate each question with respect to content as essential, beneficial, or non-essential.
Then, the responses were calculated based on this formula:
Finally, the resulting CVR amounts higher than 59% were accepted based on Lawshe Table.
To calculate the content validity index, those 11 experts examined each question based on the three criteria of relevance, clarity, and simplicity. CVI is the sum of the number of answers 3 and 4 by the total number of answers:
The resulting amounts higher than 79% were accepted. In the qualitative analysis, the experts were asked to express their opinions on each item.
Determination of face validity
Face validity was determined both qualitatively and quantitatively. In the qualitative phase, 20 students of 13 to 15 years of age (10 male and 10 female) were interviewed face-to-face. Their views on the questions were regarded. Finally, the necessary modifications were made by the research team. In the next stage, the quantitative method was used to remove the inappropriate questions and determine the significance of each question. The same 20 students were asked to examine the questions based on a 5-point Likert scale scoring and select one. Then, the impact score of each question was calculated.
Scores higher than 1.5% were considered acceptable.[22] No question was removed at this stage.
Determination of construct validity
Based on at least 10 samples for each question designed for the questionnaire,[23] 770 students were selected to meet the requirements for determining construct validity. To determine this validity, exploratory factor analysis with varimax rotation was employed. To perform exploratory factor analysis, two tests of sampling adequacy Kaiser-Mayer-Olkin (KMO) and Bartlett's test of sphericity were utilized. The amount of 0.8 was determined to be adequate.[23]
Stage 4. To determine the reliability of the instrument, test-retest and internal consistency were utilized.
Determination of reliability
Cronbach's alpha was calculated to determine the internal consistency and Cronbach's alpha of between 70% and 80% was set.[24] Test-retest was employed to investigate the stability of the instrument over time: a 15-day gap between the two tests. A correlation coefficient of higher than 70% was considered adequate for the questions. The questionnaire was completed by 40 adolescents (20 female and 20 male). After 15 days, the same students filled out the questionnaire [Figure 1].
Figure 1.
Flowchart of the design and psychometric stages of the questionnaire
Data analysis
CVR/CVI and impact scores were calculated to determine content validity and face validity, respectively. Construct validity was calculated through exploratory factor analysis (EFA) with varimax rotation.
Cronbach's alpha coefficient was calculated to determine the internal consistency. To check the stability of the instrument, the internal correlation coefficient (ICC) was used. SPSS16 was consulted for data analysis.
Ethical consideration
The researchers observed all the ethical codes including informed consent, confidentiality, plagiarism, double publication, data manipulation, and fake data generation. The ethical research code for this study is IR.SBMU.PHNS.REC.1398.146 from Shahid Beheshti Medical Sciences University.
Results
Participants
In this study, 770 people participated. The participants' descriptive characteristics are listed in Table 1.
Table 1.
Demographic information of the Participants
| Variables | Group Sub | Number | Percent |
|---|---|---|---|
| Age | 13 | 267 | 35 |
| 14 | 247 | 32 | |
| 15 | 256 | 33 | |
| Gender | Girl | 453 | 59 |
| Boy | 317 | 41 | |
| Grade education | Seventh | 270 | 36 |
| Eighth | 242 | 31 | |
| Ninth | 258 | 33 | |
| Fathers’ occupation | Employee | 223 | 29 |
| Self-employed | 407 | 54 | |
| Unemployed | 48 | 6 | |
| Retired | 92 | 11 | |
| Mothers’ occupation | Employed | 247 | 32 |
| House keeping | 523 | 68 | |
| Fathers’ education | Illiterate | 25 | 3 |
| Primary | 58 | 7 | |
| Intermediate | 155 | 20 | |
| Secondary | 296 | 39 | |
| Institutes/College | 236 | 31 | |
| Mothers’ education | Illiterate | 17 | 2 |
| Primary | 72 | 9 | |
| Intermediate | 116 | 15 | |
| Secondary | 324 | 43 | |
| Institutes/College | 241 | 31 | |
| Economic situation | Poor | 67 | 8 |
| Middle | 268 | 35 | |
| Good | 304 | 39 | |
| Excellent | 131 | 17 |
Question design
Having explored various instruments and studied relevant papers and documents, the research team came up with an initial list of 77 items. Then, similar sentences (12 items) and irrelevant ones (8 items) were removed and the first draft of the questionnaire with 57 questions was designed.
