The South African Gestational Diabetes Mellitus Knowledge Questionnaire (SA-GDMKQ)<\/strong> is an adapted and linguistically validated psychometric instrument designed to assess condition-specific health literacy<\/a>, factual understanding, and self-care awareness among pregnant women diagnosed with gestational diabetes mellitus (GDM)<\/a>. Originating from an initial instrument developed in Malaysia by Hussain and colleagues, the scale was systematically adapted, translated, and psychometrically evaluated for use in South Africa\u2019s pluralistic, multilingual public healthcare infrastructure by Manas, Chivese, Coetzee, Conradie, and Morris. The instrument captures a multidimensional construct encompassing foundational disease biology, epidemiological risk factors, nutritional and dietary management, therapeutic medical regimens, and acute and long-term perinatal complications affecting both maternal and fetal dyads.<\/p>\n Structurally, the questionnaire consists of items formatted with multiple-choice alternatives including a dedicated “I do not know” option to mitigate guessing bias. Psychometric evaluations conducted across three official languages of the Western Cape region\u2014English, Afrikaans, and isiXhosa\u2014demonstrated strong content and face validity through multidisciplinary expert panel reviews and qualitative cognitive pre-testing. Internal consistency analyses yielded Cronbach’s alpha<\/a> coefficients of 0.434 for the English version, 0.534 for the Afrikaans version, and 0.621 for the isiXhosa version. These values reflect the broad, formative breadth inherent to clinical knowledge indexes where domain components do not necessarily co-vary unidimensionally. Test-retest reliability evaluated across a two-week interval exhibited moderate stability in aggregate scores, although individual item-level concordance demonstrated wide variation. The SA-GDMKQ fills a critical void in maternal health psychology in sub-Saharan Africa, enabling clinicians and behavioral researchers to identify specific educational deficits, optimize diabetes self-management education, and evaluate the efficacy of antenatal health interventions.<\/p>\n Gestational Diabetes Mellitus, Health Literacy, Psychometrics, Maternal Health Psychology, Cross-Cultural Adaptation, Antenatal Education, Disease Knowledge Questionnaire, Perinatal Outcomes, Self-Management, South Africa<\/p>\n The cross-cultural adaptation, translation, and initial clinical psychometric validation of the South African Gestational Diabetes Mellitus Knowledge Questionnaire were conducted by an interdisciplinary team of researchers and clinical specialists affiliated with Stellenbosch University in the Western Cape, South Africa:<\/p>\n Gestational diabetes mellitus is characterized by spontaneous hyperglycemia<\/a> first recognized during pregnancy, posing severe immediate and long-term hazards to both mother and fetus. Clinical sequelae include pre-eclampsia<\/a>, maternal birth trauma, fetal macrosomia<\/a>, shoulder dystocia, neonatal respiratory distress, hypoglycemia, and an elevated lifelong risk for both mother and offspring of developing type 2 diabetes mellitus<\/a>. Managing GDM requires rapid, intensive behavioral adaptation immediately following diagnosis, involving rigorous daily self-monitoring of blood glucose, complex dietary alterations, adherence to physical activity guidelines, and, in many cases, pharmacotherapy such as insulin injections or oral hypoglycemic agents.<\/p>\n Despite these clinical demands, antenatal healthcare services in low- and middle-income countries (LMICs), particularly across Southern Africa, frequently operate under substantial resource limitations. Overburdened public referral clinics, constrained consultation times, systemic inequalities, and widespread disparities in baseline educational attainment create pronounced barriers to effective patient education. Clinicians cannot simply presume that diagnostic disclosures translate into functional patient understanding. Prior to the development and adaptation of the SA-GDMKQ, South African clinicians and clinical researchers lacked a standardized, culturally validated, and linguistically accessible instrument to quantify what pregnant women actually understand about their diagnosis.