Proceso de adaptación cultural del “Questionnaire for Assesing the Childbirth Experience (QACE)”

Introducción: Las experiencias negativas durante el parto se han asociado con desempoderamiento de la mujer, depresión postparto, trastorno por estrés postraumático y bajas tasas de lactancia maternal, entre otros. El Questionnaire for Assessing the Childbirth Experience (QACE) es una herramienta de 23 ítems útil para identificar mujeres que han tenido una mala experiencia en su proceso de parto y evitar así futuras complicaciones en embarazos posteriores o en la relación de pareja.Objetivo: El objetivo general consiste en adaptar el Questionnaire for Assessing the Childbirth Experience (QACE) a la población española y obtener sus características psicométricas.Metodología: El proceso de adaptación cultural ha consistido en la traducción y retro traducción al español, evaluación de la equivalencia conceptual por un comité de jueces, evaluación de la comprensibilidad y una entrevista cognitiva a un grupo de mujeres puérperas. Las características psicométricas se han obtenido mediante el análisis factorial, los test de Kaiser-Meyer-Olkin (KMO) y Bartlett y el alfa de Cronbach.Resultados: Tras el proceso de adaptación transcultural, el grupo de expertos realizó las modificaciones necesarias para conseguir una mayor compresión del cuestionario en la población española, evitar malentendidos y palabras ofensivas en la lengua de destino. Se necesitaron 138 participantes para obtener el análisis factorial. El KMO (0,838) y el test de Bartlett (p < 0,001) confirmaron la adecuación del análisis factorial y el grafico de sedimentación mostró 6 factores con un poder predictivo del 73,75% del total de la varianza. La consistencia interna se obtuvo mediante un alfa de Cronbach de 0,896.Conclusiones: Los datos obtenidos en este estudio demuestran que la versión española del QACE es una herramienta válida y fiable para medir la experiencia en el nacimiento en la población española. Background: Negative experiences during delivery are associated with women disempowerment, postpartum depression, post-traumatic stress disorder, and low breastfeeding rates. The Questionnaire for Assessing the Childbirth Experience (QACE) is a 23-item screening tool useful for discovering women with a negative experience in their birth process and avoids future complications in following pregnancies or couple's relationships. Objective: The general objective is to adapt the Questionnaire for Assessing the Childbirth Experience (QACE) to the Spanish population and to obtain its psychometric characteristics.Methodology: The cultural adaptation process consisted of forwarding translation and back translation into Spanish, conceptual equivalence evaluation by a committee of judges, comprehensibility evaluation and cognitive interview to a postpartum group. Psychometric characteristics were obtained throughout the factorial analysis, Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity and Cronbach alpha level.Results: After complete the adaptation process, the committee of judges made several adjustments to achieve a better comprehension in the Spanish population, avoid misunderstandings or offensive words in the target language. 138 participants were needed to calculate factor analysis. The KMO (0.838) and Bartlett test (p < 0.001) confirmed the adequacy of factor analysis and the Scree plot showed 6 factors with the predictive power of 73.75% supported total variance. Internal consistency was assured using a Cronbach α of 0.896.Conclusions: Data from this study demonstrate that the Spanish version of QACE is a valid and reliable measure of childbirth experience in the Spanish population.

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Trait anxiety and unplanned delivery mode enhance the risk for childbirth-related post-traumatic stress disorder symptoms in women with and without risk of preterm birth: A multi sample path analysis

PLoS ONE ◽

10.1371/journal.pone.0256681 ◽

2021 ◽

Vol 16 (8) ◽

pp. e0256681

Author(s):

Sarah Sommerlad ◽

Karin Schermelleh-Engel ◽

Valentina Lucia La Rosa ◽

Frank Louwen ◽

Silvia Oddo-Sommerfeld

Keyword(s):