Content validity
In the qualitative phase of content validity, much attention was paid to experts' suggestions.
CVI and CVR were used to quantitatively measure the content validity. Five items were removed and 52 questions remained. The average CVR and CVI were 0.75 and 0.82, respectively, for the whole questionnaire.
Qualitative face validity
In the qualitative phase of face validity, based on participants' feedback, some questions were modified to minimize ambiguity.
Quantitative face validity
In the quantitative phase, the student's responses were analyzed. Since the impact scores of all the questions were higher than 1.5, no question was removed at this stage. Next, the questionnaire with 52 items was analyzed for construct validity.
Structural validity
KMO index and Bartlett's test of sphericity showed the adequacy of the data for performing factor analysis. The KMO test result demonstrated the adequacy of the data (KMO = 0/91), and so did Bartlett's test (P </001).
According to Table 2, five factors with particular amounts higher than one were extracted.
Table 2.
Rotated component matrix, eigenvalue, and cumulative variance contribution rate
| Special amount of extraction agents by rotation (Rotation Sums of Loadings) | |||
|---|---|---|---|
|
| |||
| Fact | Eigenvalues% | Variance% | Cumulative% |
| General knowledge | 3.78 | 12.62 | 12.62 |
| Symptoms of disease | 2.49 | 8.30 | 29.99 |
| Behavioral risk factors | 2.11 | 7.03 | 37.02 |
| Long-term consequences | 2.71 | 9.06 | 21.68 |
| Medium-term consequences | 2.05 | 6.85 | 43.88 |
Based on the results, five factors were extracted from factor analysis with varimax rotation [Table 3]. Twenty-two expressions/questions that had a loading lower than 0.4 were removed from the questionnaire. The number of questions was reduced to 30 items.
Table 3.
Factor load of knowledge questionnaire items based on factor analysis with varimax rotation
| Questions | Component | ||||
|---|---|---|---|---|---|
|
| |||||
| 1 | 2 | 3 | 4 | 5 | |
| A decline in cholesterol level can prevent type-2 diabetes. | 0.721 | ||||
| Adequate sleep (between 7 and 8 hours) can prevent type-2 diabetes. | 0.655 | ||||
| Controlling blood pressure (ideally 120/80 mm Hg) can play a role in preventing type-2 diabetes. | 0.638 | ||||
| Combatting stress and depression can curb type-2 diabetes. | 0.621 | ||||
| Regular physical activity can prevent type-2 diabetes. | 0.612 | ||||
| Vitamins D and K can reduce type-2 diabetes risks. | 0.586 | ||||
| Maintaining a healthy weight can minimize the risk of type-2 diabetes. | 0.568 | ||||
| Controlling blood sugar (less than 100 mg/dL) can reduce type-2 diabetes risks. | 0.512 | ||||
| A healthy diet (less sugar, salt, and fat; more fruit and vegetables) can prevent type-2 diabetes. | 0.491 | ||||
| Type-2 diabetes is one major cause of death. | 0.641 | ||||
| Diabetic foot ulcers and amputations are some of the complications of type-2 diabetes. | 0.636 | ||||
| Type-2 diabetes can increase household expenses. | 0.622 | ||||
| Type-2 diabetes reduces the quality of life. | 0.609 | ||||
| Type-2 diabetes can cause blurred vision or blindness. | 0.566 | ||||
| Extreme hunger is one of the symptoms of type-2 diabetes. | 0.579 | ||||
| Constant feeling of exhaustion can be one of the symptoms of type-2 diabetes. | 0.573 | ||||
| Frequent urination is one of the symptoms of type-2 diabetes. | 0.558 | ||||
| Excessive and persistent thirst (polydipsia) is one of the symptoms of type-2 diabetes. | 0.531 | ||||
| Chronic skin wounds can be one of the symptoms of type-2 diabetes. | 0.483 | ||||
| Blurred vision is one symptom of type-2 diabetes. | 0.467 | ||||
| Tingling fingers and toes can be a symptom of type-2 diabetes. | 0.458 | ||||
| Vitamin and nutrient deficiency (D, K) is one cause of type-2 diabetes. | 0.623 | ||||
| High TV viewing (more than 3 h a day) can contribute to type-2 diabetes. | 0.603 | ||||
| Smoking can increase type-2 diabetes risk. | 0.545 | ||||
| Sleep deprivation (less than 7 h) or insomnia can result in type-2 diabetes. | 0.541 | ||||
| Type-2 diabetes can lead to strokes. | 0.636 | ||||
| Nonalcoholic fatty liver disease (NAFLD) is one of the complications of type-2 diabetes. | 0.537 | ||||
| Type-2 diabetes can contribute to depression. | 0.526 | ||||
| Type-2 diabetes can increase the risk of cardiovascular diseases. | 0.523 | ||||
| Type-2 diabetes can lead to hypertension. | . | 0.429 | |||
Reliability
Internal instrument compatibility was 82% and the stability of the instrument was 87% [Table 4].