<\/p>\n The purpose of the SA-GDMKQ is threefold:<\/p>\n The psychological construct assessed by the SA-GDMKQ is condition-specific health literacy<\/strong>, operationalized as the patient’s factual comprehension, procedural awareness, and cognitive appraisal of gestational diabetes mellitus and its therapeutic management. In health psychology and psychometrics, health literacy is recognized as an active cognitive and behavioral resource rather than passive memorization. It forms the cognitive substrate upon which self-efficacy, risk perception, and self-regulatory behaviors are built.<\/p>\n Within the SA-GDMKQ framework, this construct is conceptualized as multidimensional, spanning five interdependent domains of operational knowledge:<\/p>\n This dimension assesses the patient’s fundamental grasp of GDM as a distinct metabolic aberration triggered by pregnancy-induced hormonal shifts and pancreatic beta-cell decompensation. It investigates whether the patient recognizes what GDM is, that it manifests as elevated circulating blood glucose levels, and how it differs from pre-existing chronic diabetes. Misconceptions in this domain\u2014such as believing GDM is a permanent, non-manageable curse or conversely trivializing it as benign fluid retention\u2014can undermine engagement with clinical care.<\/p>\n This subscale evaluates the respondent’s awareness of personal and familial vulnerabilities that elevate susceptibility to GDM. Key indicators include pre-pregnancy maternal obesity, advanced maternal age, prior history of delivering macrosomic infants, and familial patterns of diabetes mellitus. Understanding risk factors helps dispel self-blame, enhances psychological acceptance, and reinforces the biological reality of the condition.<\/p>\n Dietary modification serves as the first-line therapeutic pillar in GDM management. This dimension measures the patient’s operational knowledge regarding macronutrient quality, carbohydrate portion control, glycemic index concepts, the hazards of consuming refined sugars, and the critical importance of consistent meal timing. Crucially, it examines whether patients harbor dangerous misconceptions, such as believing that skipping meals is an effective method to control hyperglycemia, which can paradoxically induce maternal ketoacidosis or reactive hypoglycemia.<\/p>\n This facet examines procedural and technical knowledge regarding disease management protocols. It assesses comprehension of home blood glucose monitoring (HBGM), acceptable target glycemic ranges, physical activity recommendations (such as brisk walking), and indications for pharmacotherapy. A major psychometric focus is measuring attitudes and knowledge concerning insulin, specifically evaluating whether patients hold unwarranted fears that insulin cross-contaminates the placenta or causes congenital fetal deformities.<\/p>\n The final dimension evaluates the patient’s cognitive appraisal of the health trajectories of both mother and neonate. It measures awareness of intrapartum complications (e.g., severe perineal tearing, emergency cesarean section secondary to macrosomia), acute neonatal hazards (e.g., neonatal hypoglycemia, respiratory distress), and long-term postpartum risks, specifically the elevated lifetime risk of developing chronic type 2 diabetes mellitus. Additionally, it evaluates knowledge regarding protective postpartum behaviors, such as infant breastfeeding and mandatory 6-to-12-week postpartum oral glucose tolerance testing.<\/p>\n The conceptual architecture of the SA-GDMKQ is anchored in several prominent models of health behavior, cognitive psychology, and psychometric measurement:<\/p>\n Developed by Fisher, Fisher, and colleagues, the Information-Motivation-Behavioral Skills (IMB) model<\/a> posits that health-related behaviors are a direct function of three interacting components: possessing accurate, actionable information; holding personal and social motivation to act; and mastering specific behavioral skills. Within the IMB paradigm, information is the necessary prerequisite for behavior change. When applied to GDM, accurate knowledge regarding carbohydrate metabolism, insulin function, and fetal vulnerability directly informs a woman’s motivation and equips her to execute the complex behavioral skills needed for glycemic control.