ORIGINAL ARTICLES
Cross-cultural Adaptation and Validation of the French
Version of the Diabetic Foot Self-care Questionnaire of the
University of Malaga
Irene Garcia-Paya, PhD*
Yves Lescure, BP†
Sebastian Delacroix, PhD†
Gabriel Gijon-Nogueron, PhD*
Methods: Cross-cultural adaptation was performed according to relevant international
guidelines (International Society for Pharmacoeconomics and Outcomes Research), and
the factor structure was determined. Internal consistency was measured using the
Cronbach a. Item-total and inter-item correlations were assessed.
Results: The French data set comprised 146 patients. The mean 6 SD patient age was
62.60 6 15.47 years. There were 47 women and 99 men. The structure matrix (with
three factors) was tested by confirmatory factor analysis. The 16-item questionnaire had
a Cronbach a of 0.92. The mean value for inter-item correlations was 0.48 (range, 0.17–
0.86). The rotated solution revealed a three-factor structure that accounted for 48.10%
of the variance observed. A significant inverse correlation was observed between
questionnaire scores and hemoglobin A 1c levels (r ¼ –0.17; P , .01).
Conclusions: This study validates the French-language version of the DFSQ-UMA,
which can be used as a self-reported outcome measure for French-speaking patients in
France. (J Am Podiatr Med Assoc 109(5): 357-366, 2019)
Foot ulcers affect 15% to 25% of patients with
diabetes at some time in their lives, and the
associated complications can have a severe effect
on persons with this condition.1
In general, foot care education for people with
diabetes is directed at patients with a history of
complications, especially those with rising levels of
hemoglobin A1c (HbA1c), and those who have had
diabetes for several years.2 In addition, although
many studies have focused on preventing ulcers and
reducing the risk of amputation,3-6 very few have
sought to determine the level of foot self-care in the
*Department of Nursing and Podiatry, University of
Malaga, Malaga, Spain.
†Institut National de Podologie, Paris, France.
Corresponding author: Gabriel Gijon-Nogueron, DPM,
Department of Nursing and Podiatry, University of Malaga,
Facultad de Ciencias de la Salud C/ Arquitecto Francisco
Peñalosa 3 (Ampliación Campus Teatinos), Malaga 29071,
Spain. (E-mail: gagijon@uma.es)
population with diabetes mellitus.2,7-10 In most
clinical guidelines, patient education and self-care
are recommended to prevent complications of the
diabetic foot.11
Patient-reported outcome questionnaires are
commonly used in this context.12 However, there
must be evidence to support the interpretation of
the scores obtained by such instruments.13
Many instruments are available for evaluating
care and self-care in diabetic patients, including the
Neuropathy Total Symptom Score14 and the Social
Support Scale for Self-care in Middle-Aged Patients
with Type II Diabetes,15 but very few specifically
address foot self-care, and even these combine
questions about self-care with others regarding
general care (eg, the Diabetic Foot Ulcer Scale16
and the Diabetic Foot Ulcer Scale–Short Form17).
Currently available instruments that more specifically address foot self-care are inadequate in
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Background: Diabetic foot care management is directed at patients with a history of
complications, especially those with rising levels of hemoglobin A 1c, and those who have
had diabetes for several years. The aim of this study was to cross-culturally adapt a
French-language version of the Diabetic Foot Self-care Questionnaire of the University
of Malaga (DFSQ-UMA) for use in France.
various areas, such as having an excessive number
of items18 or having undergone an incomplete or
insufficiently rigorous validation process.8
On the other hand, a valid and reliable questionnaire to assess foot self-care by diabetic patients
without amputation—the Diabetic Foot Self-care
Questionnaire of the University of Malaga (DFSQUMA)19—has been proposed, but to date only the
Spanish-language version has been validated.
This study has two main aims: 1) to perform a
cross-cultural adaptation of the DFSQ-UMA into
French and 2) to determine the psychometric
properties of the French-language version of the
DFSQ-UMA (DFSQ-UMA-Fr).
