Diabetes Self-Management Questionnaire User information & scoring guide

Diabetes Self-Management Questionnaire (DSMQ)

- User information and scoring guide -

Copyright:
Dr. Andreas Schmitt, PhD, Clin Psych, Research Institute of the Diabetes Academy
Mergentheim, Diabetes Center Mergentheim, Theodor-Klotzbuecher-Str. 12, 97980 Bad
Mergentheim, Germany, email: [email protected]

Related publications:
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;11:138. https://doi.org/10.1186/1477-7525-11-138
Schmitt A, Gahr A, Hermanns N, Kulzer B, Haak T. [The Diabetes Self-Management
Questionnaire (DSMQ): Psychometric Analysis of a new questionnaire on the quality of
diabetes self-care] [abstract in German]. Diabetol Stoffwechsel 2013;8(Suppl.1):S13.
https://doi.org/10.1055/s-0033-1341698
Schall S, Schmitt A, Hermanns N, Queri S, Kulzer B, Haak T. [Consistency of self-reported
diabetes self-managment with clinical/medical outcome measures] [abstract in German].
Diabetol Stoffwechsel 2014;9(Suppl 1):S48-S49. https://doi.org/10.1055/s-0034-1375026
Schmitt A, Hermanns N, Kulzer B, Reimer A, Schall S, Haak T. The Diabetes Self-Management
Questionnaire (DSMQ) can detect inadequate self-care behaviour and help identify
patients at risk of a negative diabetes prognosis. [abstract] Diabetologia 2014;57(Suppl
1):S1-S564. http://www.easdvirtualmeeting.org/resources/18987
Huber JW, Hood G, Worthington A, Schmitt A, Hermanns N. Validation of the Diabetes Self-
Management Questionnaire (DSMQ) in an English sample [abstract]. Diabetes
2015;64(Suppl 1):A224.
Schmitt A, Reimer A, Hermanns N, Huber J, Ehrmann D, Schall S, Kulzer B. Assessing diabetes
self-management with the Diabetes Self-Management Questionnaire (DSMQ) can help
analyse behavioural problems related to reduced glycaemic control. PLoS One
2016;11:e0150774. https://doi.org/10.1371/journal.pone.0150774
Schmitt A, Reimer A, Hermanns N, Kulzer B, Ehrmann D, Krichbaum M, Huber J. Haak T.
Depression is linked to hyperglycaemia via suboptimal diabetes self-management: A
cross-sectional mediation analysis. J Psychosomatic Res 2017;94:17-23.
https://doi.org/10.1016/j.jpsychores.2016.12.015
Bukhsh A, Lee SWH, Pusparajah P, Schmitt A, Khan TM. Psychometric properties of the
Diabetes Self-Management Questionnaire (DSMQ) in Urdu. Health Qual Life Outcomes
2017;15:200. https://doi.org/10.1186/s12955-017-0776-8

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Diabetes Self-Management Questionnaire User information & scoring guide

Scale development
The Diabetes Self-Management Questionnaire (DSMQ) was developed at the Research
Institute of the Diabetes Academy Mergentheim, Bad Mergentheim, Germany and was
designed to assess diabetes self-management activities associated with glycaemic control in
common treatment regimens for people with type 1 and type 2 diabetes.

