diabetes research and clinical practice 94 (2011) 45–52

Contents lists available at ScienceDirect

Diabetes Research
and Clinical Practice
journ al h ome pa ge : www .elsevier.co m/lo cate/diabres

Adaptation of the Audit of Diabetes-Dependent Quality

of Life questionnaire to people with diabetes in China

Danli Kong a,b,1, Yuanlin Ding b,1, Xiaoyu Zuo c, Weiyang Su c, Liangchang Xiu b,
Meihua Lin b, Shaoqi Rao b,c,*, Shouyi Yu a
a
Department of Epidemiology, School of Public Health and Tropical Medicine, Southern Medical University, Guangzhou 510515, China
b
Department of Medical Statistics and Epidemiology, School of Public Health, Guangdong Medical College, Dongguan 523808, China
c
Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou 510080, China

article info abstract

Article history: Aim: This study was intended to cross-culturally adapt and evaluate the Chinese version of
Received 18 February 2011 the Audit of Diabetes Dependent Quality of Life (ADDQoL) – the Chinese Normal Audit of
Received in revised form Diabetes-Dependent Quality of Life (CN-ADDQoL) in Mainland, China.
15 May 2011 Methods: The standard procedure for cross-culture adaptation was used to develop the
Accepted 16 May 2011 Chinese version CN-ADDQoL. After the linguistic validation, the validity and reliability of
Published on line 17 June 2011 CN-ADDQoL questionnaire were evaluated based on a sample of 697 Type 2 diabetes
patients. The Cronbach’s a coefficient, correlation analysis and the structural equation
Keywords: model (SEM) were applied, respectively.
Type 2 diabetes Results: We developed 19 items for the CN-ADDQoL questionnaire. The estimated Cron-
Quality of life bach’s a coefficient was 0.941, indicating an excellent internal consistency of the scale. All
Cross-cultural adaptation items had high performance in the structural validity evaluation, with most factor loading
Validity values being larger than 0.40 (varied from 0.44 to 0.88).
Reliability Conclusions: The Chinese version CN-ADDQoL has maintained its original psychometric
properties and achieved adequate reliability and validity. Therefore, it could be efficiently
used to evaluate the current trend of diabetes self-management education programs and
multinational clinical research trials.
# 2011 Elsevier Ireland Ltd. All rights reserved.

In the past decades several projects have been conducted to

1. Introduction
Diabetes is a chronic metabolic disturbed disease with a great
impact on the health status and quality of life of human
beings. Once viewed as a disease that only had influence on
people in Western countries, diabetes is becoming the hub of
global health concern. The number of people with diabetes is
increasing because of population growth, aging, urbanization,
and increasing prevalence of obesity and physical inactivity.
quantify the prevalence of diabetes and the number of people
affected by diabetes [1–5]. One study showed that between 1995
and 2025, there would be a 35% increase in the prevalence of
diabetes worldwide, from 4.0% to 5.4% [2]. Another study
showed that the world prevalence of diabetes among adults
(aged 20–79) would be 6.4%, affecting 285 million adults, in 2010,
and would increase to 7.7%, affecting 439 million adults by 2030
[5]. Diabetes is considered as an urgent public health issue for its
potential of being pandemic [3].