The study was approved by the medical research
ethics committees of the University of Malaga
(Spain) and Institute National de Podologie
(France) and it was conducted in accordance with
the provisions of the Declaration of Helsinki. All of
the participants gave their signed consent. They
were recruited at the Institute National de Podologie (Paris, France) and the following inclusion
criteria were applied: age 18 years or older, diabetic,
French mother tongue, and able to read, understand, and complete the questionnaire unaided.
Cross-cultural Adaptation
The cross-cultural adaptation process was conducted following the guidelines of the International
Society for Pharmacoeconomics and Outcomes
Research for the translation and validation of
patient-reported outcome measures.20 The process
took place in eight stages: 1) forward translation, 2)
forward translation reconciliation, 3) back translation, 4) back translation review, 5) harmonization,
6) pilot testing/cognitive debriefing, 7) pilot testing/
cognitive debriefing review, and 8) proofreading.
The process is summarized in Figure 1.
Forward Translation. Two forward translations
into French were performed from the original
Spanish version of the DFSQ-UMA by two health
professionals, working independently, who were
native French speakers, residents of France, and
fluent in both Spanish and French. Both translators
based their translations on the International Society
for Pharmacoeconomics and Outcomes Research
guidelines.
Forward Translation Reconciliation. The two
forward translations were reconciled into a single
version (draft 1) by the two original translators,
358
Complete the translated DFSQ-UMA and note the
time needed to do so.
Comment on the response options provided.
Comment on any wording that was difficult to
understand.
Suggest alternative wording/phrasing for any
wording that was difficult to understand.
Describe in their own words what the wording
meant to them. These responses were recorded
verbatim and translated into Spanish. The five
patients’ responses were summarized by the
senior investigator. This summary also reflected
the changes, recommendations, and suggestions
indicated by the participants and the in-country
investigators.
Pilot Testing/Cognitive Debriefing Review.
To improve the translated questionnaire, the pilot
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Methods
together with a third, independent translator and
with input from the project leader (G.G-N.).
Back Translation. The reconciled French-language version (draft 1) was back translated into
Spanish by two professional Spanish native translators resident in France, working independently.
These translators had no previous knowledge of the
DFSQ-UMA and were not given the original wording
of the Spanish version of the DFSQ-UMA.
Back Translation Review. The senior investigator, a native French speaker resident in Spain and
fluent in both languages, reviewed the back translation for any discrepancies in meaning or terminology. Any problematic item was discussed until
the discrepancies were resolved. This process
resulted in a second draft of the French translation
(draft 2).
Harmonization. To produce the final French
language translation, a harmonization meeting was
held with the three French translators, the project
leader, and the developer of the original DFSQ-UMA.
During this meeting, any discrepancies or issues
arising from the back translation were discussed, the
translated version of the DFSQ-UMA was evaluated,
and a final version was agreed on.
Pilot Testing/Cognitive Debriefing. Once the
translation process was completed, the translation
was formatted to match the original version. The
translated DFSQ-UMA was initially assessed for
comprehensibility by five patient participants, who
were French residents and native speakers, met the
inclusion criteria, and had a low educational
background without being illiterate. At this stage,
each participant was asked by the in-country
investigator to perform the following tasks:
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Figure 1. Cross-cultural adaptation process. DFSQ-UMA, Diabetic Foot Self-care Questionnaire of the
University of Malaga. (continued on next page)
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359
test results were reviewed by the in-country
investigators. At this stage, any item that caused
comprehension difficulties for more than 40% of the
participants was reviewed, and any modifications
suggested by the respondents were considered for
incorporation in the final translated version.
Proofreading. The project leader and another
translator not involved in the initial translation
process independently proofread the final formatted
translation and discussed possible changes. Furthermore, the Flesch Reading Ease test and the
Flesch-Kincaid Grade Level test were conducted to
determine the readability of the text.21
The draft of the DFSQ-UMA, translated and
360
culturally adapted into French for France, was thus
finalized and the cross-cultural validation phase
begun to obtain the final draft. The following data
for each participant were recorded: age, sex,
occupational status, education level, and diabetesrelated diagnosis.