Development steps:
• A pool of 37 items was originally developed with item contents regarded as putative
predictors of glycaemic outcomes in either or both major types of diabetes:
1. Adherent medication intake – considered important in both T1DM and T2DM.
2. Adjustment of one’s diet towards diabetes – considered important in both T1DM and T2DM,
acknowledging that dietary recommendations are diverse for these types.
3. Checking/monitoring one’s glucose levels (blood or interstitial) – important for the
management of diabetes/glucose levels in insulin-treated PWD (both types) and as a means of
evaluating the results of one’s glucose management in general.
4. Physical exercise as a means of diabetes control is more common in T2DM, but it may also be
effective in T1DM according to a meta-analytic review (ref. 47 in HQLO 2013;11:138). Moreover, it
may have beneficial effects on insulin sensitivity in both diabetes types.
5. Adherence to (vs. avoidance of) appointments with health-care professionals can predict
glycaemic control independently of visit frequency according to some studies (see ref. 50/51 in
HQLO 2013;11:138). Moreover, regular contact with the treating doctor is important for choosing
the best treatment and may increase treatment motivation.
• All items were formulated as behavioural self-descriptions. Respondents are asked to rate
to which extent each statement applies to one’s self-management during the past eight
weeks (The time frame was chosen with a view to the outcome HbA 1c which reflects
blood glucose levels of the past 8 to 12 weeks).
• A four-point Likert-type rating scale was chosen (applies to me very much; applies to me
to a considerable degree; applies to me to some degree; does not apply to me). This
avoids a neutral response option to force a specific response by the respondent.
• To enable individual adjustment in items assessing aspects not necessarily required in all
treatment regimens, specifically SMBG and anti-diabetic medication, boxes offering to
tick ‘…is not required as a part of my treatment’ were added to these items.
• Exclusion of items with suboptimal properties from the original item pool (see HQLO
2013;11:138 for details) resulted in the 16-item DSMQ which consists of a total scale as
well as several subscales reflecting specific self-management activities (details below).
• The questionnaire was translated into English using standard forward-backward
translation. (Two independent bilingual speakers performed the forward translation; results
were reviewed and matched; one independent bilingual translator completed the backward
translation; back-translated and original versions were matched yielding the final version.)

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Diabetes Self-Management Questionnaire User information & scoring guide

Scale description and scoring guide

Scale structure (original 16-item version)
a) The Total score is a global measure of diabetes self-management; it comprises all 16
items (item 16 is included in this scale only; reverse-scored items: 5, 7, 10, 11, 12, 13,
14, 15 and 16); Cronbach’s α* T1DM: 0.86 / T2DM: 0.84
b) 4 or 5 subscales:
- Dietary control on diabetes-related dietary management behaviours; comprising
items 2, 5, 9 and 13 (5 and 13 reverse-scored); Cronbach’s α* T1DM: 0.78 /
T2DM: 0.77
- Glucose management on blood glucose monitoring and medication adherence;
comprising items 1, 4, 6, 10 and 12 (10 and 12 reverse-scored); Cronbach’s α*
T1DM: 0.82 / T2DM: 0.76. This factorially derived scale may be divided into two
separate scales which is recommended if scale consistency is supportive:
o Glucose monitoring (items 1, 6, 10; 10 reverse-scored); Cronbach’s α*
T1DM: 0.78 / T2DM: 0.81
o Medication adherence (items 4, 12; 12 reverse-scored); Cronbach’s α*
T1DM: 0.70 / T2DM: 0.52
- Physical activity on activity/exercise as a means of diabetes management;
comprising items 8, 11, 15 (11 and 15 reverse-scored); Cronbach’s α* T1DM: 0.76
/ T2DM: 0.69
- Physician contact on adherence to diabetes-related doctors’ appointments;
comprising items 3, 7, 14 (7 and 14 reverse-scored); Cronbach’s α* T1DM: 0.66 /
T2DM: 0.57
* mean of α coefficients from 7 study samples with T1DM and T2DM patients in Germany.

Item scoring
4-point Likert scale: ‘Applies to me very much’ = 3 points / ‘Applies to me to a considerable
degree’ = 2 points / ‘Applies to me to some degree’ = 1 point / ‘Does not apply to me’ = 0
points
If ‘…is not required as a part of my treatment’ is stated in an item, that item should not be
scored.

