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Validity and Realiability Test of The Indonesian Version for Diabetes Quality of
Life -Brief Clinical Inventory

Article  in  Indian Journal of Public Health Research and Development · January 2021

DOI: 10.37506/ijphrd.v12i1.13885

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434 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1

Validity and Realiability Test of The Indonesian Version for

Diabetes Quality of Life - Brief Clinical Inventory

Sevia Rani Irianti1, Anggi Lukman Wicaksana2, Heny Suseani Pangastuti2

1Student, School of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (UGM).
2
Assistant Professor, Department of Medical Surgical Nursing, Faculty of Medicine, Public Health, and Nursing,
UGM

Abstract
Objective: To test the validity and reliability of the Indonesian version of diabetes quality of life-brief
clinical inventory (DQoL-BCI).

Methods: A cross-cultural adaptation was performed using forward and backward translation. Validity and
reliability tests were conducted at Public Health Center (PHC) in Yogyakarta with 75 adult type 2 diabetes
(T2D) patients. Content validity and construct validity were conducted. The reliability test was assessed by
internal consistency.

Results: The average age was 60years and most respondents were female with high school education and
unemployment. The results showed content validity index (CVI) score were 0.80-1.00 and 0.90 for item
and scale, respectively. The correlation among items indicated moderate association (r = 0.255-0.581). The
EFA resulted in the KMO 0.633, Bartlett test 310.604, p = 0.000, and total variance of explained QoL was
64.22%. Cronbach alpha of the Indonesian version of DQoL-BCI was 0.735, indicated adequate result.

Conclusion: The Indonesian version of DQoL-BCI is a reliable and valid instrument to assess health related
quality of life on T2D patients.

Keyword: DQoL-BCI, diabetes mellitus, validity, reliability, quality of life

Introduction The DQoL-BCI is available in several languages

such as Malaysian2, Iranian3, Polish4 and Greec5, but
Diabetes quality of life (DQoL) is a specific and it is not available in Indonesia. Before the application
common tool to measure quality of life (QoL) among in specific diabetes patients, the instrument should
diabetic patients. Due to the illness progress, the be tested for validity and reliability. A psychometric
instrument was developed in a short, but valid inventory, testing is essential during development or adopting an
known as the DQoL-BCI. The questionnaire was instrument6. Only a valid and reliable tool can guarantee
conceptualized from several diabetes QoL instruments an appropriate and trustable outcomes7. To our best
and made in a shorter version to minimize the filling knowledge, there is no a cross-cultural adaptation study
time. The DQoL-BCI consists of 15 questions and is of DQoL-BCI in Indonesia. Therefore, a methodological
useful for clinical practice and research1. study is required to check the validity and reliability of
the DQoL-BCI in Indonesian version. The purpose of
this study was to identify the validity and reliability
Corresponding author: indicators of the Indonesian version of DQoL-BCI on
Anggi L. Wicaksana, Ismangoen Bd. 2F, Jl. Farmako, diabetic patients.
Sekip Utara, UGM Yogyakarta, Indonesia, 55281.
E-mail: [email protected]
 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 435