Once the definitive items were designated, a scale
with five options representing the adequacy of the
patient’s self-care behavior was incorporated into
the questionnaire: 1, very inadequate; 2, inadequate;
3, fair; 4, adequate; 5, very adequate. Exceptionally,
for some items that explored the frequency of a
particular self-care activity, the following scale was
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Figure 1. continued
used: 1, never; 2, rarely; 3, sometimes; 4, often; 5,
always (Fig. 2).
Data Analysis
Results
Translation and Cross-cultural Adaptation
Process
The DFSQ-UMA was translated into French and then
culturally adapted (Fig. 1). The resulting text was
termed DFSQ-UMA-Fr (Fig 2). The pilot test revealed
no discrepancies in meaning or terminology between
the French and Spanish versions of the question-
Figure 2. French questionnaire: the Diabetic Foot
Self-care Questionnaire of the University of Malaga.
naire. Moreover, the respondents did not request
assistance in interpreting the questionnaire, and,
therefore, no modification to the text was required.
Evidence of Validity
A total of 146 patients were included in this study,
although one was excluded from the data analysis
after failing to complete the questionnaire. Of these
146 respondents, 47 were women and 99 were men,
with a mean 6 SD age of 62.60 6 15.47 years. The
characteristics of the study sample are presented in
Table 1.
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For the descriptive statistics, means, standard
deviations, and absolute and relative frequencies
were calculated. The normality of the distributions
was evaluated by the Kolmogorov-Smirnov test and
by analysis of symmetry and kurtosis. Internal
consistency was calculated using Cronbach a, for
which a score of 0.70 to 0.95 was considered
‘‘good.’’22 Item-total and inter-item correlations
were also assessed. Pearson correlations were
calculated to assess the convergent validity between DFSQ-UMA and HbA1c level.
Floor and ceiling effects were evaluated, taking
values between 1% and 15% as optimal.23 To evaluate
test-retest reliability, a subsample of patients (n ¼
30) was asked to repeat the questionnaire. Kappa
statistics with 95% confidence intervals (CIs) were
computed to verify the level of interrater agreement
concerning the different care categories (minimum,
intermediate, semi-intensive, and intensive).
Exploratory factor analysis was conducted, and
the factor structure was determined using principal
component analysis with nonorthogonal rotation
(oblimin). The Kaiser-Meyer-Olkin test and the
Bartlett test of sphericity were used to assess the
appropriateness of the sample for the factor
analysis. Eigenvalues greater than 1 and a scree
plot were used to determine the number of factors.
Factor loadings of 0.4 or greater were considered
appropriate.10 Criterion validity was analyzed by
parametric and nonparametric correlation coefficients between the questionnaire and HbA1c and
glucose levels. This test was conducted because of
the high risk of foot complications derived from
HbA1c values greater than 7%24 and the relation
between HbA1c levels and patient self-care.
All of the statistical analyses were performed
with IBM SPSS Software for Windows, Version 20.0
(IBM Corp, Armonk, New York).
The mean 6 SD score for each item in the foot
health questionnaire was 2.55 6 1.47 points. The
highest mean 6 SD score (2.90 6 1.28) was
obtained for the question Do you generally examine
your foot yourself? and the lowest score (2.16 6
1.66) for Is it hard to find socks that are right for
your feet? Table 2 shows the distribution of the
scores. No ceiling/floor effect was detected.
Reliability Analysis
A Cronbach a of 0.922 was obtained, and the mean
value for inter-item correlations was 0.48 (range,
0.17–0.86). Table 2 lists the distribution of scores
and item-total correlations. The inter-item correlation matrix is detailed in Table 3.