Scale scoring (original 16-items version):

The DSMQ contains 7 positively and 9 negatively keyed items (with view to effective self-
management); negatively keyed items have to be reverse-scored so that higher values
indicate more effective self-management before summing to scale scores.
Example: ‘I could improve my diabetes self-care considerably’ (Item 16)
Raw scores Inverse scores to be summed
‘Applies to me very much’ = 3 points = 0 points
‘Applies to me to a considerable degree’ = 2 points = 1 point
‘Applies to me to some degree’ = 1 point = 2 points
‘Does not apply to me’ = 0 points = 3 points

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Diabetes Self-Management Questionnaire User information & scoring guide

Based on recoded item scores the scale scores are computed as follows (Please always
check/approve sufficient internal consistency reliability before summing to scales!):
---------------------------------------------------------------------------------------------------------------------------
SCALE SCORE = ACTUAL SUM OF ITEMS / MAXIMUM POSSIBLE SUM OF ITEMS x 10
---------------------------------------------------------------------------------------------------------------------------
The transformed scale score can vary between 0 und 10. If an item was skipped, the
numerator should be corrected by –3.

Examples (original 16-items version):

‘Dietary control’ (if all four items were answered):

8 (exemplary sum) / 12 (maximum possible sum of 4 Items) x 10 = 6.7 points

‘Glucose management’ (if all five items were answered):

14 (exemplary sum) / 15 (maximum possible sum of 5 Items) x 10 = 9.3 points

‘Physical activity’ (if all three items were answered):

5 (exemplary sum) / 9 (maximum possible sum of 3 Items) x 10 = 5.6 points

‘Physician contact’ (if all three items were answered):

9 (exemplary sum) / 9 (maximum possible sum of 3 Items) x 10 = 10 points

‘Total score’ if all sixteen items were answered:

37 (exemplary sum) / 48 (maximum possible sum of 16 Items) x 10 = 7.7 points
if two items were skipped:
30 (exemplary sum) / 42 (maximum possible sum of 14 Items) x 10 = 7.1 points

Reference values from German PWD (original 16-items version):

Table: DSMQ-scores of people with T1DM/T2DM, distinguished by HbA 1c-value

Scale Total sample HbA1c ≤ 7.5% HbA1c ≥ 7.6 ≤ 8.9% HbA1c ≥ 9.0% p-Wert
T1DM DC 4.8 ± 2.4 6.2 ± 1.9 4.7 ± 2.3 3.9 ± 2.4 <0.001
(n=344) GM 7.1 ± 2.6 8.5 ± 1.7 7.3 ± 2.3 5.6 ± 2.8 <0.001
PA 6.2 ± 2.5 6.8 ± 2.4 6.1 ± 2.4 6.0 ± 2.6 0.030
PC 8.2 ± 2.1 8.6 ± 1.8 8.4 ± 2.1 7.6 ± 2.5 0.001
TS 6.5 ± 1.9 7.6 ± 1.3 6.6 ± 1.6 5.5 ± 2.0 <0.001
T2DM DC 5.4 ± 2.4 6.5 ± 2.1 5.7 ± 2.3 4.4 ± 2.3 <0.001
(n=230) GM 7.5 ± 2.3 8.6 ± 1.6 7.8 ± 2.1 6.6 ± 2.4 <0.001
PA 4.9 ± 2.7 5.9 ± 3.0 4.8 ± 2.5 4.3 ± 2.5 0.002
PC 8.0 ± 2.1 8.7 ± 1.9 8.0 ± 1.9 7.5 ± 2.2 0.003
TS 6.5 ± 1.7 7.5 ± 1.3 6.6 ± 1.4 5.7 ± 1.7 <0.001
DC, Dietary control; GM, Glucose management; PA, Physical activity; PC, Physician contact; TS, Total score.

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Diabetes Self-Management Questionnaire User information & scoring guide

Screening criteria/detecting of clinical cases:

NOT RECOMMENDED: To detect persons with suboptimal or non-adherent self-management

behaviours, a cut-off score of < 6 on the total scale has been utilized in some studies – This is
not recommended! This criterion most likely originates from an abstract publication (see ref.
no. 4 above) reporting on a study in which 226 German PWD were categorised according to
their DSMQ total scores using median split. (“the median split yielded a cut-off score of ≈ 6
on the DSMQ scale ranging from 0 to 10.”) By design, this score split the sample into two
halves, reflecting that a cut-off score of < 6 would identify about half of the sample with
suboptimal self-management behaviour, thus not being suitable for detecting clinical cases.