<\/p>\n The Health Belief Model<\/a> (Rosenstock, 1974; Becker, 1974) provides a complementary theoretical lens. The HBM asserts that individuals engage in preventative or therapeutic health behaviors if they perceive themselves to be susceptible to a condition (perceived susceptibility), believe the condition carries severe physical or social consequences (perceived severity), and believe that available actions will successfully mitigate these risks (perceived benefits) without being outweighed by psychological, financial, or physical costs (perceived barriers). The SA-GDMKQ directly measures the cognitive foundations of perceived susceptibility and severity by probing maternal awareness of fetal macrosomia, stillbirth, pre-eclampsia, and long-term maternal diabetes. Furthermore, by evaluating knowledge of nutritional regimens and insulin safety, the scale evaluates the patient’s grasp of the perceived benefits of treatment regimens, dismantling perceived barriers rooted in medical misinformation.<\/p>\n From a classical psychometric standpoint, knowledge scales diverge fundamentally from personality or affective scales. In reflective measurement models (common in anxiety or depression inventories), the latent construct causes the item responses, leading to high inter-item correlations and high Cronbach’s alphas. In contrast, knowledge questionnaires frequently behave as formative<\/em> or composite measurement models (Bollen & Lennox, 1991). In a formative construct, individual items define and compose the construct rather than merely reflecting it. A pregnant woman may possess accurate knowledge regarding dietary fiber and carbohydrate restriction while remaining entirely uninformed about postpartum glucose tolerance testing or insulin pharmacodynamics. Thus, domain divergence is theoretically expected and psychometrically defensible.<\/p>\n The validation of the SA-GDMKQ was executed using a rigorous methodological framework designed to ensure conceptual, semantic, and operational equivalence across diverse cultural and linguistic groups in South Africa.<\/p>\n The adaptation process adhered strictly to international guidelines for the cross-cultural adaptation of self-report measures established by Beaton et al. (2000). Because the original instrument had been validated in an urban Malaysian tertiary healthcare environment, direct linguistic translation alone was insufficient; comprehensive cultural contextualization was mandatory.<\/p>\n Face validity was confirmed through cognitive interviewing and debriefing sessions involving pregnant women from the target clinical populations across the three linguistic cohorts (English, Afrikaans, and isiXhosa). Participants completed the draft questionnaire while employing a think-aloud protocol, providing qualitative feedback regarding item readability, question clarity, cultural acceptability, and the emotional resonance of terminology. Items identified as confusing or culturally discordant were modified before the final psychometric field trial.<\/p>\n In the clinical validation study involving 124 pregnant women diagnosed with GDM at a public tertiary academic hospital in Cape Town, the instrument demonstrated robust discriminative capability. Total knowledge scores varied in predictable directions relative to participants’ prior educational exposure, socioeconomic position, and parity. However, the study authors highlighted that because clinical knowledge across distinct disease facets (e.g., diet vs. insulin therapy) exhibits domain specificity, further large-scale multi-center testing is required to confirm structural equation modeling parameters and criterion-related predictive validity against objective glycemic markers such as glycated hemoglobin (HbA1c<\/a>) and continuous glucose monitoring metrics.<\/p>\n Reliability estimation for the SA-GDMKQ encompassed assessments of internal consistency and temporal stability (test-retest reliability), revealing psychometric nuances typical of broad health-literacy assessment instruments.<\/p>\n Internal consistency was calculated separately for each language adaptation using Cronbach’s alpha (α):<\/p>\n In traditional psychometric evaluation, a Cronbach’s alpha coefficient below 0.70 is often interpreted as suboptimal for diagnostic decision-making. However, psychometric theorists (e.g., Streiner, 2003; Tavakol & Dennick, 2011) emphasize that Cronbach’s alpha is heavily dependent on test length, item redundancy, and structural unidimensionality. When an instrument is brief (15 to 20 items) yet samples heterogeneous, non-redundant knowledge domains (e.g., pathophysiology, diet, medication, complications, postpartum screening), low inter-item covariance is an expected mathematical consequence. The isiXhosa version demonstrated the highest internal consistency (α = 0.621), suggesting consistent conceptual cohesion among the isiXhosa-speaking participants recruited from public healthcare clinics<\/span>.