Table 4.
The ICC and the Cronbach’s α coefficient of each factor and the whole questionnaire
| Factor | Number of Items | Cronbach’s alpha coefficient | Intra-class Correlation Coefficient ICC (n=40) |
|---|---|---|---|
| General knowledge | 9 | 0.78 | 0.86 |
| Symptoms of disease | 7 | 0.70 | 0.74 |
| Behavioral risk factors | 4 | 0.73 | 0.93 |
| Long-term consequences | 5 | 0.70 | 0.70 |
| Medium-term consequences | 5 | 0.70 | 0.70 |
| Total | 30 | 0.80 | 0.87 |
Final tool
The designed questionnaire included 30 questions in five dimensions. The scoring procedure was as follows: “correct answers” 2 points, “wrong answers” zero, and “I don't know” 1 point. The maximum obtainable score was 58 and the lowest score was zero.
Discussion
This study aims at designing a psychometric tool for assessing adolescents' awareness of type-2 diabetes. This study gave rise to a questionnaire with 30 items and five factors were extracted: public awareness, symptoms, behavioral risk factors, medium-term effects, and long-term effects. The findings of this study provide clear evidence concerning the validity and reliability of the psychometric tool or the questionnaire. In any measure, a researcher is interested in representing the characteristics of the subject accurately and consistently. The desirable characteristics of a measure are reliability and validity. Both are important for the conclusions about the credibility of good research.[25] To check the validity of the questionnaire, content validity, face validity, and construct validity were used in this project. Content validity is defined as the degree to which elements of an assessment instrument are relevant to a representative of the targeted construct for a particular assessment purpose.[26] Evaluation of the content of the questionnaire by experts constitutes a great way to gather evidence in support of the validity of a measurement tool.[27] Eleven eminent professors conducted the process of content validation of the present questionnaire. They were asked to give their verdict on the questions. According to Lawshe Table, the amounts higher than 0.59 and 0.79 for CVR and CVI, respectively, were accepted.
Face validity was determined through qualitative and quantitative methods. In fact, face validity is an evaluation of the layman's perception of an instrument, and demonstrates that the designed instrument measures exactly what it has been designed to measure.[28] In the quantitative analysis, since the impact scores of all the questions were above 1.5, all the questions were considered appropriate for further analysis. Considering the feedback from the research population, this result indicates that the resulting questionnaire has been simple to understand and respond to. It also highlights the fact that the expressions used have been relevant and significant.
In the qualitative analysis of the face validity, students' comments on some items resulted in slight modifications of some of the questions.
