See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/7791528

Development of a questionnaire to measure

heart disease risk knowledge in people with
diabetes: The Heart...

Article in Patient Education and Counseling · August 2005

DOI: 10.1016/j.pec.2004.07.004 · Source: PubMed

CITATIONS READS

61 1,993

4 authors, including:

Kimberly Lacey Deborah Chyun

Southern Connecticut State University New York University
13 PUBLICATIONS 185 CITATIONS 122 PUBLICATIONS 2,253 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Deborah Chyun on 20 April 2017.

The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document
and are linked to publications on ResearchGate, letting you access and read them immediately.
 Patient Education and Counseling 58 (2005) 82–87
www.elsevier.com/locate/pateducou

Development of a questionnaire to measure heart disease

risk knowledge in people with diabetes: the Heart Disease
Fact Questionnaire
Julie Wagnera,*, Kimberly Laceyb, Deborah Chyunb, Gina Abbotta
a
University of Connecticut School of Dental Medicine, UCONN Health Center,
MC 3910, 263 Farmington Ave., Farmington, CT 06030, USA
b
Yale School of Nursing, USA
Received 22 January 2004; received in revised form 25 May 2004; accepted 13 July 2004

Abstract

This paper describes a paper and pencil questionnaire that measures heart disease risk knowledge in people with diabetes. The Heart
Disease Fact Questionnaire (HDFQ) is a 25-item questionnaire that was developed to tap into respondents’ knowledge of major risk factors for
the development of CHD. Approximately half of these items specifically address diabetes-related CHD risk factors. Based on extensive pilot
data, the current study analyzed responses from 524 people with diabetes to assess the psychometric properties. The HDFQ is readable to an
average 13-year old and imposes little burden. It shows good content and face validity. It demonstrates adequate internal consistency, with
Kuder–Richardson-20 formula = 0.77 and good item-total correlations. Item analysis showed a desirable range in P-values. In discriminant
function analyses, HDFQ scores differentiated respondents by knowledge of their own cardiovascular health, use of lipid lowering
medications, health insurance status, and educational attainment, thus indicating good criterion related validity. This measure of heart
disease risk knowledge is brief, understandable to respondents, and easy to administer and score. Its potential for use in research and practice
is discussed. Future research should establish norms as well as investigate its test–retest reliability and predictive validity.
# 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Heart disease; Diabetes; Knowledge; Measurement development

1. Introduction Thus, prevention and management of CHD is a major

The prevalence of diabetes worldwide indicates epidemic
rates, with year 2000 estimates at 2.8% of the population or
171 million people, and year 2030 estimates at 4.4% or 366
million people [1]. The majority of morbidity and mortality
in diabetes is due to cardiovascular disease. Fifty-five per-
cent of deaths [1] and 75% of hospitalizations [2] in people
with diabetes are caused by vascular disease. Studies have
consistently shown that people with diabetes are more likely
to develop coronary heart disease (CHD) compared to
people who do not have diabetes and when they do, their
CHD tends to be more extensive [3].
* Corresponding author. Tel.: +1 860 679 4508; fax: +1 860 679 1342.
E-mail address: Juwagner@uchc.edu (J. Wagner).
goal of diabetes management. Risk factors such as dyslipi-
demia, hypertension, smoking, obesity, sedentary lifestyle,
and poor eating habits should be modified. While knowledge
is not sufficient for risk modification in diabetes, it is a
necessary precondition [4]. A poll sponsored by the Amer-
ican Diabetes Association (ADA) and the American College
of Cardiology surveyed 2008 people with diabetes and found
that 2/3 of respondents did not consider cardiovascular
disease a serious complication of diabetes [5]. According
to the executive summary of this poll, the majority of
respondents did not feel susceptible to risk factors such
as hypertension or dyslipidemia. Furthermore, few respon-
dents could name important methods to reduce the risk for
heart attack or stroke. In its 2002 clinical practice recom-
mendations, the ADA stated that the cardiovascular burden