* Corresponding author at: Department of Medical Statistics and Epidemiology, School of Public Health, Guangdong Medical College,
#1 New City Avenue, Songshan Lake Science and Technology Industry Park, Dongguan 523808, China. Tel.: +86 20 87332513;
fax: +86 20 87332513.
E-mail address: paulsrrao@yahoo.com.cn (S. Rao).
1
The first two authors joined the first authors in this work.
0168-8227/$ – see front matter # 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.diabres.2011.05.026
46 diabetes research and clinical practice 94 (2011) 45–52
The major part of the increase in numbers of adults with
diabetes occurs in developing countries [4,5]. The largest
developing country, China, has experienced a rapid economic
growth during the past three decades. Simultaneously,
Chinese people have rapidly changed their lifestyles. This
resulted in the increased prevalence of diabetes, from 1% in
early 1980s to 5.5% in the late 1990s [6,7]. For the large-size
population, the number of adults with diabetes in China, even
with a low or moderate prevalence, could be enormous. It is
estimated that by 2010 China will become the second largest
country with diabetes patients in the world, approximately
43.2 million [5]. Hence, diabetes has become a major health
burden in China [8].
Diabetes is a complex disease associated with both
physical and psychological impact on patients [9]. Clinical
treatments including insulin regimen and oral antidiabetic
drug, may concern more on patients’ physically health
outcome or serological index (such as acetylated hemoglobin
(HbA1C) values or blood glucose) and somewhat ignore
patients’ perception on the disease. Considering the chronic
and complex nature of diabetes, quality of life (QoL) is widely
recommended as the assessment of diabetes burden instead
of biological measures. Measuring QoL, more specially, health-
related quality of life (HRQoL), is essential for its capability of
providing informed, rational, and patient-oriented advices
during the generic diabetes treatment [10].
Until recently, there are various instruments that assess
the quality of life of diabetes, including generic and diabetes-
specified scales [11], for example, Short-Form 36 (SF36) [12],
Diabetes Quality of Life measure (DQoL) [13], Audit of Diabetes-
Dependent Quality of Life (ADDQoL) [14], Diabetes-39 (D-39)
[12], and Diabetes-Specific Quality of Life Scale (DSQoLS) [15].
In addition, several instruments are developed for special
purposes in diabetes care and treatment. For example,
Confidence in Diabetes Self-Care scale [16], and Insulin
Delivery System Rating Questionnaire [17]. However, diabe-
tes-specific QoL instruments in China are still limited.
Currently, two Chinese versions of diabetes-specific QoL
instruments are recognized and frequently used. One is called
Diabetic Quality of Life (DQoL) scale, designed originally in
Chinese [18], but fails to cover the items related to sex life.
Diabetes can interfere with sexual function in numerous ways
[19]. Sex life is a very important part of perceived quality of life
for diabetes patients. The other is Adjusted Diabetes Quality of
Life (A-DQoL) measure, used in our previous study [20]. The A-
DQoL measure, which is based on DQoL measure, has
unperfected performance on internal consistency in some
dimensions and unacceptable subscale reliability [21]. Fur-
thermore, the Diabetes Quality of Life measure (DQoL) is not
totally diabetes-specific [22] and originally designed for Type 1
diabetes [21].
The Audit of Diabetes-Dependent Quality of Life question-
naire (ADDQoL) was designed originally in 1994 and updated in
the next years. So far, it has been widely applied in many
countries, viewed as a special and useful scale of diabetes-
specific QoL [11,21]. Very recently, this scale has been applied
to Chinese-speaking Singaporeans with Type 2 diabetes
mellitus [23]. The ADDQoL scale is an individualized instru-
ment aiming at measuring the individual’s feelings on the
impact of diabetes [10,13,14,24]. It is somewhat special for its
evaluation of different aspects of patients’ life without
diabetes and is a complex but rational scoring method [21].
Reported studies showed that the ADDQoL scale had satisfac-
tory validity and reliability, with the Cronbach’s a coefficient
of 0.85–0.94 and an excellent performance in factor analysis
(all items loading >0.50 on one factor), respectively
[13,14,21,23]. The utility of ADDQoL instrument is gradually
recognized in many fields, such as diabetes treatment,
intervention and evaluation, especially in the current trend
of diabetes self-management education (DSME) programs and
multinational clinical research trials [25]. It is recommended
as an individualized measure of the diabetes-specific QoL by
many diabetes research institutes.
The primary objective of our study was to develop the
Chinese version of the Audit of Diabetes-Dependent Quality of
Life (ADDQoL) instrument – the Chinese Normal Audit of
Diabetes-Dependent Quality of Life (CN-ADDQoL) question-
naire, and to validate its application to Type 2 diabetes
patients in China.
2. Materials and methods
2.1. Subjects and data collection
Patients participated in this study were recruited from the
outpatient centers or inpatient departments of the affiliated
hospitals of Guangdong Medical College, by the convenience
sampling method. Under the approval of the Ethics Committee
of Guangdong Medical College, all patients who met our
inclusion criteria were asked to participate in this study. The
inclusion criteria were as follows: (1) age  20; (2) Chinese
native; (3) a Mandarin Chinese speaker or a Cantonese speaker
who could fully understand Mandarin Chinese; (4) with
physician-diagnosed Type 2 diabetes. Patients who were
physically evaluated as Type 1 diabetes, secondary diabetes,
or gestational diabetes were excluded. Finally, the patients
whose previous medical records were not complete were also
excluded.
All patients were diagnosed in the light of the diagnostic
criteria recommended by WHO in 1999 [26]. Patients partici-
pated in this study met one of the following conditions: (1)
having symptoms of diabetes (e.g. polyuria, polydipsia,
unexplained weight loss), fasting blood glucose 126 mg/dL
(7.0 mmol/L) after a minimum of an 8-h fast or 2 h post-
glucose load 200 mg/dL (11.1 mmol/L), or both; (2) without
the above symptoms, only fasting blood glucose 126 mg/dL
(7.0 mmol/L) or 2 h post-glucose load 200 mg/dL (11.1 mmol/
L), repeating the test on another day and getting the same
result; (3) without the above symptoms, only fasting blood
glucose 126 mg/dL (7.0 mmol/L) or 2 h post-glucose load
200 mg/dL (11.1 mmol/L), but glucose level 200 mg/dL
(11.1 mmol/L) 2 h after glucose challenge (GTT) with the
standardized 75-g oral load of glucose.