Preterm Birth ◽

Pain Intensity ◽

Trait Anxiety ◽

Sample Path ◽

Delivery Mode ◽

Ptsd Symptoms ◽

Post Traumatic Stress ◽

Sample Path Analysis ◽

Childbirth Experience ◽

Post Traumatic

Childbirth-related post-traumatic stress disorder (CB-PTSD) occurs in 3–7% of all pregnancies and about 35% of women after preterm birth (PTB) meet the criteria for acute stress reaction. Known risk factors are trait anxiety and pain intensity, whereas planned delivery mode, medical support, and positive childbirth experience are protective factors. It has not yet been investigated whether the effects of anxiety and delivery mode are mediated by other factors, and whether a PTB-risk alters these relationships. 284 women were investigated antepartum and six weeks postpartum (risk-group with preterm birth (RG-PB) N = 95, risk-group with term birth (RG-TB) N = 99, and control group (CG) N = 90). CB-PTSD symptoms and anxiety were measured using standardized psychological questionnaires. Pain intensity, medical support, and childbirth experience were assessed by single items. Delivery modes were subdivided into planned vs. unplanned delivery modes. Group differences were examined using MANOVA. To examine direct and indirect effects on CB-PTSD symptoms, a multi-sample path analysis was performed. Rates of PTS were highest in the RG-PB = 11.58% (RG-TB = 7.01%, CG = 1.1%). MANOVA revealed higher values of CB-PTSD symptoms and pain intensity in RG-PB compared to RG-TB and CG. Women with planned delivery mode reported a more positive birth experience. Path modeling revealed a good model fit. Explained variance was highest in RG-PB (R2 = 44.7%). Direct enhancing effects of trait anxiety and indirect reducing effects of planned delivery mode on CB-PTSD symptoms were observed in all groups. In both risk groups, CB-PTSD symptoms were indirectly reduced via support by medical staff and positive childbirth experience, while trait anxiety indirectly enhanced CB-PTSD symptoms via pain intensity in the CG. Especially in the RG-PB, a positive birth experience serves as protective factor against CB-PTSD symptoms. Therefore, our data highlights the importance of involving patients in the decision process even under stressful birth conditions and the need for psychological support antepartum, mainly in patients with PTB-risk and anxious traits. Trial registration number: NCT01974531 (ClinicalTrials.gov identifier).

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Women’s Perceptions of Living a Traumatic Childbirth Experience and Factors Related to a Birth Experience

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph16091654 ◽

2019 ◽

Vol 16 (9) ◽

pp. 1654 ◽

Cited By ~ 8

Author(s):

Julián Rodríguez-Almagro ◽

Antonio Hernández-Martínez ◽

David Rodríguez-Almagro ◽

José Miguel Quirós-García ◽

Juan Miguel Martínez-Galiano ◽

...

Keyword(s):

Maternal Mental Health ◽

Developed Countries ◽

World Health ◽

Healthcare Personnel ◽

Negative Consequences ◽

Birth Experience ◽

Birth Process ◽

Childbirth Experience ◽

Monitoring Protocols ◽

Traumatic Childbirth

Although identified by the World Health Organization (WHO) as a global health priority, maternal mental health does not receive much attention even in the health systems of developed countries. With pregnancy monitoring protocols placing priority on the physical health of the mother, there is a paucity of literature documenting the traumatising effects of the birth process. To address this knowledge gap, this qualitative descriptive study aimed to investigate women perceptions of living a traumatic childbirth experience and the factors related to it. Qualitative data, collected via semi-structured interviews with 32 participants recruited from parent support groups and social media in Spain, were analyzed through a six-phase inductive thematic analysis. Data analysis revealed five major themes―“Birth Plan Compliance”, “Obstetric Problems”, “Mother-Infant Bond”, “Emotional Wounds” and “Perinatal Experiences”—and 13 subthemes. The majority of responses mentioned feelings of being un/misinformed by healthcare personnel, being disrespected and objectified, lack of support, and various problems during childbirth and postpartum. Fear, loneliness, traumatic stress, and depression were recurrent themes in participants’ responses. As the actions of healthcare personnel can substantially impact a birth experience, the study findings strongly suggest the need for proper policies, procedures, training, and support to minimise negative consequences of childbirth.

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Nigerian (Yoruba) version of Disabilities of the Arm, Shoulder and Hand questionnaire (DASH-Y): Cross-cultural adaptation and initial validation

Hand Therapy ◽

10.1177/1758998316656659 ◽

2016 ◽

Vol 21 (4) ◽

pp. 140-150 ◽

Cited By ~ 4

Author(s):

Adesola C Odole ◽

Nse A Odunaiya ◽

Chidinma F Mbaike ◽

Peter O Ibikunle ◽

Adefemi A Akinseloyin ◽

...