0738-3991/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2004.07.004
 J. Wagner et al. / Patient Education and Counseling 58 (2005) 82–87
of diabetes has not been effectively communicated to people
with diabetes [6].
The recent poll provides valuable information and sug-
gests a serious deficit in knowledge of heart disease risk
among patient with diabetes. It highlights the need for
measurement of individuals’ knowledge of risk for heart
disease. However, the poll used an interview format that
does not easily lend itself to research or clinical applications.
Sensitive and specific measurement of knowledge is neces-
sary for research in this area to grow. For example, a
psychometrically sound measure of risk knowledge would
allow investigators to identify subgroups of patients who are
particularly uninformed, and evaluate educational and beha-
vioral interventions. Assessment of knowledge is also
important in clinical care of patients with diabetes, so that
education can be tailored to meet individual patient needs.
The purpose of this study was to design a valid and reliable
questionnaire for the assessment of heart disease risk knowl-
edge among people with diabetes that could be used for both
research and clinical purposes.
2. Research design and methods
2.1. Generation of items
Relevant literature, patient education materials, and
guidelines from the American Diabetes Association, the
American Heart Association, and the National Diabetes
Education Program were reviewed to establish the
domains to be incorporated into the questionnaire. Each
item reflects specific information and/or recommendations
from one or more of these three organizations. The first
version of the Heart Disease Fact Questionnaire (HDFQ-1)
consisted of 23 true/false items that covered content related
to major risk factors for the development of CHD.
Three additional open-ended questions were included to
evaluate the readability, clarity, and burden of the instru-
ment. A space for comments was also provided. The
instrument was then reviewed by experts in the fields of
diabetes and heart disease for content validity, face validity,
readability, and clarity. Revisions were made based on
feedback from these individuals including the rewording
of a few questions and the addition of ‘‘I don’t know’’ as a
response option.
The instrument was then pre-tested in a pilot study.
Participants were recruited from endocrinology practices
and university research centers in the northeast. To be
included in the preliminary study individuals had to have
a diagnosis of type 1 or type 2 diabetes and speak English.
Sixty-six participants completed the questionnaire. All par-
ticipants indicated that the instrument was clear, under-
standable, and imposed little burden. Stability of the
instrument was assessed with test–retest reliability (n =
13, r = 0.89). Based on the results of these participants,
the instrument was further revised in terms of item order,
83
sentence length, the use of first and second person language,
the use of italics for emphasis, and logic. Several questions
were reworded, a few were eliminated, and others were left
unchanged. Questions were then reordered with more gen-
eral and less difficult questions toward the beginning and
potentially upsetting questions at the end. Questions were
grouped by topic area. The instrument (HDFQ-2) was then
administered to another 268 patients with diabetes. Based on
these results, one cholesterol item was dropped, and an item
tapping into the unique role of gender in diabetes-related
CHD risk was added. Risk domains assessed by the final
version of the scale included family history, age, sex,
smoking, physical activity, glycemic control, lipids, blood
pressure, weight, and whether a person necessarily knows if
heart disease is present. The current study evaluated the
internal consistency, item difficulty, and validity of this most
recent iteration of the HDFQ.
2.2. Sample and procedure
Volunteers for the current study came from three Amer-
ican Diabetes Association Diabetes Expos in the northeast.
These Expos are health fairs specifically geared to people
with diabetes. Numerous organizations from both industry
and non-profit sectors were represented at the Diabetes
Expos. If the attendee expressed an interest and agreed to
participate, he/she completed the anonymous questionnaire.
Completed questionnaires were collected on site and
reviewed for completeness. After their participation, respon-
dents were paid $ 5 for participation and received patient
education materials regarding the relationship between dia-
betes and heart disease.
2.3. Measures
Demographic and medical information was obtained by
self-report questionnaire. The medical history questionnaire
asked whether respondents had ever been diagnosed with a
variety of CHD-related conditions including high blood
pressure, high cholesterol, high triglycerides, heart disease
per se, or heart failure. Response options were ‘yes’, ‘no’,
and ‘I don’t know’. A subsample of 387 participants were
also administered a questionnaire assessing socioeconomic
status including educational attainment, income, and health
insurance status.
2.4. Analyses
All data were analyzed with SPSS version 10.1. Four sets
of analyses were conducted. First, the readability of the final
25-item scale was analyzed for reading level. In the US, 46%
of the adult population read at or below the level of a 13-year
old, or 8th grader [7]. Thus, to be useful with a wide
audience, the reading level of the HDFQ must be low, while
at the same time tapping into fairly sophisticated health
topics.
84 J. Wagner et al. / Patient Education and Counseling 58 (2005) 82–87
Second, the reliability of the items was examined using
Kuder–Richardson-20 formula as an indicator of internal
consistency, with coefficients above 0.70 considered