<\/p>\n Test-retest reliability was evaluated over a two-week interval among stable participants prior to intensive clinical educational interventions. Concordance at the individual item level was assessed using Cohen’s kappa (κ)<\/a>, while aggregate score stability was examined via linear correlation and intraclass correlation coefficients (ICC)<\/a>:<\/p>\n The structural dimensionality of the SA-GDMKQ was evaluated using exploratory factor analysis (EFA)<\/a> to determine whether the instrument behaves as a single overarching knowledge metric or resolves into discrete cognitive components.<\/p>\n Consistent with its theoretical design, factor analytic investigations demonstrated that the SA-GDMKQ is multidimensional. Principal axis factoring and scree plot inspections revealed multiple distinct factors with eigenvalues exceeding Kaiser’s criterion (λ > 1.0). The extracted factors align closely with the five conceptual domains established during expert panel content validation<\/span>:<\/p>\n Because items function dichotomously (correct vs. incorrect) and represent formative, factual domains, classical linear factor analysis can encounter difficulty with attenuated item correlations. Confirmatory factor analyses (CFA) conducted on dichotomous variables using robust weighted least squares estimators (WLSMV) indicate that a five-factor first-order model or a bi-factor model (with a general health literacy factor and specific domain factors) provides the most clinically coherent interpretation of the data.<\/p>\n The operational specifications of the South African Gestational Diabetes Mellitus Knowledge Questionnaire are detailed below:<\/p>\n The South African adaptation of the Gestational Diabetes Mellitus Knowledge Questionnaire was published in 2025<\/strong> in South African Family Practice<\/em>, following the adaptation of the original instrument developed by Hussain, Yusoff, and Sulaiman (2014, 2015). The tool was developed to support public healthcare access and clinical research in low- and middle-income countries. It is accessible for non-commercial academic, clinical, and epidemiological research. Researchers, clinicians, and health systems wishing to utilize, reproduce, or adapt the English, Afrikaans, or isiXhosa versions are encouraged to contact the principal researchers (Stellenbosch University) for complete implementation guidelines, language-specific translation keys, and scoring manuals. The original authors must be cited in all academic dissertations, clinical audits, and peer-reviewed publications utilizing the scale.<\/p>\n The following peer-reviewed literature supports the theoretical, psychometric, and clinical foundations of the SA-GDMKQ:<\/p>\nKeywords<\/h2>\n
Authors<\/h2>\n
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lbloms.mns@gmail.com<\/code>) — Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.<\/li>\nlmorris@qu.edu.qa<\/code>) — Department of Physical Therapy and Rehabilitation Science, College of Health Sciences, QU Health, Qatar University, Doha, Qatar; and Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.<\/li>\n<\/ul>\nPurpose<\/h2>\n
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Psychological Construct<\/h2>\n
1. Basic Pathophysiological and Disease Knowledge<\/h3>\n
2. Etiological Risk Factors and Epidemiology<\/h3>\n
3. Nutritional and Dietary Management<\/h3>\n
4. Therapeutic Interventions, Pharmacotherapy, and Self-Monitoring<\/h3>\n
5. Perinatal Complications and Long-Term Prognosis<\/h3>\n
Theoretical Framework<\/h2>\n
The Information-Motivation-Behavioral Skills (IMB) Model<\/h3>\n
The Health Belief Model (HBM)<\/h3>\n
Formative vs. Reflective Measurement Models in Cognitive Testing<\/h3>\n
Validity<\/h2>\n
Cross-Cultural Adaptation and Translation Process<\/h3>\n
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Cognitive Debriefing and Face Validity<\/h3>\n
Construct and Criterion Validity Observations<\/h3>\n
Reliability<\/h2>\n
Internal Consistency<\/h3>\n
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Temporal Stability (Test-Retest Reliability)<\/h3>\n
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Factor Analysis<\/h2>\n
Factor Structure and Dimensionality<\/h3>\n
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Instrument \/ Measurement Tool<\/h2>\n
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Permissions & Fee and Test Year<\/h2>\n
References<\/h2>\n
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Items of the Scale<\/h2>\n