Keyword(s):

Factor Analysis ◽

Upper Extremity ◽

Rank Correlation ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Data Set ◽

Initial Validation ◽

Culturally Adapted ◽

Conceptual Equivalence ◽

Dash Questionnaire

Introduction The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is a widely used upper extremity outcome measure. However, it is yet to be translated into any of the major languages in Nigeria, thus limiting its utility in the Nigerian clinical setting. The aim of this study was to cross-culturally adapt the DASH questionnaire into Yoruba, a major Nigerian language and investigate its initial validation. Methods The English version of DASH was adapted into Yoruba through forward–back translations, experts’ committee meetings, pretesting and cognitive debriefing interview in accordance with the guidelines recommended by the developers of DASH. Fifty-two purposively selected patients with upper extremity musculoskeletal disorders participated in a cross-sectional survey. Factor analysis was performed to ensure structural validity of Yoruba version, and construct validity was investigated with Spearman rank correlation coefficient. Results The Yoruba version of DASH has semantic, idiomatic, linguistic and conceptual equivalence with the English DASH. Thirty linear components were identified within the data set. Principal factor analysis of the Yoruba DASH revealed a seven factor scale, having fulfilled all the necessary conditions. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.61, and Barlett’s test of Sphericity was adequate and significant (χ2 (1066) = 435, p = 0.001). Significant correlation (r = 0.994, p = 0.001) exists between scores obtained on English and Yoruba versions of DASH. Conclusion A cross-culturally adapted, valid Yoruba version of DASH is available for use in in south western Nigeria and other similar populations.

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The German Adaptation of the Therapist Beliefs about Exposure Scale: a Validation Study among Licensed Cognitive Behavioural Therapists in Germany

Behavioural and Cognitive Psychotherapy ◽

10.1017/s1352465818000371 ◽

2018 ◽

Vol 47 (2) ◽

pp. 164-180 ◽

Cited By ~ 2

Author(s):

Sarah Schumacher ◽

Nadine M. Schopka ◽

Manuel Heinrich ◽

Christine Knaevelsrud

Keyword(s):

Factor Analysis ◽

Clinical Training ◽

Factor Model ◽

Post Traumatic Stress ◽

Negative Attitudes ◽

Present Sample ◽

Negative Beliefs ◽

Cognitive Behavioural ◽

German Speaking ◽

German Adaptation

Background: Exposure is an effective intervention in the treatment of pathological anxiety, but it is insufficiently disseminated. Therapists’ negative attitudes towards exposure might be of relevance when considering factors contributing to the non-application of this intervention. Aims: In order to be able to measure concerns in German-speaking therapist populations, the study aimed at validating a German version of the Therapist Beliefs about Exposure Scale.Method: The scale was translated into the German language and validated in a sample of 330 German licensed cognitive behavioural therapists. Results: In the present sample, the mean total score was significantly lower than in the original study including US-American therapists. Confirmatory factor analysis did not confirm the proposed one-factor model, while the exploratory factor analysis indicated that more than one factor is necessary to explain the structure of negative attitudes towards exposure. The internal consistency was high. Higher scores (more negative beliefs) were significantly correlated with older age, holding a master's degree (vs PhD), not being specialized in the treatment of anxiety disorders and with less experience with performance of exposure gained during clinical training. Negative beliefs about exposure were further associated with the self-reported average number of sessions spent on exposure in current treatment of post-traumatic stress disorder and panic disorder, and with negative attitudes towards application of exposure sessions presented in case vignettes. Conclusions: The German adaptation provides the opportunity of measuring concerns regarding application of exposure in German-speaking therapist populations. However, the presented data reveal suggestions for further scale development.