After informed consent was obtained, all participants
were interviewed face to face by the interns or physicians
who were specially trained before the formal start of this
investigation. During the interviews, the interviewers recorded
and completed the questionnaire based on the participants’
self-report on their own perception to these questions. When a
 diabetes research and clinical practice 94 (2011) 45–52
participant provided an ambiguous answer or not sure of his
perception, this person or his close family members, like his
spouse and offspring, was helped to understand the question(s)
using more easily understood language or examples. All the
physical assessments, including evaluation of diabetes-related
complications, diabetes diagnosis and classification, and
physiological measurements (e.g. height and body weight)
were performed by the well-trained interns or physicians.
A total number of 732 subjects were recruited during
August 2005 and January 2006, of which 45 patients were
excluded due to missing information on some important
features, or suffering from other diseases such as hyperthy-
roidism prior to diabetes onset, or with uncertain information
about the time sequence of diabetes. Hence, a sample of 697
diabetes patients was actually used in the following data
analysis.
2.2. Instrument
The latest version of ADDQoL assessed perceived impact of
diabetes on 19 life domains, which was simplified in various
ways in the light of development of the MacDQoL and
RetDQoL for people with macular disease and diabetic
retinopathy, respectively [13,14,24]. Physical functioning,
symptoms, psychological well-being, social well-being, role
activities and personal constructs were contained. It was an
individualized QoL instrument that allows respondents to
evaluate only those life domains concerned with them-
selves, and to assess both the impact of diabetes on those
domains and the relative importance of those domains to
their QoL.
The first two overview items of the ADDQoL questionnaire
were about the present QoL and the diabetes-dependent QoL.
One measured the general QoL and the other measures
diabetes-specific QoL. The next items ask respondents to rate
how the particular aspects of their life would be if they did not
have diabetes. For each of these items, respondents could
provide both impact ( 3 to +1) and importance (0–3) scores.
The impact rating and importance rating were multiplied to
compute the weighted impact scores, which ranged from 9
(maximum negative impact of diabetes) to +3 (maximum
positive impact of diabetes). ‘‘Unimportant’’ domains scored 0,
regardless of the magnitude of its impact. Similarly, domains
with no diabetes impact scored 0, regardless of their
importance to QoL. Then, by dividing the sum of weighted
ratings for applicable domains by the number of the applicable
domains, we obtained the average weighted rating score,
which reflected the weighted impact of diabetes on QoL. More
negative scores indicated worse QoL and more negative
impact of diabetes on QoL.
2.3. Cultural adaptation of ADDQoL
One of most intrinsic difficulties in introducing the ADDQoL
questionnaire was the consideration of the specific cultural
background and equivalence between the translated version
and the original one. Therefore, in the process of introduction,
we followed the internationally fundamental guidelines
[15,27,28] and the widely accepted translation procedures
recommended by MAPI Research Institute [29].
47
We first got author’s authorization, and set up a group
consisted of diabetes experts, epidemiologists, psychologists,
and statisticians. In the forward translation step, two
professional members, who were native speakers of Chinese
and fluent in English, independently carried out the transla-
tions from English to Chinese. After comparing the differences
between the two manuscripts, we got the first translated draft.
Then backward translation of the draft to the original
language was performed by two professional translators,
respectively. After comparing the original version and the
backward translated version of the questionnaire, we con-
cluded the discrepancies and the associated reasons between
the two versions. After several rounds of forward and
backward translation, a linguistically comparative and satis-
factory version was developed. In the following step, the latest
version was reviewed and evaluated by some psychologists
and clinicians for the psychological and clinical equivalence to
the original one, respectively. Feedbacks were received for
further psychological and clinical revision and adaptation,
yielding a more adapted and suitable version for clinical
application. At the next stage, we evaluated its cognitive
nature of the revised questionnaire using five diabetes
volunteers in a clinic, aiming to evaluate the simplicity and
comprehension in clinical application. After this revision, a
final version of Chinese Normal Audit of Diabetes-Dependent
Quality of Life (CN-ADDQoL) was produced, a 5-classes LIKERT
measurement scale including 19 items with 5 operations for
each item, as shown in Table 1.
2.4. Evaluation of necessity of assigning weights to
impact ratings
Because of the goal for providing an individualized measure-
ment of diabetes-specific QoL, the ADDQoL permitted each
respondent to assess the life domains he (or she) concerned
about, by rating both the impact of diabetes on these domains
and the importance of these domains to his (or her) QoL. Both
ratings were used to calculate the weighted scores. The
concept of weighting was one of the main characteristics of
CN-ADDQoL that was distinct from other diabetes-specific
QoL instruments. To illustrate the importance and necessity
for assigning weights to impact ratings, we counted the
number of ‘‘unimportant’’ responses (score 0) and compared
the change in items ranking with and without weighting. In
addition, we also calculated the frequency of applying the ‘‘not
applicable’’ (NA) options to show the individualized property
of the ADDQoL.
2.5. Factor structure and reliability of CN-ADDQoL
The factor structure of CN-ADDQoL was studied using a two-
steps approach. First, data were subjected to an unforced
factor analysis. Second, data were subjected to a factor
analysis with forced one-factor solution, in order to provide
a single summary score. The first two overview items were not
included in the factor analysis. It was anticipated that all 19
items could load together with high factor loadings on a single
factor in this type of factor analysis. The reliability of CN-
ADDQoL could be demonstrated if the one-factor solution was
supported, and then Cronbach’s a coefficient was computed to
48 diabetes research and clinical practice 94 (2011) 45–52