RECOMMENDED: If a categorisation of patients is required, establishing one’s own cut-off

score based on one’s own population data and patient characteristics/treatment regimens is
recommended. A median or quartile split or score determination using distribution
characteristics (e.g. 1 SD from M) or even ROC analysis against poor HbA 1c values etc. should
always be performed based on one’s own patient sample data. Criteria are likely to differ
across diabetes types, treatment regimens and cultural backgrounds.

RECOMMENDED: If criteria for detecting “clinical cases” (i.e. persons not sufficiently
adhering to their self-management regimen) are required, establishing more conservative
cut-off criteria may be considered. Clinical criteria can be established with a view to those
response categories reflecting problematic behaviour, i.e. all or most items of a particular
scale being answered with “applies to me to some degree” or “does not apply to me” for
positively-keyed items (the other way around for negatively-keyed items), suggesting low
adherence in this area.
For the 16-item DSMQ, this would translate into a (raw) scale score of <= 4 for the dietary
control scale (4 items); <= 3 for the blood glucose monitoring scale; <= 2 for the medication
adherence scale; and so on. Referring to a larger data set of German secondary care patients
these criteria would identify 30.6%, 24.3% and 11.7%, respectively, of those with T1D and
25.4%, 23.1% and 4.9%, respectively, of those with T2D, suggesting low adherence with
regard to dietary regimens, checking of glucose levels and consistent taking
medication/insulin. The observed HbA 1c values of these groups, as compared to the total
group, were: 9.1% (+-1.8), 9.5% (+-1.8) and 10.4% (+-2.1) versus 8.3% (+-1.6) for T1D, and
8.7% (+-1.6), 8.4% (+-2.1) and 10.1% (+-2.3) versus 8.0% (+-1.7) for T2D, supporting that
clinical cases (i.e. those with worse diabetes control) were indeed detected.

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Diabetes Self-Management Questionnaire User information & scoring guide

DSMQ-R (2015)
20 items + 7 optional items regarding intensive insulin treatment

A revised form of the original 16-item DSMQ was developed in 2015. This was done due to
specific concerns regarding single items as well as findings suggesting suboptimal scale
consistency of single subscales in some studies, particularly the physician contact scale. Also
some activities relevant for people with intensive insulin treatment were considered not
satisfactorily addressed, thus some new items were added. Also some items were updated
subsequently to consort with new technologies in diabetes management such as CGM.
In the revised form most the original items were either kept unchanged (3 items) or only
minimally altered (e.g. adding explanatory terms for better understanding) (7 items), while
6 items were altered more substantially at which it was seeked not to change the basic
meaning. The numerical order of the items remains unchanged, except for item 16 which is
number 20 in the revised form.
A detailed description of the item revisions is given below (a comparison of original and
revised items is provided in the below table):
• Items 5, 13 and 16 remain unchanged.
• Items 1, 2, 4, 10, 11, 12 and 14 were minimally altered at which the meaning of each statement
was not changed, i.e. minor changes of the wording were made or specific terms were added for
better understanding or to conform with new developments (e.g. in items regarding ‘blood sugar
checking’ the term ‘glucose levels’ was added in parentheses referring to people measuring
interstitial glucose using CGM rather than blood glucose).
• Items 3, 6, 7, 8, 9 and 15 were revised more significantly due to specific considerations; however,
it was tried not to alter the basic meaning of the statement:
o In items 3 and 7 regarding contact with the diabetes-treating doctor, the concept of ‘keeping
doctor’s appointments’ was revised to ‘seeing the doctor regularly’ which was considered
less compliance-oriented. In addition, the term ‘diabetes specialist’ was added in
parentheses to reflect provision of care by a diabetes team rather than the doctor only.
o Item 6 (‘I record my blood sugar levels regularly (or analyse the value chart with my blood
glucose meter).’) was revised to ‘I keep records of my blood sugar values (or CGM data) to
better manage my diabetes.’ The second part of the original item had led to
questions/confusion of respondents sometimes suggesting revision. In addition, the sense of
recording glucose levels to reflect/better manage one’s blood glucose was highlighted, and
potential automatic collection of glucose data by CGM was addressed.
o Item 8 (‘I do regular physical activity to achieve optimal blood sugar levels.’) was revised to ‘I
am regularly physically active to improve my diabetes/my health.’ to reflect the relevance of
physical activity in the treatment of both T2DM and T1DM more appropriately. (Although
physical activity can actually improve glucose control in T1DM, too, it is less common as a
means of controlling glucose compared to T2DM.)
o Item 9 (‘I strictly follow the dietary recommendations given by my doctor or diabetes
specialist.’) was considered overly compliance-oriented and thus revised to ‘I follow relevant