Interrater Reliability
Two independent researchers each assessed the
foot health of 15 patients using the questionnaire.
The interrater levels of agreement ranged from
kappa 0.84 (95% CI, 0.37–0.98) to 0.97 (95% CI, 0.93–
1.0), and the intraclass correlation ranged from 0.89
(95% CI, 0.78–0.94) to 0.92 (95% CI, 0.81–0.96) (Table
4).
Men
(n ¼ 99)
Age (mean 6 SD [years])
61.62 6 16.09
Duration of diabetes
13.28 6 10.23
(mean 6 SD [years])
Glucose (mean 6 SD [mg/dL])
129.57 6 37.30
7.19 6 1.02
HbA1c (mean 6 SD [g/dL])
BMI (mean 6 SD)
27.02 6 6.34
Type of diabetes (No. [% by gender]
Type I
8 (61.54)
Type II non–insulin-dependent
20 (33.9)
Type II insulin-dependent
34 (45.95)
Educational level (No. [%])
Minimum
2 (28.57)
Primary
20 (44.44)
Secondary
29 (50.87)
University
26 (70.27)
ICC
Women
(n ¼ 47)
ICC
Total
(N ¼ 146)
56.17–65.11
12.57–17.16
64.07 6 15.53
16.37 6 11.42
60.3–66.56
11.67–18.58
.02
.187
128.45–150.28
7.04–7.36
26.65–28.83
143.23 6 39.77
7.02 6 0.89
29.53 6 6.89
112.14–136.45
6.59–7.13
26.79–29.09
.470
.057
.640
5 (38.46)
39 (66.1)
40 (54.05)
13
59
74
5 (71.43)
25 (55.6)
38 (49.13)
11 (29.73)
7
45
67
37
P Value
.368
.249
Abbreviations: BMI, body mass index; HbA1c, hemoglobin A1c; ICC, intraclass correlation coefficient.
Table 2. Descriptive Scores and Reliability of Items
Score
(Mean 6 SD)
Item
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Do you generally examine your foot yourself?
Do you look for sores and examine the state of the skin of your feet by yourself?
Do you inspect your nails?
How important do you consider personal care of your feet?
Regarding the recommendations on how to take care of your own feet . . .
To treat skin sores, dry skin patches, and calluses
To dry your feet . . .
Is it hard to find comfortable shoes for your feet?
How often do your cut or treat your toenails?
Is it hard for you to dry your feet after showering?
Regarding socks ...
Regarding conventional footwear, before using it . . .
Is it hard to find socks that are right for your feet?
Regarding new shoes . . .
Regarding summer footwear, with excessive heat, . . .
To warm your feet ...
362
2.9
2.7
2.67
2.59
2.49
2.37
2.49
2.64
2.87
2.25
2.16
2.68
2.7
2.44
2.6
2.6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
1.28
1.65
1.48
1.38
1.58
1.74
1.49
1.55
1.08
1.55
1.66
1.30
1.38
1.6
1.37
0.79
Corrected
Item-Total
Correlation
Cronbach
a if Item
Deleted
0.471
0.559
0.619
0.754
0.83
0.731
0.763
0.581
0.267
0.781
0.769
0.646
0.41
0.712
0.716
0.382
0.921
0.919
0.917
0.914
0.911
0.914
0.913
0.918
0.925
0.912
0.912
0.917
0.923
0.914
0.915
0.925
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Table 1. Characteristics of the 146 Study Patients
Table 3. Inter-item Correlation Matrix
Item No.
Item
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
1
0.589 1
0.573 0.607 1
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1. Do you generally
examine your
foot yourself?
2. Do you look for
sores and
examine the
state of the skin
of your feet by
yourself?
3. Do you inspect
your nails?
4. How important do
you consider
personal care of
your feet?
5. Regarding the
recommendations
on how to take
care of your own
feet . . .
6. To treat skin
sores, dry skin
patches, and
calluses . . .
7. To dry your feet
...