Table 1 – Structure of the Chinese Normal Audit of loadings to get the correlation coefficients (denoted by ls)
Diabetes-Dependent Quality of Life (CN-ADDQoL) in- between the weighted scores (observed variables) and the
strument. factors (latent variables), which were actually the regression
A. 2 overview items coefficient of the weighted scores and the factors. The range of
Present quality of life ls was from 0 to 1, and the closer to 1, the better it was [30].
In general, my present quality of life is:
excellent/very good/good/neither good nor bad/bad/very
bad/extremely bad
2.7. Statistical analysis
Score rangea: 3 to +3
Quality of life without diabetes For descriptive statistics, means, standard deviation (SD),
If I did not have diabetes, my quality of life would be: absolute and relative frequencies were calculated. Cron-
very much better/much better/a little better/the same/worse bach’s a coefficient was used to assess the reliability of CN-
Score rangea: 3 to +1
ADDQoL. SEM and correlation analysis were applied to
B. Diabetes-specific questions
evaluate the validity of the instrument. P-values of less than
Impact of diabetes on a particular life domain
If I did not have diabetes, my (life domain) would be: 0.05 were considered to indicate statistical significance. All
very much greater/much greater/a little greater/the same/less statistical analyses were performed with SAS 8.1 and LISREL
Score rangea: 3 to +1 8.70.
My (life domain) is:
very important/important/somewhat important/not at all
important
3. Results
Score rangeb: +3 to 0
C. Life domains in ADDQoL
Leisure activities (LEI) 3.1. Characteristics of respondents
Working lifec (WORK)
Local or long-distance journeys (JOR) Among the 697 patients (respondents), approximately half
Holidaysc (HOL) were male gender (359 cases, 51.51%). The age of patients
Physical health (PHY) ranged from 20 to 87, with a mean of 58.85 years (SD 11.38). 309
Family lifec (FAM)
patients (44.33%) had some diabetes-associated complica-
Friendship and social life (FREN)
Closest personal relationshipc (PER)
tions. More details about the respondents’ characteristics are
Sex lifec (SEX) shown in Table 2.
Physical appearance (APP)
Self-confidence (CONF) 3.2. Distribution of responses
Motivation (MOV)
People’s reaction (RXN)
The distributions of responses and the weights assigned to
Feelings about the future (FUT)
impact rating are shown in Table 3. Diabetes had the greatest
Financial situation (FIN)
Living conditions (LIV) impact on ‘Working life’ (mean impact rating 1.71, SD
Dependence on others (DEP) (standard deviation) 0.77) and the least impact on ‘People’s
Freedom to eat (EAT) reaction’ (mean 1.00, SD 0.94). ‘Family life’ (mean importance
Freedom to drink (DRK) rating 2.25, SD 0.62) and ‘Local or long distance journeys’
a
Less negative scores indicate better QOL.
b
Higher scores indicate greater importance.
c
These items include a preliminary ‘‘Yes/No’’ question
to determine if the item is applicable. Table 2 – Characteristics of respondents.
Characteristics n %
further evaluate the internal consistency of the one-factor Sex
scale. Male 359 51.51
Female 338 48.49
2.6. Validity of CN-ADDQoL Marital status
Single 5 0.72
Married 582 83.50
To evaluate the construct validity of CN-ADDQoL, we
Widowed 88 12.63
computed the correlation coefficients of average weighted Divorced and others 22 3.15
impact (AWI) scores with the general QoL scores and diabetes- Education
specific QoL scores, respectively. Moreover, we examined the Illiterate 113 16.21
relationships between the CN-ADDQoL and other variables, Primary school 185 26.54
such as gender, education, marital status and diabetes- Junior high school 151 21.66
Senior high school 156 22.38
associated complications.
College 92 13.20
Considering that the scale contained many variables that Complications
we were not able to measure precisely and directly (i.e. latent Yes 309 44.33
variables), we used a structure equation model (SEM) to assess No 388 55.67
the structure validity of the scale. After standardizing the Mean (SD) Range
weighted scores of the life domains, we acquired some factor Age 58.85 (11.38) 20–87
BMI (kg/m2) 22.38 (3.11) 13.11–35.38
loadings fitted by SEM. Then, we back-transformed the factor
 diabetes research and clinical practice 94 (2011) 45–52 49