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Diabetes Self-Management Questionnaire User information & scoring guide

dietary recommendations for people with diabetes (e.g. given to me by my doctor or

diabetes specialist).’
o Item 11 (‘I avoid physical activity, although it would improve my diabetes.’) was revised to ‘I
avoid physical activity although it would be good for my diabetes/my health’. (See also the
above remarks regarding item 8.)
o The original item 15 (‘I tend to skip planned physical activity.’) was actually not directly
related to diabetes self-management constituting a potential limitation of this item. It was
thus revised to ‘I am less physically active than would be optimal for my diabetes/my health.’

Since most items either remain unchanged or were only minimally changed and the basic
meaning was generally kept, the original 16-item DSMQ is essentially included in the
revised form. Therefore, scale scores based on the original version’s items might still be
estimated if needed (e.g. when comparisons with former scores of individuals or former
study findings based on the original form are intended).

In addition to these amendments, several new items were added to the revised DSMQ.
Four items were added to cover several aspects which were not satisfactorily addressed in
the original version, resulting in a new total of 20 items.
• Item 16 (in DSMQ-R): ‘I could improve my diabetes self-care considerably.’ This item requires an
overall evaluation of one’s diabetes self-management, comparably to the original version’s item
16 (item 20 in DSMQ-R: ‘My diabetes self-care is poor’). However, it is less judgemental i.e.
probably less prone to response bias. Like item 20 it is to be included in the total score only.
• Item 17: ‘I estimate the carbohydrate content of my meals (for achieving better glucose control).’
This item addresses carbohydrate estimation, an aspect which was not included in the original
version although it is important for achieving good glucose control generally and constitutes a
basis for insulin adaption in insulin users specifically. The item is part of the total scale and the
dietary control subscale.
• Item 18: ‘I eat without regard to my diabetes.’ This is an addition to the dietary control scale
formerly consisting of four items on choosing foods facilitating glucose control (item 2); eating
high-carb foods (item 5); following dietary recommendations (item 9); and potential binging (item
13). It constitutes a contrary to item 2 i.e. is a negatively-keyed item on choosing proper foods for
easier diabetes management.
• Item 19: ‘I check/discuss my diabetes treatment with the doctor (diabetes specialist) regularly.’
This item addresses collaboration with health specialists for optimisation of treatment modalities
and procedures; this aspect constitutes the basis for choosing the best medical treatment and
contributes to treatment motivation and more appropriate self-care. This was not satisfactorily
covered by the original version.

Further 7 items were newly added in the revised version to cover specific aspects of
particular interest regarding intensive insulin treatment. These items are optional, and
respondents are asked to respond only if they use rapid acting insulin i.e. inject before
meals.