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Psychometric properties of the Children's Revised Impact of Events Scale (CRIES) with Bangladeshi children and adolescents

10.7287/peerj.preprints.337 ◽

2014 ◽

Author(s):

Farah Deeba ◽

Ronald M Rapee ◽

Tania Prvan

Keyword(s):

Factor Analysis ◽

Confirmatory Factor Analysis ◽

Psychometric Properties ◽

Children And Adolescents ◽

Convergent Validity ◽

Traumatic Events ◽

Post Traumatic Stress ◽

Confirmatory Factor ◽

Impact Of Events Scale ◽

And Gender

Identification of possible cases suffering post-traumatic stress disorder (PTSD) is important, especially in developing countries where traumatic events are typically prevalent. The Children’s Revised Impact of Events Scale is a reliable and valid measure that has two brief versions (13 items and 8 items) to assess reactions to traumatic events among young people. The current study evaluated the psychometric properties of both versions of the CRIES in a sample of 1342 children and adolescents aged 9-17 years (M=12.3 years, SD=2.12) recruited from six districts of Bangladesh. A sub-group of 120 children from four schools was re-tested on the measures within 3.5 weeks. Confirmatory factor analysis supported factor structures similar to those found in other studies for both versions of the CRIES. Multiple group confirmatory factor analysis showed gender and age-group differences within the sample, supporting established age and gender differences in prevalence of PTSD symptoms. Analyses also indicated moderate to excellent internal consistency and test-retest reliability and clear discriminant and convergent validity. These data support use of both the CRIES-13 and CRIES-8 to provide quick and psychometrically sound assessment of symptoms of PTSD among children and adolescents from Bangla-speaking communities.

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Psychosocial factors associated with postpartum psychological distress during the Covid-19 pandemic: a cross-sectional study.

10.21203/rs.3.rs-54728/v2 ◽

2020 ◽

Author(s):

Luca Ostacoli ◽

Stefano Cosma ◽

Federica Bevilacqua ◽

Paola Berchialla ◽

Marialuisa Bovetti ◽

...

Keyword(s):

Psychological Distress ◽

Attachment Style ◽

Traumatic Stress ◽

Protective Factor ◽

Post Traumatic Stress ◽

Childbirth Experience ◽

Stress Symptoms ◽

Epidemic Area ◽

Post Traumatic ◽

The Impact

Abstract Background Trauma, natural and man-made catastrophic events can be predictors of postpartum psychological distress. In a public health response due to coronavirus disease 2019 outbreak, the Italian government imposed a lockdown from March 9 to May 3. This extraordinary situation may have been challenging for maternal psychological health. The aim of this study was to investigate the prevalence of depressive and post-traumatic stress symptoms in women giving birth during the Covid-19 pandemic and its associations with quarantine measures, obstetrical factors, and relational attachment style. Methods Women who gave birth in a high-volume obstetric/gynaecological medical centre located in an epidemic area during the Covid-19 pandemic (March 8 to June 15) were asked to complete an online survey about their childbirth experience and the perceived effect of the pandemic. The Edinburgh Postnatal Depression Scale (EPDS), the Impact of Event Scale-Revised (IES-R), and the Relationship Questionnaire (RQ) were administered to assess levels of postpartum depressive and post-traumatic stress symptoms (PTSS) and relational style of attachment, respectively. Multivariate analysis was applied to identify associations between quarantine measures, childbirth experience, attachment style, and EPDS and IES-R scores.Results The survey was completed by 163 women (response rate 60.8%). The prevalence of depressive symptoms was 44.2% (EPDS cut-off score ≥11) and the PTSS rate was 42.9% (IES-R cut-off score ≥24). Dismissive and fearful avoidant attachment styles were significantly associated with the risk of depression and PTSS, respectively. Perceived pain during birth was a risk factor for postpartum depression. Perceived support provided by healthcare staff was a protective factor against depression and PTSS. Another protective factor against PTSS was quiet on the ward due to the absence of hospital visitors. Conclusion This study reports a high prevalence of postpartum depressive and PTSS in women who gave birth during the Covid-19 pandemic. Postnatal psychological distress seemed to be associated more with the prenatal experience and other individual factors than with the pandemic hospital restrictions. Early detection during pregnancy of an insecure attachment style is fundamental to provide targeted preventive and therapeutic psychological interventions.