Table 3 – Distribution of response (n = 697) and necessity of assigning weights to impact rating.
Domain NA response (% of response) Impact rating Importance Weighted
rating impact score

Mean SD Mean SD Mean SD

Leisure activities 1.07 0.81 1.51 0.87 1.90 1.94
Working life 54.38 1.71 0.77 2.10 0.63 1.74 2.42
Journeys 1.33 0.90 1.33 0.91 2.14 2.14
Holidays 43.19 1.62 0.84 1.66 0.83 1.71 2.34
Physical health 1.25 0.82 1.47 0.79 2.08 1.93
Family life 0.57 1.46 0.92 2.25 0.62 3.39 2.58
Friendship and social life 1.21 0.96 1.88 0.65 2.45 2.31
Personal relationship 1.58 1.23 0.99 2.10 0.58 2.68 2.56
Sex life 45.45a 1.65 0.90 1.67 0.83 1.62 2.41
Physical appearance 1.48 0.80 1.70 0.73 2.74 2.20
Self-confidence 1.58 0.78 1.97 0.71 3.37 2.37
Motivation 1.53 0.78 1.92 0.69 3.21 2.26
People’s reaction 1.00 0.94 1.61 0.76 1.92 2.22
Feelings about future 1.50 0.78 1.88 0.65 3.04 2.18
Financial situation 1.59 0.77 2.12 0.68 3.57 2.25
Living conditions 1.51 0.76 2.01 0.56 3.19 2.08
Dependence on others 1.17 0.87 1.66 0.82 2.27 2.06
Freedom to eat 1.52 0.74 1.77 0.74 2.88 2.14
Freedom to drink 1.31 0.82 1.46 0.82 2.03 1.90
a
161 patients answered the question.