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Diabetes Self-Management Questionnaire User information & scoring guide

The optional items assess the following activities (full items are shown in the below table):
• Checking blood sugar/glucose before each meal (item 21) – This is the basis for proper
insulin adaption;
• Adapting insulin doses to the carbohydrate content of the meals (item 22);
• Adjusting the timing of insulin injection and food intake (item 23);
• Adapting insulin doses to current glucose levels as well as activities (item 24);
• Ensuring regular meal times over the day (item 25) – Consistent meal times may facilitate
glucose management as treatment activities may follow a more structure time schedule
and similar activities may be performed each day;
• Carrying fast carbohydrates for quick treatment of hypoglycaemia (item 26);
• Taking appropriate amounts of carbohydrates when treating hypoglycaemia to avoid
causing hyperglycaemia (item 27).

In summary, the 20-item DSMQ-R contains 9 positively and 11 negatively keyed items. The
full form including the 7 optional items regarding intensive insulin treatment contains 16
positively and 11 negatively keyed items. All negatively keyed items must be reverse-
scored so that higher values indicate more effective self-management before summing to
scale scores.

The DSMQ-R has not been reported in a peer-reviewed paper yet. It has nevertheless been
used (is used) in several studies in Germany and abroad. Available evidence regarding
reliability/validity includes cross-sectional data from a survey with 333 German people
with T1DM and 256 with T2DM.
Scoring recommendations based on the findings in German PWD together with estimates
of scale reliability are provided on the following page 11.
Correlations with HbA 1c as a basis for validity estimation are provided on the following
page 12.

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 Diabetes Self-Management Questionnaire User information & scoring guide

Table: Comparison of items of the original and revised DSMQ

Original form Revised form
Item Item wording Level Item Item wording
no. of no.
accor-
dance
1. I check my blood sugar levels with care and = 1. I check my blood sugar levels (glucose
attention. levels) with care and attention.
2. The food I choose to eat makes it easy to = 2. The foods I choose to eat make it easy for
achieve optimal blood sugar levels. me to achieve good blood sugar levels.
3. I keep all doctors’ appointments ≈ 3. I regularly see the doctor (diabetes
recommended for my diabetes treatment. specialist) regarding my diabetes.
4. I take my diabetes medication (e. g. insulin, = 4. I take my diabetes medication (e.g. insulin,
tablets) as prescribed. tablets) as prescribed/agreed.
5. Occasionally I eat lots of sweets or other = 5. Occasionally I eat lots of sweets or other
foods rich in carbohydrates. foods rich in carbohydrates.
6. I record my blood sugar levels regularly (or ≈ 6. I keep records of my blood sugar values (or
analyse the value chart with my blood CGM data) to better manage my diabetes.
glucose meter).
7. I tend to avoid diabetes-related doctors’ ≈ 7. I tend to avoid seeing the doctor (diabetes
appointments. specialist) regarding my diabetes.
8. I do regular physical activity to achieve ≈ 8. I am regularly physically active to improve
optimal blood sugar levels. my diabetes/my health.
9. I strictly follow the dietary ≈ 9. I follow the relevant dietary
recommendations given by my doctor or recommendations for people with diabetes
diabetes specialist. (e.g. given to me by my doctor or diabetes
specialist).
10. I do not check my blood sugar levels = 10. I do not check my blood sugar levels
frequently enough as would be required (glucose levels) frequently enough for
for achieving good blood glucose control. achieving good glucose control.
11. I avoid physical activity, although it would = 11. I avoid physical activity although it would
improve my diabetes. be good for my diabetes/my health.
12. I tend to forget to take or skip my diabetes = 12. I tend to forget or skip my diabetes
medication (e. g. insulin, tablets). medication (e.g. insulin, tablets).
13. Sometimes I have real ‘food binges’ (not = 13. Sometimes I have real ‘food binges’ (not
triggered by hypoglycaemia). triggered by hypoglycaemia).
14. Regarding my diabetes care, I should see = 14. Regarding my diabetes, I should see my
my medical practitioner(s) more often. doctor (diabetes specialist) more often.
15. I tend to skip planned physical activity. ≈ 15. I am less physically active than would be
optimal for my diabetes/my health.
16. My diabetes self-care is poor. = 20. My diabetes self-care is poor.
/ 16. I could improve my diabetes self-care
considerably.
/ 17. I estimate the carbohydrate content of my
meals (for achieving better glucose
control).
/ 18. I eat without regard to my diabetes.
/ 19. I check/discuss my diabetes treatment with
the doctor (diabetes specialist) regularly.
Level of accordance: = ‘basically identical content’; ≈ ‘comparable content’; / ‘no corresponding item in original
form’.