8. Is it hard to find
comfortable
shoes for your
feet?
9. How often do you
cut or treat your
toenails?
10. Is it hard for you
to dry your feet
after showering?
11. Regarding socks
...
12. Regarding
conventional
footwear, before
using it . . .
13. Is it hard to find
socks that are
right for your
feet?
14. Regarding new
shoes . . .
15. Regarding
summer
footwear, with
excessive heat,
...
16. To warm your
feet ...
1.
0.529 0.508 0.596 1
0.406 0.49
0.31
0.594 0.746 1
0.351 0.46
0.64
0.701 1
0.387 0.492 0.518 0.667 0.666 0.675 1
0.233 0.419 0.367 0.375 0.611 0.461 0.492 1
0.155 0.407 0.284 0.279 0.224 0.188 0.169 0.173 1
0.159 0.315 0.343 0.533 0.714 0.756 0.661 0.629 0.164 1
0.256 0.394 0.402 0.523 0.66
0.741 0.703 0.623 0.12
0.385 0.26
0.418 0.5
0.393 0.554 0.61
0.203 0.297 0.183 0.321 0.32
0.857 1
0.342 0.138 0.508 0.428 1
0.141 0.276 0.176 0.094 0.34
0.273 0.459 1
0.314 0.327 0.411 0.546 0.638 0.557 0.569 0.401 0.198 0.623 0.652 0.585 0.359 1
0.137 0.298 0.348 0.528 0.646 0.557 0.651 0.477 0.179 0.742 0.687 0.542 0.41
0.657 1
0.225 0.108 0.261 0.273 0.253 0.339 0.212 0.115 0.037 0.372 0.298 0.442 0.409 0.344 0.306
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Table 4. Factor Analysis
Component
Factor
Is it hard for you to dry your feet after showering?
To dry your feet . . .
To treat skin sores, dry skin patches, and calluses . . .
Regarding summer footwear, with excessive heat, . . .
Regarding socks..
Regarding new shoes. . .
Is it hard to find comfortable shoes for your feet?
Regarding the recommendations on how to take care of your own feet . . .
Do you generally examine your foot yourself?
Do you inspect your nails?
Do you look for sores and examine the state of the skin of your feet by yourself?
How often do you cut or treat your toenails?
How important do you consider personal care of your feet?
To warm your feet ...
Regarding conventional footwear, before using it . . .
Is it hard to find socks that are right for your feet?
Construct Validity (Factor Analysis)
The Kaiser-Meyer-Olkin test result was 0.89, and the
Bartlett test of sphericity was significant (P , .001).
Therefore, the study sampling technique was
assumed to be adequate. The rotated solution
revealed a three-factor structure for the questionnaire, and these factors jointly accounted for 48.10%
of the variance observed: factor 1, (items 5-8, 10, 11,
14, and 15), factor 2 (items 1-4 and 9), and factor 3
(items 12, 13, and 16.)
Criterion Validity
The correlation between questionnaire scores and
HbA1c levels was significant and inverse (r ¼ –0.17;
P , .01).
Discussion
This study provides evidence to support use of the
DFSQ-UMA-Fr for French speakers, following the
successful translation and cross-cultural adaptation
of the original Spanish version. During the pilot
study, the participants had no difficulty understanding the questionnaire, and the translated version
obtained good results in the readability tests.
Further evidence of its validity was provided by
factor analysis and assessment of the criterion
validity.
In general, the results obtained for the psychometric performance of the DFSQ-UMA-Fr are
similar to those of the Spanish version.19 The
364
2
3
0.897
0.721
0.783
0.766
0.881
0.636
0.703
0.727
0.784
0.75
0.81
0.511
0.581
0.767
0.663
0.758
DFSQ-UMA-Fr presents excellent internal consistency, with a Cronbach a score of 0.922. Because
this is the first cross-cultural adaptation and
validation of the DFSQ-UMA, it cannot be compared
with other translations.