(mean 1.33, SD 0.91) were rated as the most and the least
important items to them, respectively. After weighted, the
‘Financial situation’ domain (mean weighted scores 3.57, SD
2.25) and the ‘Sex life’ domain (mean 1.62, SD 2.41) became
the most and least impacted QoL domains, respectively.
On some domains, respondents assigned zero value to
the importance rating, which indicated that certain life
domains assessed by the CN-ADDQoL were not of sufficient
importance to them. As a result, the impact of diabetes on
QoL might be over-estimated. On the other hand, some
respondents chose the importance rating 3 (very important).
If the impact of diabetes was not weighted by the
importance score, the impact would be under-estimated.
Comparing the ranks in Table 4, we found that the change in
importance ranking exceeded three levels for eight items
(‘Working life’, ‘Holiday’, ‘Family life’, ‘Friendship and social
life’, ‘Personal relationship’, ‘Sex life’, ‘People’s reaction’,
‘Dependence on others’), of which the importance of three
items (‘Working life’, ‘Holiday’ and ‘Sex life’) were reduced
and the remaining five items (‘Family life’, ‘Friendship and
social life’, ‘Personal relationship’, ‘People’s reaction’, and
‘Dependence on others’) were increased. The frequency of
using NA options ranged from 0.57 (family life) to 54.38
(working life).

Table 4 – Differences in ranks between unweighted and weighted means.

Domain Ranks of unweighted Ranks of weighted 0 value to importance
means means (% of respondent)
Leisure activities 18 16 16.07
Working life 1 17 1.89
Journeys 12 12 24.35
Holidays 3 18 9.62
Physical health 14 13 14.14
Family life 11 2 0.72
Friendship and social life 16 10 3.91
Personal relationship 15 9 1.02
Sex life 2 19 9.64
Physical appearance 10 8 6.18
Self-confidence 5 3 2.74
Motivation 6 4 3.45
People’s reaction 19 15 9.21
Feelings about future 9 6 3.03
Financial situation 4 1 2.02
Living conditions 8 5 0.86
Dependence on others 17 11 12.50
Freedom to eat 7 7 4.17
Freedom to drink 13 14 12.57
50 diabetes research and clinical practice 94 (2011) 45–52

Table 5 – Unforced factor analysis with varimax method Table 6 – Results of structural validity analysis using
for the CN-ADDQoL weighted scores. structural equation model (SEM).
Component Domain l SE ls