Methods dieticians, and nursing faculty, reviewed the Indonesian

and original version. A content analysis recommends
Design and samples
inviting three to ten multidisciplinary experts in a
A quantitative research using cross-sectional design panel11. The procedure of evaluating the content validity
was conducted between August-September 2018. to gain CVI for scale and item was similar with previous
Adult T2D patients were invited to participate using study12,13. The outcome of expert review was then piloted
consecutive sampling technique. The included criteria to 10 T2D patients in one PHC in Yogyakarta to check
were native Indonesian and agreed to join a study. readability and estimated time for accomplishment.
Meanwhile, the T2DP who had mental problems were
The final version of Indonesian DQoL-BCI was
excluded.
administered in two PHC units to test construct validity
The minimum samples for the cross-cultural study and internal consistency. The nurse in charge provided
was at least five participants in each item8. There are 15 a list of T2D patients who participated in diabetes
items in DQoL-BCI and then researchers require a total meeting–known as Prolanis. All T2D patients were
of 75 participants for validity and reliability testing. screening using inclusion/exclusion criteria and eligible
patients received research information. Then, they
Measurement were requested to sign if they agree to join the study.
The DQoL-BCI was developed by Burroughs et Researchers provided a time for participants to self fill-
al.1 to assess the QoL in patients with T1D and T2D. in the questionnaire and directly returned in a closed
The researchers provided an approval for translation envelop after completion.
from the original authors9. The DQoL-BCI consists of
Data Analysis
15 questions. Each item in the DQoL-BCI has a 5-point
Likert’s scale (1=Very Dissatisfied/All the Time, An IBM SPSS for Windows version 15.0 was used
2=Moderately Dissatisfied/Often, 3=Neither/Sometimes, to test validity and reliability. Researchers tested the
4=Moderately Satisfied/Very Seldom, 5=Very Satisfied/ content and construct validity and internal consistency
Never). For sake of analysis, a minimum of two-third for reliability test. Item and scale CVI were identify
(10 out of 15) of total items should be completed1. The adequate when the outcome indicated ≥ 0.80 and ≥
final score of the DQoL-BCI was obtained by calculating 0.90, respectively, for less than 6 experts in expert
the average score of total items. The possible range is judgment11,13. The construct validity used Pearson
between 1 and 5, in which number 1 shows the lowest product moment test and the exploratory factor analysis
QoL of diabetic patients and number 5 shows the highest (EFA). The results of Pearson test were compared
QoL. The higher number of obtained values indicates a with r table to indicate the valid/non-valid items14.
better QoL1,9. The EFA was applied using the principal component
analysis (PCA) with Varimax rotation as following
Procedures for data collection the construct of instrument. The Keiser-Meyer-Olkin
(KMO) and Bartlett test were assessed and only factor
A cross-cultural adaptation process was applied
loading ≥ 0.32 was proceeded12. Internal consistency
using a guideline of Beaton et al.10 which consists of
using Cronbach’s Alpha coefficient was used to indicate
5 stages; forward translation, synthesis, backward
reliable questionnaire. Alpha coefficient ≥ 0.70 indicates
translation, expert review, pilot testing and validity/
acceptable internal consistency11-13.
reliability test. First, the DQoL-BCI was independently
forward translated into Indonesian version by two
Results
bilingual (English-Indonesian) speakers. Secondly, the
researchers synthetized forward translation results. Next, A total of 75 participants in this study and the
two English native speakers who understand Indonesian, characteristics were mostly females (65.3%), with senior
back translated questionnaire into English version. Five high school or above education (53.4%), unemployed
multidisciplinary experts on diabetes, consisting two (61.3%), and the average age was 60 (± 8.46) years.
internal medicine nurses, consultant endocrinologist,
436 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1

The items CVI resulted a range between 0.80-1.00 for the responses.
and the scale CVI was 0.90. The experts suggested
Moreover, the expert advised to provide an
modifying the sequence of questions regarding the type
explanation and examples for several items (1, 2, 4, 5, 6, 7,
of responses. We modified the original question order
13, and 14) of Indonesian DQoL-BCI beside the original
to Indonesian DQoL-BCI (#3→#10, #4→#11, #5→#3,
question to avoid confusedness during completing the
#6→#4, #7→#12, #8→#5, #10→#13, #11→#6,
questionnaire because it was self-reported questionnaire
#12→#14, #13→#15, #14→#7, #15→#8, item no
(Table 1). The pilot testing on 10 respondents indicated
#1, #2, and #9 were in the same order). The first eight
that they all agreed that the instrument was easy to
questions used responses of very satisfied, satisfied and
understand and required an 11 minutes to complete.
soon while the rest items used never, very seldom etc.

Table 1. Further explanation and examples of Indonesian version of DQoL-BCI

No Explanation and examples

Diabetes treatment includes physical activity, diabetes education, medication, smoking cessation, avoiding alcohol,
#1
maintaining a diet and monitoring blood sugar.

To manage diabetes, it is required proper diabetes management. This activities can be carried out in PHC, NCD
#2
community services or the nearest health care facilities.