It has been reported that HbA1c values greater
than 7% constitute a risk factor for the development
of foot ulcers,24 and, therefore, we hypothesize that
patients with poorer self-care of the feet will tend to
have elevated HbA1c values. Accordingly, the DFSQUMA-Fr could be used to help detect patients with
risk factors for foot ulcers, although further
research, with a larger sample, is needed to confirm
this hypothesis.
Almost 40% of the patients (n ¼ 57) who obtained
a questionnaire result of less than 32 points,
corresponding to inadequate or very deficient selfcare behavior,19 had HbA1c values of 7% or greater,
although the difference is not statistically significant. In addition, these patients with a questionnaire
score less than 32 points and HbA1c values greater
than 7% may have lower levels of health-related
quality of life.25 However, we lack questionnaire
data with which to confirm or reject this possibility.
Questionnaire items 1 (Do you generally examine
your foot yourself?), 2 (Do you look for sores and
examine the state of the skin of your feet by
yourself?), and 9 (How often do your cut or treat
your toenails?) received the highest mean scores
and may also be those of greatest importance
because one of the most dangerous complications
of diabetes is the formation of foot ulcers,4 a
condition that can lead to amputation and, in severe
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10.
7.
6.
15.
11.
14.
8.
5.
1.
3.
2.
9.
4.
16.
12.
13.
1
Conclusions
This study validates the French-language version of
the DFSQ-UMA, enabling its use as a self-reported
outcome measure for French-speaking patients,
both in clinical practice and in the research context.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
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19. NAVARRO-FLORES E, MORALES-ASENCIO JM, CERVERA-MARÍN
JA, ET AL: Development, validation and psychometric
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20. WILD D, GROVE A, MARTIN M, ET AL: Principles of Good
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21. LINNEY S: The Flesch reading ease and Flesch-Kincaid
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https://readable.com/blog/the-flesch-reading-ease-
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cases, is associated with increased mortality.26
Therefore, correct self-care of the feet by patients
with diabetes could help prevent the formation of
ulcers and their consequences.
This study has certain limitations. First, convenience sampling was used, with the patients being
recruited exclusively from the National Institute of
Podiatry (Paris, France). Nevertheless, although the
sample was not prespecified to be explicitly
representative, it did include patients of different
ages, from different educational backgrounds, and
with different types of employment status. Moreover, because the statistical analysis confirmed the
validity of the DFSQ-UMA-Fr, the sampling approach is unlikely to have had a significant influence
on the conclusions drawn. Because this study
validates this French-language version of the
DFSQ-UMA specifically for use in France, further
cross-cultural validation would be required if the
questionnaire were to be used in other Frenchspeaking countries, such as Canada or elsewhere.
Finally, it should be acknowledged that the sample
size is insufficient for a confirmatory analysis to be
conducted to provide the results with more consistency. An increase in the sample size would be in
line with the approach taken with the original
DFSQ-UMA.
and-flesch-kincaid-grade-level/. Accessed August 5,
2019.
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were proposed for measurement properties of health
status questionnaires. J Clin Epidemiol 60: 34, 2007.
23. MCHORNEY CA, TARLOV AR: Individual-patient monitoring
in clinical practice: are available health status surveys
adequate? Qual Life Res 4: 293, 1995.
24. GARCÍA-MORALES E, LÁZARO-MARTÍNEZ JL, MARTÍNEZ-HERNÁNDEZ D, ET AL: Impact of diabetic foot related complica-
tions on the Health Related Quality of Life (HRQol) of
patients: a regional study in Spain. Int J Low Extrem
Wounds 10: 6, 2011.
25. RIBU L, HANESTAD BR, MOUM T, ET AL: Health-related
quality of life among patients with diabetes and foot
ulcers: association with demographic and clinical
characteristics. J Diabetes Complications 21: 227, 2007.
26. VAN SCHIE CHM: A review of the biomechanics of the
diabetic foot. Int J Low Extrem Wounds 4: 160, 2005.
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