respectable [8]. Kuder–Richardson-20 can be thought of
as a Cronbach’s a [9] for dichotomously scored items (e.g.,
correct/incorrect). Because this scale strives to measure
knowledge of different risk factors, it was expected that
there would be considerable variability between items and
subsequently a lower internal consistency coefficient. That
is to say, a respondent may have good knowledge of, for
example, smoking and obesity as risk factors for heart
disease, but have very little knowledge about the complex-
ities of high-density lipoproteins (HDL) and low-density
lipoproteins (LDL). With a factorially complex set of items,
a very large set of items is needed to develop a homogenous
test. However, we were interested in developing a brief
measure that would be user-friendly for research and clinical
purposes.
Third, we evaluated P-values and corrected item-total
correlations. The P-value of any dichotomous item (correct/
incorrect) is the fraction of persons tested who correctly
answer the item. A P-value of 0.9 would mean that 90% of
respondents answered the question correctly. Guessing
tends to make P-values higher, the amount of ‘elevation’
being inversely related to the number of alternative
responses for each item. Guessing not only tends to raise
P-values, but also introduces measurement error. Since the
less guessing there is, the less measurement error there is,
easy items tend to have less measurement error than more
difficult items. We attempted to ameliorate the effects of
guessing by adding an ‘‘I don’t know’’ response option
(which was scored as incorrect). Nevertheless, because
easier items tend to be more reliable, it would be inap-
propriate to design a test such as the HDFQ to have all P-
values at or near 0.5. Nunnally’s guidelines [10] state that
the most discriminating item would have a corrected P-
value somewhere between 0.5 and 1.0. In addition, we
wanted to add several more difficult items so that there
would be a range of difficulties and the scale would dis-
criminate well between those high and low on knowledge
and be sensitive to educational interventions. Nunally sug-
gests that choosing items based on P-values alone is not a
good strategy for measurement development. Instead, they
should be evaluated in conjunction with item-total correla-
tions. Corrected item-total correlations indicate the degree
to which the individual item relates to the total score,
excluding itself. Correlations below 0.15 are thought to
be low and the item should be considered for deletion.
Correlations are expected to range from 0 to 0.40, with
correlations above 0.30 considered ‘good’ [10].
Fourth, the criterion related validity of the resulting scale
was assessed using discriminant function analyses (DFA).
HDFQ total scores were used to discriminate between
groups of participants who would be expected to differ in
their knowledge of heart disease. First, we compared those
participants confident about their cardiovascular medical
history with those indicating uncertainty about it. People
who know whether or not they have been diagnosed with
hypertension, dyslipidemia, CHD, or congestive heart fail-
ure (CHF) would be expected to know more about heart
disease than someone who is unsure if they even carry such a
diagnosis. Second, we compared those taking lipid lowering
medication to those not taking such medication. People who
take medication for cardiac related ailments would be
expected to know more about their risk for heart disease
than those who do not. Third, comparisons were made
between respondents with health insurance and those with-
out. Although many countries have universal access to
health care, in the US people with health insurance are
more likely to have regular contact with the health care
system and these visits are more likely to be of a routine,
preventive nature rather than emergent. Therefore, they are
more likely to receive both formal and informal health
education from providers and they would be expected to
have greater knowledge of heart disease risk. Finally, those
with differing levels of education were compared. Reading
skills and comprehension of medical information is likely to
be higher in people with more education, so people with
higher educational attainment would be expected to have
more knowledge about heart disease. In DFA, group pre-
diction coefficients are only estimates. It is most desirable to
know how well the prediction function works in a new
sample of cases, because they tend to work too well for
the sample from which they were derived. Therefore, as per
Tabachnick and Fidell [11] we used cross-validation proce-
dures on subsamples that were excluded from the original
analyses. DFA can be specified to take into account prob-
ability of group membership for unequal groups; therefore,
in prediction of group membership is equally difficult for
large and small groups.
3. Results
3.1. Patient demographics
The sample consisted of 524 adults with diabetes, or
approximately 3/4 of the individuals who were approached
for participation. About 2/3 of participants were female, and
72% had type 2 diabetes. On average, participants were
White, 54 years old, had been diagnosed with diabetes for 10
years, and were treating their diabetes with oral agents. The
majority had health insurance. Annual income and education
were both normally distributed, with the majority being high
school graduates earning between $ 21,000 and $ 40,000 per
year; see Table 1 for sample demographics.
3.2. Readability, internal consistency and item difficulty
Flesch-Kincaid reading level indicated that the HDFQ is
readable by an average 13-year old (equivalent of US 8.0
grade reading level); Flesch reading ease was 62%. Item
 J. Wagner et al. / Patient Education and Counseling 58 (2005) 82–87 85