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Validation of the care providers version of the Rainbow Model of Integrated Care-Measurement Tool in Chinese primary care systems

10.21203/rs.2.20137/v2 ◽

2020 ◽

Author(s):

Yixiang Huang ◽

Paiyi Zhu ◽

Lijin Chen ◽

Xin Wang ◽

Pim Valentijn

Keyword(s):

Primary Care ◽

Factor Analysis ◽

Psychometric Properties ◽

Integrated Care ◽

Exploratory Factor Analysis ◽

Internal Consistency ◽

Internal Consistency Reliability ◽

Measurement Tool ◽

Adaptation Process ◽

Care Systems

Abstract Background: The original Rainbow Model of Integrated Care Measurement Tool (RMIC-MT) is based on the Rainbow Model of Integrated Care (RMIC), which provides a comprehensive theoretical framework for integrated care. To translate and adapt the original care provider version of the RMIC-MT and evaluate its psychometric properties by a pilot study in Chinese primary care systems.Methods: The translation and adaptation process were performed in four steps, forward and back-translation, experts review and pre-testing. We conducted a cross-sectional study with 1610 community care professionals in all 79 community health stations in the Nanshan district. We analyzed the distribution of responses to each item to study the psychometric sensitivity. Exploratory factor analysis with principal axis extraction method and promax rotation was used to assess the construct validity. Cronbach’s alpha was utilized to ascertain the internal consistency reliability. Lastly, confirmation factor analysis was used to evaluate the exploratory factor analysis model fit.Results: During the translation and adaptation process, all 48 items were retained with some detailed modifications. No item was found to have psychometric sensitivity problems. Six factors (person- & community-centeredness, care integration, professional integration, organizational integration, cultural competence and technical competence) with 45 items were determined by exploratory factor analysis, accounting for 61.46% of the total variance. A standard Cronbach’s alpha of 0.940 and significant correlation among all items in the scale (>0.4) showed good internal consistency reliability of the tool. And, the model passed the majority of goodness-to-fit test by confirmation factor analysis Conclusions: The results showed initial satisfactory psychometric properties for the validation of the Chinese RMIC-MT provider version. Its application in China will promote the development of people-centered integrated primary care. However, further psychometric testing is needed in multiple primary care settings with both public and private community institutes.

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Validation of the Iranian version of the childbirth experience questionnaire 2.0

BMC Pregnancy and Childbirth ◽

10.1186/s12884-019-2606-y ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 5

Author(s):

Solmaz Ghanbari-Homayi ◽

Anna Dencker ◽

Zahra Fardiazar ◽

Mohammad Asghari Jafarabadi ◽

Sakineh Mohammad-Alizadeh-Charandabi ◽

...

Keyword(s):

Factor Analysis ◽

Correlation Coefficient ◽

Intraclass Correlation Coefficient ◽

Internal Consistency ◽

Intraclass Correlation ◽

Group Method ◽

Childbirth Experience ◽

Childbirth Experience Questionnaire ◽

Experience Questionnaire ◽

Childbirth Experiences

Abstract Background Assessing women’s childbirth experiences is a crucial indicator in maternity services because negative childbirth experiences are associated with maternal mortalities and morbidities. Due to the high caesarean birth rate in Iran, measuring childbirth experience is a top priority, however, there is no standard tool to measure this key indicator in Iran. The aim of present study is to adapt the “Childbirth Experience Questionnaire 2.0” to the Iranian context and determine its psychometric characteristics. Methods Childbirth Experience Questionnaire 2.0 was translated into Farsi. A total of 500 primiparous women, at 4 to 16 weeks postpartum, were randomly selected from 54 healthcare centres in Tabriz. Internal consistency and reliability was calculated using the Cronbach’s Coefficient alpha and Intraclass Correlation Coefficient, respectively. Construct validity was assessed using exploratory and confirmatory factor analysis and discriminant validity using the known-group method and the Mann-Whitney U-test. Results The internal consistency and reliability for the total tool were high (Cronbach’s alpha = 0.93; Intraclass Correlation Coefficient = 0.97). Explanatory factor analysis demonstrated the adequacy of the sampling (Kaiser-Meyer-Olkin = 0.923) and significant factorable sphericity (p < 0.001). Confirmation factor analysis demonstrated acceptable values of fitness (RMSEA = 0.07, SRMSEA = 0.06, TLI = 0.97, CFI > 0.91, x2/ df = 4.23). Discriminatory validity of the tool was confirmed where the CEQ score and its subdomains were significantly higher in women who reported having control over their childbirth than women who did not. Conclusion The Farsi version of the Childbirth Experience Questionnaire 2.0 tool is a valid and reliable tool and can be used to measure the childbirth experience in Iranian women.