Exploratory factor analysis was conducted to determine construct validity. Factor analysis is a multivariate statistical method to determine whether there are recognizable dimensions to describe and categorize a multitude of the variable. The primary aim of exploratory factor analysis is to reduce the number of dimensions so as to describe and use them with ease.[29] In this study, KMO and Bartlett's tests were used to determine the construct validity through exploratory factor analysis. KMO amount fluctuates between zero and one. If the amount is lower than 0.5, the data are not acceptable for factor analysis. If it is between 0.5 and 0.69, factor analysis is performed with caution. If the amount is above 0.7, the correlations between and among the data are strong enough for factor analysis. To ensure that the resulting correlation matrix is significantly different from zero in this study, Bartlett's test of sphericity was employed to justify the use of factor analysis.[30] In this project, the index was found to be 0.91 for all the constructs and the significant level was set to be 0.001 in Bartlett's test of sphericity, which confirms the adequacy of sampling and factor analysis.
By obtaining these five factors through exploratory factor analysis, the validity of the construct was verified to measure adolescents' awareness of type-2 diabetes.
Adolescents' awareness of this disease can contribute to its timely diagnosis and reduce its irreversible complications. This goal can be attained by education and training in the early stages of life. In addition, adolescents' awareness of type-2 diabetes can significantly reduce the risk of this disease in adulthood.[13] Symptoms and behavioral risk factors were other variables extracted by exploratory factor analysis. Most of these risk factors are reversible; therefore, the identification of these contributing factors plays a crucial role in preventing or at least postponing type-2 diabetes among adolescents. The other extracted factors in this study are the complications of the disease and its latent, long-term effects. It seems that type-2 diabetes among children and adolescents is more invasive than latent type-2 diabetes. The development of glucose intolerance or impaired glucose fasting (IGF) to type-2 diabetes is not necessarily linear over time and is faster among children or adolescents compared to adults.[31] Diabetes management is quite complicated among children as it involves managing diseases concomitant with diabetes and obesity.[32] It is estimated that adolescents suffering from type-2 diabetes will live 15 years less than their peers without diabetes.[33]
In this study, Cronbach's Alpha Coefficient was used to measure internal consistency reliability. This is the most common method of determining the internal consistency coefficient employed in research studies[34] and representing the degree of consistency among a group of items measuring a construct. The alpha value should be at least 0.7 or beyond so that a question can be retained in an instrument.[35]
In addition, test-retest—the most valid measure of intraclass correlation coefficient—was used to determine the consistency of the instrument. In the present study, the result obtained from the reliability of the instrument showed that the Cronbach's alpha coefficient stood at 0.80, and the consistency coefficient of 0.87 for each factor represents the internal consistency of the awareness questionnaire concerning type-2 diabetes among adolescents. According to the results, the stability, replicability, and reliability of this instrument were seen to be acceptable. Considering the prevalence of type-2 diabetes and its myriad complications among adolescents, it is imperative to adopt preventive measures to stop the growth of this disease among adolescents.
Limitations and recommendation
In addition to being reliable, valid, and replicable, one of the strong points of the instrument is the fact that it completely covers all the behavioral risk factors contributing to type-2 diabetes. One limitation of the study is self-report in data gathering.
Conclusion
In this study, an instrument was designed to measure adolescents' awareness of type-2 diabetes in Tehran. Data analysis approved the content validity, face validity, construct validity, internal consistency, and stability of the instrument. This instrument is an objective, simple yet comprehensive tool to assess adolescents' awareness of type-2 diabetes, which can be used in future research projects.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
This research was extracted from PhD thesis of Health Education & Health Promotionin from Shahid Beheshti University of Medical Sciences. Ethical research code for this study is IR.SBMU.PHNS.REC.1398.146. In addition, the authors would like to thank all junior high school students who were involved and participated in this study.