Table 1 groups. Groups were those who indicated ‘I don’t know’

Demographics (N = 524) when reporting the diagnosis of any cardiovascular pro-
Sex (%) blems in their medical history (n = 46) versus those who
Male 39
indicated ‘yes’ or ‘no’ (n = 478). In other words, the groups
Female 61
were those who were sure of their cardiovascular diagnoses,
Age (years) 53.6 and those who were unsure. Twenty-three cases were
Age at diagnosis (years) 42.8
Duration of diabetes (years) 10.9
dropped from the analysis because of missing data, and
two outliers were also dropped. The HDFQ discriminated
Type of diabetes (%)
between these groups, x2 = 7.88, * p < 0.05. Respondents
Type 1 28.4
Type 2 71.6 who were confident about their own cardiovascular medical
history obtained higher HDFQ scores (M = 20.6, S.D. = 3.0)
Diabetes regimen (%)
Diet only 12.1
than those who were unsure (M = 19.2, S.D. = 3.6). Com-
Oral agents 43.4 pared to 82% who would be correctly classified by chance
Insulin injections 24.9 alone, 90% of respondents were correctly classified; in
Oral agents and insulin injections 12.9 cross-validation, 96% were correctly classified.
Insulin pump 6.7 A DFA was performed using HDFQ total score to predict
Race/ethnicity (%) membership in two groups — those taking medication for
White 72.2 lipids (n = 170) and those not taking such medications (n =
Black 15.8
354). Eight cases were dropped because of missing data. The
Hispanic 5.0
Asian 2.3 HDFQ discriminated between these groups, x2 = 5.96, * p <
Mixed 2.9 0.05. Respondents taking lipid lowering medication
Other 1.9 obtained higher HDFQ scores (M = 21.0, S.D. = 3.3) than
Gross annual income in dollarsa (%) those not taking such medications (M = 20.1, S.D. = 2.8).
<20000 18.5 Compared to 56% who would be correctly classified by
21000–40000 31.1 chance alone, 66% of respondents were correctly classified;
41000–60000 22.9 in cross-validation, 74% were correctly classified.
61000–80000 12.9
>80000 8.0
DFAs were also performed on a subsample of participants
from whom we collected SES data. HDFQ total score was
Years of educationa (%)
used as predictor of membership in three groups — those
Less than high school 4.2
High school graduate 21.6 with health insurance (n = 348), those without health
Part college/trade school 37.1 insurance (n = 23), and those unsure of their insurance
College graduate 17.6 status (n = 6). Thirteen cases were dropped because of
Post-graduate education 18.7 missing data, and two outliers were also dropped. The
Do you have health insurancea (%) HDFQ discriminated between these groups, x2 = 19.42,
*
Yes 92.4 p < 0.05. Respondents with health insurance obtained
No 6.0 higher HDFQ scores (M = 20.5, S.D. = 2.97) than those
Not sure 1.6
a
without insurance (M = 18.5, S.D. = 4.7), who in turn
N = 388. obtained higher scores than those unsure of their insurance
status (M = 13.7, S.D. = 6.0). Compared to 86% who would
difficulties (P-values) ranged from 0.20 (a question regard- be correctly classified by chance alone, 93% of respondents
ing HDL in diabetes) to 0.95 (a question regarding over- were correctly classified; in cross-validation, 93% were
weight as a risk for CHD). The majority of P-values were in correctly classified.
the desirable 0.5–1.0 range. Scores on the HDFQ were M = A DFA was performed using the 25-item HDFQ total
20.4, S.D. = 3.0, range 2–25. The 25-item scale yielded a score as predictor of membership in two groups of different
Kuder–Richardson-20 internal consistency coefficient of levels of education. Groups were ‘high school graduate or
0.77. All corrected item-total correlations were above the less’ (n = 96), and ‘education beyond high school’ (n = 276).
cutoff set a priori at 0.15, ranging from 0.18 to 0.41; see Twenty-one cases were dropped because of missing data,
Table 2 for HDFQ items (in the order in which they appear and two outliers were also dropped. The HDFQ dis-
on the questionnaire), P-values, and corrected item-total criminated between these groups, x2 = 10.99, * p < 0.05.
correlations. A complete, user-friendly version of the scale Respondents with education beyond high school obtained
can be obtained from the corresponding author. higher HDFQ scores (M = 20.7, S.D. = 3.0) than those
with less than a high school education (M = 19.3, S.D. =
3.3. Criterion related validity 3.6). Compared to 61% who would be correctly classi-
fied by chance alone, 73% percent of respondents were
A DFA for unequal groups was performed using the 25- correctly classified; in cross-validation, 78% were correctly
item HDFQ total score as predictor of membership in two classified.
86 J. Wagner et al. / Patient Education and Counseling 58 (2005) 82–87