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Development of an Instrument to Assess Work Productivity in Individuals With Voice Disorders: The Work Hoarse

Annals of Otology Rhinology & Laryngology ◽

10.1177/0003489418803961 ◽

2018 ◽

Vol 128 (1) ◽

pp. 5-12 ◽

Cited By ~ 2

Author(s):

Qiubei Zhu ◽

Amanda Hu ◽

John Paul Giliberto ◽

Samantha Carlson ◽

Samantha Jensen ◽

...

Keyword(s):

Factor Analysis ◽

Exploratory Factor Analysis ◽

Cognitive Interview ◽

Work Productivity ◽

Activity Impairment ◽

Vocal Function ◽

Work Impairment ◽

Preliminary Validation ◽

The Impact ◽

The Voice

Objectives: Vocal function is critical to employability in the modern era. Although research clearly demonstrates that a disordered voice affects quality of life, few studies have attempted to quantitate the effects of a disordered voice on work productivity. The Voice-Related Statements battery, which originally had 20 items, was previously developed to qualitatively describe how an individual’s dysphonia affects his or her job performance. The aim of this study was to refine and reduce the item number and provide preliminary validation of this shortened instrument. Methods: The Voice-Related Statements instrument was administered to employed patients with dysphonia in conjunction with 2 additional instruments: the Voice Handicap Index (VHI) and the Work Productivity and Activity Impairment questionnaire (WPAI). Response distributions and intercorrelations were examined for item reduction. Exploratory factor analysis was conducted on retained items. Correlations were performed with other voice-related instruments. Reliability was tested using a coefficient of stability. Results: One hundred seventy-four employed patients with dysphonia were enrolled in this study. Six items were removed because of redundancy, factor analysis, and cognitive interview results. Exploratory factor analysis revealed a 1-factor structure explaining 66.28% of the total variance. The final 8-item instrument demonstrated good internal consistency (Cronbach α = 0.93), with a moderately robust correlation with the VHI ( r = 0.68, P < .001) and WPAI work impairment measures ( r = 0.63, P < .001). The VHI showed a much weaker correlation with WPAI work impairment ( r = 0.48, P < .001). Test-retest reliability was good (0.83, P < .01). Conclusions: An 8-item instrument to qualitatively measure the impact of a disordered voice at work has been developed and is called the Work Hoarse. This instrument is a better measure of voice-related work productivity impairment than the VHI and will augment quantitative work productivity instruments that are currently available.

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Psychometric Properties of the Arabic Version of the Summary of Diabetes Self-Care Activities Instrument

Research and Theory for Nursing Practice ◽

10.1891/1541-6577.30.1.60 ◽

2016 ◽

Vol 30 (1) ◽

pp. 60-69 ◽

Cited By ~ 5

Author(s):

Ola Sukkarieh-Haraty ◽

Elizabeth Howard

Keyword(s):

Factor Analysis ◽

Psychometric Properties ◽

Discriminant Validity ◽

Self Care ◽

Internal Consistency Reliability ◽

Target Language ◽

Scaling Analysis ◽

Arabic Version ◽

Glucose Testing ◽

Patients With Diabetes

Translation of instruments needs to ensure equivalence between the source and the target language to establish the psychometric properties of the translated version. The purpose of this study was to examine the psychometric properties of the Arabic version of the Summary of Diabetes Self-Care Activities (SDSCA) instrument. The 12-item English version of the SDSCA was translated into Arabic using back translation on a sample of 140 Lebanese participants with Type 2 diabetes. Construct validity was measured using exploratory factor analysis with varimax rotation. Multitrait scaling analysis was used to test for item convergent and discriminant validity based on item–scale correlations. Conceptual and content validity were examined by an expert panel in diabetes. Internal consistency reliability R was assessed using interitem correlations. The average interitem correlation for the four subscales ranged between –.05 for Diet and .66 for Glucose Testing. Factor analysis identified four factors which accounted for 60% of the variance. The preliminary results of Summary of Diabetes Self-Care Activities-Arabic Version (SDSCA-Ar) are comparable to the psychometric properties the original SDSCA. SDSCA-Ar is a valid measure of diabetes self-care in Lebanese patients with diabetes.

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