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Fulltext Sample size and non-normality effects on goodness of fit measures in structural equation models

Ainur, A.K., Sayang, M.D., Jannoo, Z., Yap, B.W.

Pertanika Journal of Science & Technology, 2017;25(2):575-586.
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A Structural Equation Model (SEM) is often used to test whether a hypothesised theoretical model agrees with data by examining the model fit. This study investigates the effect of sample size and distribution of data (normal and non-normal) on goodness of fit measures in structural equation model. Simulation results confirm that the GoF measures are affected by sample size, whereas they are quite robust when data are not normal. Absolute measures (GFI, AGFI, RMSEA) are more affected by sample size while incremental fit measures such as TLI and CFI are less affected by sample size and non-normality.
Medication adherence and diabetes self-care activities among patients with type 2 diabetes Mellitus

Jannoo Z, Mamode Khan N

Value Health Reg Issues, 2019 May;18:30-35.
PMID: 30419448 DOI: 10.1016/j.vhri.2018.06.003

BACKGROUND: The prevalence of type 2 diabetes mellitus (T2DM) is increasing at an alarming rate in developing countries. The accompanying complications of T2DM can be reduced by maintaining a good adherence to medication and self-care activities.

OBJECTIVES: To evaluate medication adherence and self-care behaviors among patients with T2DM.

METHODS: A total of 497 subjects with T2DM were recruited from three hospitals and a government clinic in the state of Selangor, Malaysia. Previously validated scales were used to measure medication adherence (Morisky Medication Adherence Scale) and diabetes self-care activities (Summary of Diabetes Self-Care Activities). Pearson correlation coefficient was used to investigate the relationship between the risk factors and medication adherence. Pearson χ2 test of association was used to test significant association.

RESULTS: The mean age of the subjects was 55.5 years. The mean Morisky Medication Adherence Scale score was 5.65 ± 1.97, indicating a moderate adherence level to medication. Among the subjects who had low adherence level, 50.9% were Malays, followed by 34.2% Indians. The Pearson χ2 test of association indicated a significant association (P = 0.000) between ethnicity and medication adherence. The subjects had better self-care behaviors in their general diet (mean 5.04 ± 1.88) and poor self-care behaviors in blood sugar testing (mean 2.13 ± 2.34).

CONCLUSIONS: The Malaysians had a moderate medication adherence level, whereas they were nonadherent to blood glucose testing. Emphasis on self-care activities and medication adherence is relevant to improve outcomes in the management of T2DM.
Assessing Diabetes Distress Among Type 2 Diabetes Mellitus in Malaysia Using the Problem Areas in Diabetes Scale

Jannoo Z, Yap BW, Khan NM, Farcomeni A

Value Health Reg Issues, 2019 May;18:159-164.
PMID: 31082796 DOI: 10.1016/j.vhri.2019.03.004

OBJECTIVES: To validate, from a psychometric perspective, the Problem Areas in Diabetes (PAID) questionnaire in patients with type 2 diabetes mellitus from Malaysia.
METHODS: A total of 497 patients with type 2 diabetes mellitus were recruited from public hospitals in the state of Selangor through convenience sampling. Construct validity was evaluated through confirmatory factor analysis. Internal consistency of the instrument was tested by Cronbach α. Criterion validity and discriminant validity were also used.
RESULTS: The PAID instrument consisted of 3 factors: social support problem, food-related problem, and emotional distress problem. The Cronbach α values of the 3 factors showed adequate internal consistency with α values greater than 0.90. The present confirmatory factor analysis model achieved a good fit with a comparative fit index value of 0.923. Satisfactory criterion validity was also demonstrated because there existed positive significant association between glycated hemoglobin A1c and diabetes duration.
CONCLUSIONS: The PAID questionnaire in Malaysia was found to be a reliable and valid instrument exhibiting good psychometric properties.
Fulltext Examining diabetes distress, medication adherence, diabetes self-care activities, diabetes-specific quality of life and health-related quality of life among type 2 diabetes mellitus patients

Jannoo Z, Wah YB, Lazim AM, Hassali MA

J Clin Transl Endocrinol, 2017 Sep;9:48-54.
PMID: 29067270 DOI: 10.1016/j.jcte.2017.07.003