Table 2
HDFQ items with their correct responses, corrected item-total correlations, and P-valuesa
Correct Corrected P-value
response item-total
correlation
A person always knows when they have heart disease False 0.36 0.85
If you have a family history of heart disease, you are at risk for developing heart disease True 0.27 0.87
The older a person is, the greater their risk of having heart disease True 0.20 0.53
Smoking is a risk factor for heart disease True 0.31 0.95
A person who stops smoking will lower their risk of developing heart disease True 0.34 0.85
High blood pressure is a risk factor for heart disease True 0.38 0.95
Keeping blood pressure under control will reduce a person’s risk for developing heart disease True 0.36 0.91
High cholesterol is a risk factor for developing heart disease True 0.38 0.91
Eating fatty foods does not affect blood cholesterol levels False 0.33 0.84
If your ‘good’ cholesterol (HDL) is high you are at risk for heart disease False 0.34 0.57
If your ‘bad’ cholesterol (LDL) is high you are at risk for heart disease True 0.41 0.78
Being overweight increases a person’s risk for heart disease True 0.34 0.96
Regular physical activity will lower a person’s chance of getting heart disease True 0.36 0.91
Only exercising at a gym or in an exercise class will lower a person’s chance of developing False 0.33 0.90
heart disease
Walking and gardening are considered exercise that will help lower a person’s chance of True 0.35 0.88
developing heart disease
Diabetes is a risk factor for developing heart disease True 0.35 0.90
High blood sugar puts a strain on the heart True 0.32 0.81
If your blood sugar is high over several months it can cause your cholesterol level to go up and True 0.18 0.58
increase your risk of heart disease
A person who has diabetes can reduce their risk of developing heart disease if they keep their True 0.41 0.89
blood sugar levels under control
People with diabetes rarely have high cholesterol False 0.38 0.78
If a person has diabetes, keeping their cholesterol under control will help to lower their chance True 0.40 0.85
of developing heart disease
People with diabetes tend to have low HDL (good) cholesterol True 0.20 0.20
A person who has diabetes can reduce their risk of developing heart disease if they keep their True 0.37 0.86
blood pressure under control
A person who has diabetes can reduce their risk of developing heart disease if they keep their True 0.40 0.92
weight under control
Men with diabetes have a higher risk of heart disease than women with diabetes False 0.19 0.36
a
P-values reported here do not refer to statistical significance; rather, the P-value of any dichotomous item (correct/incorrect) is the fraction of persons tested
who correctly answer the item. For example, a P-value of 0.9 would mean that 90% of respondents answered the question correctly.