References
- 1.Lin X, Xu Y, Pan X, Xu J, Ding Y, Sun X, et al. Global, regional, and national burden and trend of diabetes in 195 countries and territories: An analysis from 1990 to 2025. Sci Rep. 2020;10:1. doi: 10.1038/s41598-020-71908-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Barati S, Sadeghipour P, Ghaemmaghami Z, Mohebbi B, Baay M, Alemzadeh-Ansari MJ, et al. Warning signals of elevated prediabetes prevalence in the modern Iranian urban population. Prim Care Diabetes. 2021;15:472–9. doi: 10.1016/j.pcd.2021.04.002. [DOI] [PubMed] [Google Scholar]
- 3.Reinehr T. Type 2 diabetes mellitus in children and adolescents. World J. Diabetes. 2013;4:270. doi: 10.4239/wjd.v4.i6.270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Al-Saeed AH, Constantino MI, Molyneaux L, D'Souza M, Limacher-Gisler F, Luo C, et al. An inverse relationship between age of type 2 diabetes onset and complication risk and mortality: The impact of youth-onset type 2 diabetes. Diabetes Care. 2016;39:823–9. doi: 10.2337/dc15-0991. [DOI] [PubMed] [Google Scholar]
- 5.Lascar N, Brown J, Pattison H, Barnett AH, Bailey CJ, Bellary S. Type 2 diabetes in adolescents and young adults. Lancet Diabetes Endocrinol. 2018;6:69–80. doi: 10.1016/S2213-8587(17)30186-9. [DOI] [PubMed] [Google Scholar]
- 6.Australian Institute of Health and Welfare. Type 2 diabetes in Australia's children and young people – Australian Type 2 diabetes in Australia's children and young people – Australian. [Last accessed on 2017]. Available from: https://www.aihw.gov.au/getmedia/bc5d50e5-8ca0-474d-be77-f96234d9a532/15203.pdf.aspx?inline=true.pdf .
- 7.Diabetes organization. Overall Numbers, Diabetes and Prediabetes. [Last accessed on 2019 Jun 04]. Available from: http://www.diabetes.org/diabetes-basics/statistics .
- 8.International Diabetes Federation (IDF) Middle East and North African news. [Last accessed on 2019 Jun 04]. Available from: https://www.idf.org/our-network/regions-members/middle-east-and-north-africa/middle-east-and-northafrica-news.html .
- 9.Tokuyama Y, Ishizuka T, Matsui K, Egashira T, Kanatsuka A. Predictors of glycemic control in Japanese subjects with type 2 diabetes mellitus. Metabolism. 2008;57:453–7. doi: 10.1016/j.metabol.2007.11.004. [DOI] [PubMed] [Google Scholar]
- 10.Centers for Disease Control and Prevention (CDC) Who's at Risk? [Last accessed on 2017 Jul 25]. Available from: https://www.cdc.gov/diabetes/basics/risk-factors.html .
- 11.World Health Organization (WHO) Diabetes. [Last accessed on 2019 Jun 04]. Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes .
- 12.SlideShares. C14 idf diabetes in childhood and adolescence guidelines. 2011. [Last accessed on 2017 27]. Available from: https://www.slideshare.net/Diabetesforall/c14-idf-diabetes-in .
- 13.Speller V. Health knowledge. Organization. Principles and practice of health promotion: Health promotion models and theories. [Last accessed on 2016 Mar 29]. Available from: http://www.healthknowledge.org .
- 14.Gupta RK, Kumari R, Hussain S, Raina SK, Langer B, Parveen Z. A cross-sectional study to evaluate awareness about noncommunicable diseases among rural adolescents in North West India. J Dent Allied Sci. 2018;7:60. [Google Scholar]
- 15.Zabihi A, Amiri SR, Hosseini SR, Padehban V. The association of high-risk behaviors and their relationship with identity styles in adolescents. J Educ Health Promot. 2019;8:152. doi: 10.4103/jehp.jehp_375_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Attarha M, Keshavarz Z, Bakhtiari M, Jamilian M, Zayeri F. Psychometric properties of midwife- mother relationship scale in delivery Room (M.M.R.S) J Urmia Nurs Midwifery Fac. 2016;14:170–82. [Google Scholar]