Exercise shoul acomplish for at least 150 minutes/week with moderate intensity i.e. cycling, jogging, walking, brisk
#4
walking or aerobic.

Diabetes can cause sexual problems. Male diabetes patients could have erectile dysfunction and premature
#5
ejaculation while females have problems on unstable sexual mood, orgasm, and itchying in genital area.

Diabetes treatment can be a family burden. It icludes more time, energy, costs, thoughts and feelings related to
#6
diabetes management.

#7 Diabetes checkups include blood sugar monitoring, regular, foot, eyes examinations and others.

#13 Pain related to diabetes treatment is resulted by insulin injection, collecting blood samples, and diabetic wound care.

#14 Physically ill includes pain, heat, fever, tingling, body discomfort due to treatment and management of diabetes

The r table was determined as 0.227 and the outcome of Pearson test showed r= 0.255-0.581, indicated greater
results if it compared with the r table. The EFA result in the KMO 0.633, Bartlett test 310.604, and p = 0.000. Total
variance of explained QoL was 64.22% (Table 2).
 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1 437

Table 2. Factor loading of Indonesian version of DQoL-BCI

Item #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15

Loading 0.58 0.71 0.68 0.54 0.58 0.72 0.72 0.53 0.67 0.63 0.43 0.74 0.69 0.67 0.72

AIC 0.62 0.79 0.60 0.59 0.75 0.61 0.68 0.72 0.61 0.50 0.53 0.70 0.46 0.70 0.53

Total cumulative variance for extraction sum of squared loadings 64.22%

Total cumulative variance for rotation sum of squared loadings 64.22%

AIC=anti-image correlation

The Cronbach Alpha coeficient for the Indonesian the example for specific terminology (i.e. diabetes pain
DQoL-BCI was 0.735. The correlation for inter-item due to insulin injection, collecting blood samples, and
and item-total were -0.233 to 0.578 and 0.124 to 0.463. diabetic wound care). Then, there was no question
among the 10 respondents in pilot phase. The filling time
Discussion on Indonesian version of DQoL-BCI was quite similar
This study highlights the validity and reliability with the Malaysian2 and Iranian version3, in which they
outcomes of the Indonesian version of DQoL-BCI. required 10-15 minutes to complete the questionnaire. It
Our study finding indicated the acceptable outcome of is relatively short time in filling a full questionnaire and
psychometric testing for Indonesian version of DQoL- makes the DQoL-BCI applicable in clinical settings as
BCI among Indonesian T2D patients. The findings of well as research purpose1,9.
CVI for Indonesian version of DQoL-BCI were similar
The EFA results of the Indonesian version of
with Iranian3 and Greek version5. In Iranian version,
DQoL-BCI showed acceptable outcomes with explained
the review of six experts resulted item CVI value ​​in
variance of 64.22%. It is unsurprisingly because the
the range of 0.78-0.94, scale CVI of 0.84, and content
previous methodological studies in Iranian3 and Greek5
validity ratio (CVR) of 1.0083. On the other hands, the
diabetes patients indicate the similar trend. The Iranian
Greek version of DQoL-BCI indicated that item CVI
version of DQoL-BCI showed higher KMO value
scores were between 0.73 and 1.00, scale CVI was 0.87
(0.712) and resulted the three factors. This version of
and CVR was 1.007 after five diabetes expert review5.
DQoL-BCI also confirmed that there were three construct
The pilot testing on 10 diabetic patients showed a factors in DQoL-BCI; (a) diabetes complication, (b)
full agreement that the Indonesian version of DQoL-BCI therapy, follow up, and diagnosis, and (c) psychosocial
is understandable and required an average of 11 minutes effect of diabetes, and indicated adequacy results of the
for filling all items. The full agreement was achieve three constructed factors3. The three construct factors
because the DQoL-BCI was added by addendum and were also found in the Greek version of DQoL-BCI with
438 Indian Journal of Public Health Research & Development, Jan-March 2021, Vol. 12, No. 1

the total explained variance was 82.7%. This version of Diabetes Quality of Life Brief Clinical Inventory.
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Conflict of Interest: None instrument development in health care research.
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