1 2 3 4 Leisure activities 0.49 0.04 0.76

Working life 0.51 0.04 0.74
Leisure activities 0.494
Journeys 0.70 0.04 0.51
Working life 0.638
Holidays 0.60 0.04 0.63
Journeys 0.741
Physical health 0.44 0.04 0.81
Holidays 0.675
Family life 0.72 0.04 0.49
Physical health 0.483 0.402
Friendship and social life 0.83 0.03 0.32
Family life 0.766
Personal relationship 0.74 0.04 0.45
Friendship and social life 0.750
Physical appearance 0.72 0.03 0.49
Personal relationship 0.768
Self-confidence 0.78 0.03 0.40
Physical appearance 0.614
Motivation 0.79 0.03 0.38
Self-confidence 0.835
People’s reaction 0.49 0.04 0.76
Motivation 0.831
Feelings about future 0.68 0.04 0.54
People’s reaction 0.526
Financial situation 0.66 0.04 0.57
Feelings about future 0.569
Living conditions 0.49 0.04 0.76
Financial situation 0.457
Dependence on others 0.81 0.04 0.34
Living conditions 0.443 0.457
Freedom to eat 0.88 0.04 0.22
Dependence on others 0.426 0.420 0.452
Freedom to drink 0.70 0.04 0.51
Freedom to eat 0.775
x2/df 4.39
Freedom to drink 0.747
RMSEA 0.071
NNFI 0.95
CFI 0.96
3.3. Factor structure and reliability of the CN-ADDQoL
instrument
feelings, and domesticity and diet, respectively. The structural
Unforced factor analysis, with varimax method, of the CN- equation model was used to evaluate the model fitting.
ADDQoL weighted scores generated four factors with eigen- The results of the model fitting analyzed with LISREL 8.70
values >1, shown in Table 5. A four-factors solution explained are shown in Table 6. It is generally accepted that the model
57.80% of variance. The items ‘Physical health’, ‘Family life’, fitting is good if the index of the fitted model, x2/df, is lower
‘Friendship and social life’, ‘Personal relationship’ and than 5.0, Root Mean Square Error of Approximation (RMSEA)
‘People’s reaction’ were loaded on factor 1. The items ‘Physical lower than 0.08, and both Non-Normed Fit Index (NNFI) and
appearance’, ‘Self-confidence’, ‘Motivation’ and ‘Feeling about Comparative Fit Index (CFI) larger than 0.9. Based on these
future’ were loaded on factor 2. Other 9 items were loaded on criteria and the additional evidence that the factor loadings for
either factor 3 (‘Leisure activities’, ‘Working life’, ‘Local or long the 18 items were all statistically significant (P < 0.05) and
distance journeys’ and ‘Holidays’) or factor 4 (‘Financial most of factor loadings were larger than 0.4, the CN-ADDQoL
situation’, ‘Living conditions’, ‘Dependent on others’, ‘Free- instrument achieved adequate construct validity.
dom to eat’ and ‘Freedom to drink’). All factor loadings were AWI scores of the CN-ADDQoL significantly correlated with
more than 0.40. ‘Sex life’ was not brought into the factor the scores of the CN-ADDQoL diabetes-specific QoL global
analysis for too many missing values. question (rs = 0.274, P < 0.001), but did not correlate with the
In the forced one-factor solution for 18 items (excluding present QoL global question (rs = 0.013, P = 0.783). Positive
two overview items and the item ‘Sex life’), 17 items had correlation between age and AWI scores were observed
factor loadings of >0.40 and only the item ‘Freedom to drink’ (rs = 0.245, P < 0.001). Statistically, there was no difference in
was loaded with a value of 0.32 into this factor. The forced AWI scores between patients with and without any complica-
one-factor solution explained 34.59% of the total variance. tions (P = 0.396) as well as between the males and the females
The item ‘Sex life’ was excluded for the same reason as (P = 0.876). The statistically significant differences in AWI
mentioned above. This study demonstrated that the internal scores were found between patients of age 50 and <50
consistency of the scale, with Cronbach’s a of 0.941, out- (P < 0.001).
performed the original version (the reported values was 0.85 It is our surprise to find that patients with a higher
[14]). Overall, the reliability of the newly developed scale was education level reported greater negative impact of diabetes
adequate. on QoL than those patients with elementary or secondary
education did, which was inconsistent with the previous
3.4. Validity of the CN-ADDQoL instrument reports (e.g. [31]). Considering the significant influence of age
on AWI score (P < 0.001) and the potentially different age
To assess the structure validity of the CN-ADDQoL instrument, structure across different education levels, we performed a
we first configured the model structure on the basis of the stratified analysis by age (dividing into two subgroups, age 50
above exploratory factor analysis and the related professional and <50, respectively). In age < 50 group, the AWI scores for
knowledge. Then, according to the correlations between each the illiterate patients and the patients with junior high school
potential factor (latent variable) and its corresponding items education were significantly lower than the values for the
(observed variables), we aggregated the 18 items of the scale patients with college education (P = 0.002, mean difference
into 4 factors, activity and leisure, motions, psychological were 1.38 and 1.20, respectively), while no statistical
 diabetes research and clinical practice 94 (2011) 45–52
significance was observed in age  50 group (P = 0.712). The per
item test showed that higher educated patients in both age
groups reported greater negative impact in ‘‘Leisure activi-
ties’’, ‘‘Working life’’, ‘‘Journeys’’, ‘‘Holidays’’. Higher educated
patients with age < 50 reported greater negative impact on
appearance, confidence, motivation, feeling about future and
social life, while the patients of age  50 reported greater
negative impact on ‘‘Dependence on others’’ and ‘‘Financial
situation’’.
4. Discussion
The ADDQoL is a widely used diabetes-specific scale in the
world. We were the first group to introduce and develop the
specific Chinese version of ADDQoL (CN-ADDQoL) in the
Mainland China. We had performed evaluations on the
validity and reliability of the CN-ADDQoL questionnaire based
on a large sample in China. Factor analysis, Cronbach’s a
index, and structural equation model all showed satisfactory