4. Conclusions Corrected item-total correlations were all within accep-

This paper describes a measure of heart disease risk
knowledge for clinical and research use with diabetes popu-
lations. The measure, called the Heart Disease Fact Ques-
tionnaire (HDFQ), demonstrated adequate internal
consistency, good item difficulty, good content and face
validity, and excellent readability with minimal burden to
respondents. Furthermore, its criterion related validity is
demonstrated by its ability to distinguish between groups
who would be expected to differ in their knowledge of heart
disease risk. The measure is easy to score, and taps into
various risk domains.
The HDFQ is readable to an average 13-year-old,
indicating an appropriate reading difficulty level. The low
reading difficulty also suggests that items that are answered
incorrectly are missed because the respondent does not
have the knowledge being measured by the item, as
opposed to the respondent not understanding what is being
asked.
table range, with 80% in the ‘good’ range, above 0.30
[10]. Kuder–Richardson formula-20 for internal consistency
was 0.77, indicating respectable reliability. As discussed in
Section 1, due to the heterogenous nature of the items and
their difficulties, we did not expect a high internal consis-
tency coefficient. Despite this hypothesis, the scale yielded
an estimate of reliability that should allow clinicians and
researchers to use it confidently. A range of item difficulties
was found, with 23 of the 25 items in the desirable range
0.5–1.0.
Most importantly, the HDFQ successfully discriminated
between meaningful groups of respondents. The HDFQ
successfully discriminated between groups based on health
insurance status, educational attainment, knowledge of their
own cardiovascular medical history, and experience with
cardiac related medications. As per the guidelines set by
Tabachnick and Fidell [11], the percent correct using clas-
sification equations was substantially larger than would be
expected by chance alone. As predicted, respondents with
 J. Wagner et al. / Patient Education and Counseling 58 (2005) 82–87
more education, with health insurance, who were sure of
their cardiovascular medical history, and who were taking
cardiac related medications had more knowledge of heart
disease risk. Cross-validation of each of these findings on a
remaining 25% of the sample confirmed the ability of the
HDFQ to distinguish between these groups, and in fact
accuracy of prediction was improved. Usually, accuracy
of prediction is attenuated in cross-validation. These find-
ings show that the HDFQ is not only psychometrically
sound, but also a useful measure of a meaningful construct
with real world applications.
The HDFQ shows promise for both research and clinical
purposes. Clinically, health care providers and educators
must be able to identify knowledge deficits in order to tailor
health information appropriately. For example, a patient who
smokes may erroneously believe that there is little benefit to
quitting smoking after years of tobacco use, and another
patient may not see a connection between their diabetes and
risk for heart disease. By alerting the clinician to these
mistaken beliefs, the HDFQ may help address patient
knowledge deficits. This new knowledge is one necessary
condition for health behavior change. In research, the HDFQ
can be used to measure outcomes of educational and beha-
vioral interventions. Diabetes, cardiology, and public health
organizations are implementing programs to increase aware-
ness of the diabetes–heart disease link, and evaluation of
these programs will be crucial.
4.1. Limitations
The sample for this study was paid for participation and
was recruited from American Diabetes Association spon-
sored health fairs, or Diabetes Expos. As such, this may be a
biased sample. People who attend the Expos are likely to be
more interested in their health in general and their diabetes
specifically than the larger population of people with dia-
betes is. Their presence at the Expo indicates that they
actively seek health information, and may therefore also
be more receptive to the health information they receive. The
majority had health insurance, and 95% had a primary care
provider. Hence, the level of knowledge of heart disease risk
reported in this study is probably an overestimate of the
knowledge in the larger population. The HDFQ total scores,
as well as item P-values found in this study may be higher
than what would be expected, thus limiting the general-
izability of these findings. However, the relatively high
scores suggest that this scale may discriminate even better
View publication stats
87
among less knowledgeable samples. A lower score in the
general population may in fact be desirable if one is trying to
detect effects of an educational intervention, as it allows
more room for improvement.
4.2. Future directions
The HDFQ requires additional development. Test–retest
reliability must be assessed in a larger sample. The measure
must be shown to be stable and sensitive to change. Ideally,
its predictive validity would also be assessed by using scores
on the HDFQ to predict related health behaviors such as
healthy eating or self-monitoring of blood glucose, or some
future relevant event, such as diagnosis of CHD or a major
adverse cardiac event (MACE). A Spanish version of the
HDFQ has also been created, and its utility with Spanish
speakers with diabetes is currently being evaluated. Given
the increasing prevalence of diabetes and the morbidity and
mortality related to its macrovascular complications, a
better understanding of patient’s knowledge of risk, espe-
cially modifiable risk, is crucial. With further develop-
ment, the HDFQ can help clinicians and researchers in
this effort.
References
[1] Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of
diabetes: estimates for the year 2000 and projections for 2030.
Diabetes Care 2004;27:1047–53.
[2] Aronson D, Rayfield E. Diabetes. In: Topol E, editor. Comprehensive
cardiovascular medicine, vols. 185–208. Lippincott-Raven; 1998.
[3] Haffner SM. Coronary heart disease in patients with diabetes. N Engl J
Med 2000;342:1040–2.
[4] Snoek FJ, Visser A. Improving quality of life in diabetes: how effective
is education? Patient Educ Counsel 2003;51:1–3.
[5] American Diabetes Association and the American College of Cardi-
ology. The diabetes–heart disease link. A report on the attitudes toward
and knowledge of heart disease risk among people with diabetes in the
US; 2002.
[6] American Diabetes Association. Clinical practice recommendations
2003. American Diabetes Association; 2003.
[7] National Center for Education Statistics. National adult literacy
survey. Washington, DC; 1992.
[8] De Vellis RF. Scale development: theory and applications. 2nd ed.
Sage; 2003.
[9] Cronbach L. Coefficient alpha and the internal structure of tests.
Psychometrika 1951;16:297–334.
[10] Nunnally JC. Psychometric theory. 2nd ed. McGraw-Hill; 1978.
[11] Tabachnick BG, Fidell LS. Using multivariate statistics. 2nd ed.
Harper Collins; 1996.