- 17.Tol A, Sharifirad G, Eslami A, Shojaeizadeh D, Alhani F, Tehrani MM. Analysis of some predictive factors of quality of life among type 2 diabetic patients. J Educ Health Promot. 2015;4:9. doi: 10.4103/2277-9531.151903. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Schmitt A, Gahr A, Hermanns N, Kulzer B, Huber J, Haak T. The Diabetes Self-Management Questionnaire (DSMQ): Development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control. Health Qual Life Outcomes. 2013;11:1–4. doi: 10.1186/1477-7525-11-138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Yirsaw K. Thesis. Addis Ababa Ethiopia: Addis Ababa University School of Medicine; 2016. Knowledge Attitude and Practice of Blood Glucose Monitoring among Diabetic's Patients Attending at Tikur Anbesa Specialized Teaching and Referral Hospital. [Google Scholar]
- 20.Fatema K, Hossain S, Natasha K, Chowdhury HA, Akter J, Khan T, et al. Knowledge attitude and practice regarding diabetes mellitus among Nondiabetic and diabetic study participants in Bangladesh. BMC Public Health. 2017;17:364. doi: 10.1186/s12889-017-4285-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Peyman N, Alipour M. The effect of training diabetes prevention behaviors on promotion of knowledge, attitude and practice of students for prevention of diabetes in Mashhad City. Int J Pediatr. 2015;3:501–7. [Google Scholar]
- 22.Roglic G. WHO Global report on diabetes: A summary. Int J Non-Commun Dis. 2016;1:3. [Google Scholar]
- 23.Ghanbari S, Ramezankhani A, Mehrabi Y, Montazeri A. The health literacy measure for adolescents (HELMA): Development and psychometric evaluation. Payesh (Health Monitor) 2016;15:404–10. doi: 10.1371/journal.pone.0149202. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ezzati M, Riboli E. Behavioral and dietary risk factors for noncommunicable diseases. N Engl J Med. 2013;369:954–64. doi: 10.1056/NEJMra1203528. [DOI] [PubMed] [Google Scholar]
- 25.Mohajan H. Two criteria for good measurements in research: Validity and reliability. Ann. Spiru Haret. Univ. 2017;17:58–82. [Google Scholar]
- 26.Koller I, Levenson MR, Glück J. What do you think you are measuring? A mixed-methods procedure for assessing the content validity of test items and theory-based scaling. Front. Psychol. 2017;8:126. doi: 10.3389/fpsyg.2017.00126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Bernell S, Howard SW. Use your words carefully: What is a chronic disease? Public Health Front. 2016;4:159. doi: 10.3389/fpubh.2016.00159. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Fitzner K. Reliability and validity: A quick review. Diabetes Educ. 2007;33:775–80. doi: 10.1177/0145721707308172. [DOI] [PubMed] [Google Scholar]
- 29.Bolenius K, Brulin C, Grankvist K, Lindkvist M, Soderberg J. A content validated questionnaire for assessment of self-reported venous blood sampling practices. BMC Res Notes. 2012;5:39. doi: 10.1186/1756-0500-5-39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Vakili MM, Hidarnia AR, Niknami S. Development and psychometrics of an interpersonal communication skills scale (ASMA) among Zanjan health volunteers. J Hayat. 2012;18:5–19. [Google Scholar]
- 31.D'Adamo E, Caprio S. Type 2 diabetes in youth: Epidemiology and pathophysiology. Diabetes Care. 2011;34:S161–5. doi: 10.2337/dc11-s212. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Sabin MA, Ford AL, Holly JM, Hunt LP, Crowne EC, Shield JP. Characterisation of morbidity in a UK, hospital based, obesity clinic. Arch Dis Child. 2006;91:126–30. doi: 10.1136/adc.2005.083485. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Rhodes ET, Prosser LA, Hoerger TJ, Lieu T, Ludwig DS, Laffel LM. Estimated morbidity and mortality in adolescents and young adults diagnosed with type 2 diabetes mellitus. Diabet Med. 2012;29:453–63. doi: 10.1111/j.1464-5491.2011.03542.x. [DOI] [PubMed] [Google Scholar]
- 34.Hassanzadeh J, Mohammadbeigi A, Eshrati B, Rezaianzadeh A, Rajaeefard A. Determinants of inequity in health care services utilization in Markazi Province of Iran. Iran Red Crescent Med J. 2013;15:363. doi: 10.5812/ircmj.3525. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.DeVellis RF. Scale Development: Theory and Applications. Sage Publications. 2011 [Google Scholar]