results in multiple aspects of the CN-ADDQoL scale, implying
that the scale was well translated and culturally adapted for
Chinese people and could be widely used in China or some
Asian countries alike. On every domain, the impact of diabetes
on QoL was nearly all rated with negative scores except for
very few patients reporting positive impact, which agreed with
an earlier study in UK [13]. On the other hand, the impact of
diabetes on QoL cannot simply be assumed to be negative,
some items showed positive effects of diabetes on QoL.
The greatest negative unweighted impact was found in the
domain ‘Working life’ in our study, which was not consistent
with other studies, like the Singaporean report [23]. One
possible answer to this circumstance could be associated with
the current Chinese social security system. China has the
largest population in the world but only with limited social
security resource. Working is the main source of reliable and
steady source of income in China, and with utmost impor-
tance for daily life quality. Some patients had to retire from
their posts several years before the normal age of retirement
because of the diabetes mellitus. Therefore, greatest negative
on ‘Working life’ could be reasonably interpreted. When
importance rating was considered, the most affected domain
was ‘Financial situation’. As diabetes is a chronic disease,
patients had to take the medication regularly and most of
them paid their own expenses, which was a very heavy burden
for most patients.
The ADDQoL is an individualized instrument, which
permits respondents to assess the impact of diabetes on
the domains they concerned about and value the importance
of these domains to their QoL. If the impact rating was not
weighted by the importance rating, the impact of diabetes on
QoL might be over- or under-estimated. Comparing the raw
impact score and the weighted impact score, we found that
the importance of ‘Working life’, ‘Holiday’ and ‘Sex life’ was
reduced, but the positions of ‘Family life’, ‘Friendship and
social life’, ‘Personal relationship’, ‘People’s reaction’, and
‘Dependence on others’ were enhanced. This is logical
because China is a country with long history and fine
traditions that highly value the strong family ties and social
relationships. Overall, our results indicated that the CN-
51
ADDQoL was culturally appropriate for Chinese patients with
diabetes.
As shown in the Results, the CN-ADDQoL had good
psychometric properties for Chinese patients with diabetes.
The assumption of one-factor scale structure was supported
and internal consistency was high (Cronbach’s a = 0.941).
Exploratory factor analysis revealed that a four factor solution
(based on eigenvalues > 1) explained 57.80% of total variance
within 18 items, which was comparable to a three factor
solution explaining 60.63% of total variance in Slovakian
version [25] and a two factor solution explaining 57.80% of total
variance in Singaporean-English version [32], respectively. In
addition, all factor loadings were exceeding 0.40 in the
unforced factor solution, indicating that all the items had a
satisfactory correlation with their corresponding factors. In
the next confirmatory factor analysis, we divided the items of
the scale into 4 factors and obtained nearly the same output as
before. Hence, the construct validity was also proved.
To our knowledge, there are three Chinese versions of
ADDQoL derived from the original developers, Singapore
version, Taiwan version and Mainland China version, respec-
tively. Since the version for Taiwan district is not yet
published, only Singaporean version is compared here [23].
In our report, the Cronbach’s a coefficient is 0.941, which is the
same as the value for the Singaporeans. The one-factor
solution could explain 34.59% and 46% of total variance in our
report and the Singaporean report, respectively, and both
reported majority of factor loadings exceeding 0.4. In conclu-
sion, these two versions of Chinese ADDQoL achieved
comparable validity and reliability, despite the culture or
some other aspects are different in the two countries.
Despite the satisfactory results that the newly developed
ADDQoL for Mainland China achieved, we have to recognize
several limitations in our study. First, the respondents were
recruited from hospitals, in which patients might have
different demographic characteristics from the general diabe-
tes population. Second, Chinese people are usually not so
frank to talk about their sex life or other private items in clinic,
because of their culture conservation, which resulted in the
low response rate in the sex domain. Whether there was a
respondence bias remains unknown. One practical approach
to solving the problem is to introduce some easy understand-
ing but somewhat flexible questions suitable to Chinese
people, especially in rural areas.
In summary, we demonstrated that the Chinese version of
the ADDQoL (CN-ADDQoL) maintained the original psycho-
metric properties and had satisfactory reliability and validity.
CN-ADDQoL had the individualized properties and provided a
more accurate estimate of the impact of diabetes on QoL than
the unweighted scores. The items in the sex domain in the
questionnaire have to be modified to adapt the Chinese
conservative culture regarding the sex life.
Acknowledgements
We appreciate all the volunteers who participated in this
study. This work was supported by the National Natural
Science Foundation of China (Grant Nos. 30830104 and
31071166), Natural Science Foundation of Guangdong
52 diabetes research and clinical practice 94 (2011) 45–52
Province, China (Grant No. 8251008901000007), Science and
Technology Planning Project of Guangdong Province (Grant
No. 2009A030301004), the Scientific Research Foundation for
the Returned Overseas Chinese Scholars, State Education
Ministry of China (to S.-Q.R.), State Key Laboratory of Oncology
in South China (to S.-Q.R.), SYSU Labs Open-Ended Fund
(to S.-Q.R.) and the Guangdong Medical College Start-up Fund
(Grant No. XG1001, to S.-Q.R.).
Conflict of interest
There are no conflicts of interest.
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