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Diabetes Self-Management Questionnaire User information & scoring guide

Table: Comparison of items of the original and revised DSMQ (continued)

Original form Revised form
Item Item wording Level Item Item wording
no. of no.
accor-
dance
/ 21.* I check my blood sugar levels (glucose
levels) before each meal.
/ 22.* I adapt my insulin doses to the
carbohydrate content of my meals.
/ 23.* I adjust the timing of my insulin injections
and food intake.
/ 24.* I adapt my insulin doses to the current
blood sugar levels (glucose levels) as well as
preceding or planned activities.
/ 25.* I try to ensure regular meal times over the
day.
/ 26.* I carry fast carbohydrates to enable quick
treatment of hypoglycaemia (low blood
sugar).
/ 27.* In case of hypoglycaemia (low blood sugar),
I take appropriate amounts of
carbohydrates to avoid causing
hyperglycaemia (high blood sugar).
Level of accordance: = ‘basically identical content’; ≈ ‘comparable content’; / ‘no corresponding item in original
form’.
* Optional item; to be answered by people using intensive insulin treatment only.

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Diabetes Self-Management Questionnaire User information & scoring guide

Scoring for patients without intensive insulin treatment (items 1 – 20):

a) Total score: Sum of all 20 item scores (item 16 and 20 are included in the this scale
only; reverse-scored items 5, 7, 10, 11, 12, 13, 14, 15, 16, 18 and 20); Cronbach’s α*
T1DM: 0.91–0.92 / T2DM: 0.86–0.87
b) 4 or 5 subscales:
- Dietary control, 6 items: 2, 5, 9, 13, 17, 18 (5, 13 and 18 reverse-scored);
Cronbach’s α* T1DM: 0.78–0.81 / T2DM: 0.75–0.77
- Glucose management, 5 items: 1, 4, 6, 10, 12 (10 and 12 reverse-scored);
Cronbach’s α* T1DM: 0.84–0.87 / T2DM: 0.79–0.83. This factorially derived scale
can be divided into two separate scales which is recommended if scale
consistency estimates are supportive:
o Glucose monitoring, 3 items: 1, 6, 10 (10 reverse-scored); Cronbach’s α*
T1DM: 0.81–0.82 / T2DM: 0.79–0.89
o Medication adherence, 2 items: 4, 12 (12 reverse-scored); Cronbach’s α*
T1DM: 0.80–0.84 / T2DM: 0.67–0.81
- Physical activity, 3 items: 8, 11, 15 (11 and 15 reverse-scored); Cronbach’s α*
T1DM: 0.84–0.87 / T2DM: 0.73–0.76
- Physician contact, 4 items: 3, 7, 14, 19 (7 and 14 reverse-scored); Cronbach’s α*
T1DM: 0.75–0.85 / T2DM: 0.50–0.73