AIMS: Health-Related Quality of Life (HRQoL) has been increasing attention in health outcome studies. Factors that individually influence HRQoL, diabetes self-care behaviors, and medication adherence have been widely investigated; however, most previous studies have not tested an integrated association between multiple health outcomes. The purpose of this study was to formulate a hypothetical structural equation model linking HRQoL, diabetes distress, diabetes self-care activities, medication adherence and diabetes-dependent QoL in patients with Type 2 Diabetes Mellitus (T2DM).
METHODS: A cross-sectional study design was employed, and 497 patients with T2DM were recruited from outpatient clinics in three public hospitals and one government clinic. The patients completed a series of questionnaires. The hypothetical model was tested using Structural Equation Modeling (SEM) analysis.
RESULTS: The values of the multiple fit indices indicated that the proposed model provided a good fit to the data. SEM results showed that medication adherence (MMAS) had a significant direct effect on diabetes distress (PAID) (Beta = -0.20). The self-care activities (SDSCA) construct was significantly related to PAID (Beta = -0.24). SDSCA was found to have a significant relationship with HRQoL (SF-36) (Beta = 0.11). Additionally, diabetes distress had a significant effect (Beta = -0.11) on HRQoL of patients. Finally, ADDQoL had a significant effect on HRQoL (Beta = 0.12).
CONCLUSIONS: The various health outcome indicators such as self-care behaviors, diabetes distress, medication adherence and diabetes-dependent QoL need to be considered in clinical practice for enhancing HRQoL in those patients.
Study site: Hospital Tuanku Ampuan Rahimah, Hospital Sungai Buloh and Hospital Serdang; Klinik Kesihatan Botanic, Kelang, Selangor, Malaysia
An audit of diabetes-dependent quality of life in patients with type 2 diabetes mellitus in Malaysia

Jannoo Z, Yap BW, Musa KI, Lazim MA, Hassali MA

Qual Life Res, 2015 Sep;24(9):2297-302.
PMID: 25800728 DOI: 10.1007/s11136-015-0969-8

PURPOSE: The aim of this study was to evaluate and validate the ADDQoL and to assess the impact of diabetes on QoL among the type 2 diabetes mellitus patients in Malaysia.

METHODS: The Malay and English versions of the ADDQoL questionnaire were administered to patients attending routine outpatient visits in three primary hospitals and a public clinic. The construct validity of the ADDQoL was validated using confirmatory factor analysis (CFA). The sample comprised 350 Malay respondents who rated the ADDQoL Malay version and 246 non-Malay respondents (Chinese or Indian) who answered using the ADDQoL original English version.

RESULTS: CFA confirmed the presence of one-factor structure for both samples. The internal consistency was high with Cronbach's alpha values of 0.945 and 0.907 for the ADDQoL Malay and English versions, respectively. Results showed that for all three ethnicities, the most important domain is 'family life'. Overall, Malay patients stated their 'living conditions' is the most negatively affected, while for Chinese and Indians, diabetes has the greatest impact on their 'freedom to eat'.

CONCLUSIONS: The ADDQoL was found to be culturally appropriate, valid and reliable among Malay- and English-speaking type 2 diabetes mellitus patients in Malaysia.

Study site: routine outpatient visits in three primary hospitals and a public clinic
Fulltext Effects of stress and self-efficacy on quality of life of mothers with autistic children: Covariance-Based Structural Equation Modeling (CB-SEM) approach

Bee Wah Y, Mohd Nasir NN, Hadrawi MF, Kamaruddin AA, Jannoo Z, Afthanorhan A

Belitung Nurs J, 2024;10(2):201-208.
PMID: 38690312 DOI: 10.33546/bnj.3096

BACKGROUND: Mothers who have children with autism encounter significant difficulties in caring for their autistic youngsters, leading to higher stress levels and a reduced overall quality of life. External or internal factors can cause and respond to stress, affecting an individual's physical, psychological, and emotional health. Thus, it is crucial to examine the quality of life of mothers with autistic children.
OBJECTIVES: This study aimed to investigate the relationships between stress, self-efficacy, and quality of life (QoL) in mothers of children with autism.
METHODS: A cross-sectional study design was used. Self-administered questionnaires were distributed from October to November 2019 to mothers with autistic children using cluster sampling techniques to capture their demographics and perceptions of stress, self-efficacy, and QoL. The data analysis was performed using covariance-based structural equation modeling (CB-SEM).
RESULTS: Of the 290 questionnaires distributed, 238 (response rate of 82%) sets were returned, but only 181 questionnaires were usable for further analysis. The findings demonstrated a notable impact of stress and self-efficacy on quality of life and an adverse effect of stress on self-efficacy. Self-efficacy serves as an intermediary in the relationship between stress and quality of life.
CONCLUSION: In general, mothers of autistic children typically face moderate stress levels, but they have low levels of self-efficacy and quality of life. Mothers of children with autism need assistance and support from healthcare professionals, such as doctors, nurses, and psychiatrists, so that they can bear the challenges of raising children with special needs and enjoy a higher standard of living with less emotional and physical strain.