Scoring for patients with intensive insulin treatment (all 27 items can be used):
a) Total score: all 27 items (item 16 and 20 are included in the this scale only; reverse-
scored items: 5, 7, 10, 11, 12, 13, 14, 15, 16, 18 and 20); Cronbach’s α* T1DM: 0.93–
0.94 / T2DM: 0.90–0.91
b) 4 or 5 subscales:
- Dietary control, 6 items: 2, 5, 9, 13, 17 and 18 (5, 13 and 18 reverse-scored);
Cronbach’s α* T1DM: 0.78–0.81 / T2DM: 0.70–0.74
- Glucose management, 9 items: 1, 4, 6, 10, 12, 21, 22, 23, 24 (10 and 12 reverse-
scored); Cronbach’s α* T1DM: 0.91–0.93 / T2DM: 0.89–0.90 (items 25 – 27 might
be included, but scale consistency should be checked). This factorially derived
scale can be divided into two separate scales which is recommended if scale
consistency estimates are supportive:
o Glucose monitoring, 4 items: 1, 6, 10, 21 (10 reverse-scored); Cronbach’s
α* T1DM: 0.86–0.87 / T2DM: 0.83–0.92
o Medication adherence, 5 items: 4, 12, 22, 23, 24 (12 reverse-scored);
Cronbach’s α* T1DM: 0.85–0.89 / T2DM: 0.77–0.78
- Physical activity, 3 items: 8, 11, 15 (11 and 15 reverse-scored); Cronbach’s α*
T1DM: 0.84–0.87 / T2DM: 0.77–0.81
- Physician contact, 4 items: 3, 7, 14, 19 (7 and 14 reverse-scored); Cronbach’s α*
T1DM: 0.75–0.85 / T2DM: 0.58–0.79
* α coefficients from 2 study samples with T1DM and T2DM patients in Germany.

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Diabetes Self-Management Questionnaire User information & scoring guide

Based on recoded item scores the scale scores are computed as follows (Please always
check/approve sufficient internal consistency reliability before summing to scales!):
---------------------------------------------------------------------------------------------------------------------------
SCALE SCORE = ACTUAL SUM OF ITEMS / MAXIMUM POSSIBLE SUM OF ITEMS x 10
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The transformed scale score can vary between 0 und 10. If an item was skipped, the
numerator should be corrected by –3.

For screening/detecting of clinical cases, please see the above considerations (page 5).
Criteria for DSMQ-R should be set/used accordingly.

Bivariate Pearson correlations between the DSMQ-R scales and HbA 1c based on the 20
mandatory DSMQ-R items (scoring as explained above)
T1DM T2DM
(n = 333) (n = 256)
Total score (20 items) r = -0.57** r = -0.34**
Total score (original 16 items counted only) r = -0.56** r = -0.34**
Dietary control (6 items) r = -0.42** r = -0.30**
Dietary control (original 4 items counted only) r = -0.40** r = -0.32**
Glucose management (5 items) r = -0.58** r = -0.26**
Glucose monitoring (3 items) r = -0.53** r = -0.14*
Medication adherence (2 items) r = -0.55** r = -0.44**
Physical activity (3 items) r = -0.28** r = -0.14*
Physician contact (4 items) r = -0.32** r = -0.22**
Physician contact (original 3 items counted only) r = -0.30** r = -0.21**
* p < 0.01, ** p < 0.05

Bivariate Pearson correlations between the DSMQ-R scales and HbA 1c based on all 27
DSMQ-R items where applicable (scoring as explained above)
T1DM T2DM with IIT
(n = 261) (n = 91)
Total score (27 items) r = -0.57** r = -0.48**
Total score (original 16 items counted only) r = -0.55** r = -0.37**
Dietary control (6 items) r = -0.45** r = -0.37**
Dietary control (original 4 items counted only) r = -0.39** r = -0.28*
Glucose management (9 items) r = -0.58** r = -0.50**
Glucose management (original 5 items counted only) r = -0.57** r = -0.43**
Glucose monitoring (4 items) r = -0.53** r = -0.41**
Glucose monitoring (original 3 items counted only) r = -0.51** r = -0.38**
Medication adherence (5 items) r = -0.57** r = -0.52**
Medication adherence (original 2 items counted only) r = -0.55** r = -0.43**
Physical activity (3 items) r = -0.29** r = -0.04
Physician contact (4 items) r = -0.31** r = -0.21*
Physician contact (original 3 items counted only) r = -0.28** r = -0.16
IIT = intensive insulin treatment.
* p < 0.01, ** p < 0.05

Last updated: 16 Aug 2018 12