December 2006 // Volume 44 // Number 6 // Tools of the Trade // 6TOT1

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Developing Culturally Appropriate Evaluation Instruments for Hispanics with Diabetes

Type 2 diabetes is a major health problem among Hispanics in the United States. This article describes the process of developing a Spanish-language version of an evaluation instrument of Hispanic seniors who participated in a diabetes education program. Content, face validity, and reliability are also discussed. A team of Extension educators, evaluation experts, diabetes educators, and community partners representing the Hispanic community contributed to the success of the process. The process can be used with other non-English speaking groups with diabetes. Recommendations for other methods of data collection are discussed.

Marisa B. Warrix
Extension Agent, Family and Consumer Sciences
Ohio State University Extension, Cuyahoga County
Cleveland, Ohio

Ruben D. Nieto
Former Extension Associate
Ohio State University Extension
Columbus, Ohio

Mary Ann Nicolay
Registered Dietetic Technician
Diabetes Association of Greater Cleveland
Beachwood, Ohio


Type 2 diabetes is a major health problem among Hispanic Americans. Latinos (especially Mexicans and Puerto Ricans) are twice as likely as non-Latino whites to develop diabetes and almost twice as likely to die from it (National Alliance for Hispanic Health, 2001). There is also a high prevalence of undetected diabetes in the Latino population. Obesity and diet are largely correlated with diabetes in Hispanics. In a study conducted of the Hispanic population in Cleveland, Ohio, 22 % of those surveyed had diabetes, and diabetes was identified as number one among perceived health problems for the elderly (Federation for Community Planning, 1991).

Hispanic seniors in Cleveland are a vulnerable population with a higher prevalence of undiagnosed diabetes than among whites and more severe health problems leading to a high need for help with activities of daily living. Barriers to treatment identified by study participants include:

  • Language and cultural problems caused by a lack of Hispanic staff in healthcare and social service agencies,

  • Lack of transportation,

  • Long waits at physicians' offices, and

  • The Anglo ignorance of Hispanic diversity and culture.

The educational approach that healthcare providers must use is an important determinant of patients' adherence to the behavioral changes necessary for living successfully with Type 2 diabetes (Lipton, Losey, Giachello, Mendez, & Lipton, 1998). Findings indicated that diabetes education programs provided to the Hispanic community in Cleveland were non-existent. Hispanic seniors, who are at higher risk, live isolated on the near west side of Cleveland and speak little English.

In an attempt to provide needed diabetes education to this under-served population, the Diabetes Association of Greater Cleveland, in collaboration with Hispanic social service organizations, developed a bilingual, culturally sensitive diabetes education program titled Proyecto Cambiar (to change). The program was funded by a grant from United Way of Cleveland. The programming was presented in the form of daylong retreats taught in Spanish. Six retreats were presented over a 2-year period, with156 participants. Each retreat included the following:

  • Health screening (i.e., blood pressure, glucose, ht/wt, eye and foot screens);

  • Nutrition education component with emphasis on portion control, meal consistency, and selecting and preparing low-fat foods;

  • Stress management and relaxation techniques; and

  • Exercise education, stressing the positive effects on blood glucose levels.

Recruitment of the participants was done through the Hispanic Senior Center, churches, social service organizations, and neighborhood health clinics. Word-of-mouth and personal invitations proved to be the best form of recruitment. A culturally appropriate evaluation instrument was developed in Spanish to assess knowledge, attitude, and behaviors of Proyecto Cambiar participants.

Research Instrument

In an attempt to determine whether the educational program made a difference in the participants' attitudes, knowledge, and behavior toward the disease, a research instrument was developed by the investigators. The research instrument consisted of eight sections:

  1. Intake frequency of certain foods

  2. Wellness

  3. Healthcare access

  4. Self-image wellness

  5. Knowledge about diabetes

  6. Attitude toward the disease

  7. Demographic characteristics

  8. Medical and physical data

For the purposes of this article, sections dealing with attitude, knowledge, and behavior changes will be discussed. Because the majority of the participants lacked English skills, the research instrument was translated into Spanish by a bi-lingual evaluation specialist at Ohio State University. The instrument is available on the web in both Spanish and English at <>.

Content Validity

A panel of experts was selected to review the research instrument. Members of the panel were selected based on their knowledge in instrument design, expertise with the content of the educational program, and familiarity with the intended audience. Indicating the extent to which the research instrument measured participants' attitude, knowledge, and behavior about diabetes was the major task of the panel of experts.

In addition, they commented on the format of the instrument, different scales used, wording of the statements and questions, and instructions for completing the questionnaire. The panel consisted of four faculty members at The Ohio State University who were experts in research/evaluation design, two health professionals from the Diabetes Association of Greater Cleveland, and two employees from the Hispanic Senior Center who were familiar with the senior population.

Face Validity

To establish face validity, employees at the Hispanic Senior Center were asked to conduct a field test of the research instrument with a group of 15 seniors at a Hispanic church in a neighboring county. Field test participants had similar demographic characteristics to subjects participating in Proyecto Cambiar. Field test participants were asked to comment on the clarity of instructions, user friendliness of the scales, wording and clarity of the statements/questions, appropriateness of Spanish words, and the participants' willingness to respond to the questions. Field test suggestions and comments were incorporated into the final version of the research instrument.

In addition, the Spanish version of the questionnaire was reviewed by a group of six health professionals who had extensive knowledge of the Puerto Rican community. These individuals were asked to comment on the appropriateness of the translation, particularly when referring to the names of the Puerto Rican foods and medical terminology.


Internal consistency coefficients were calculated for the knowledge and attitude sections of the research instrument. Data from the posttest administration of the questionnaire were used to determine internal consistency coefficients. A Cronbach's alpha of .80 was computed for the attitude section of the instrument. For the knowledge portion of the questionnaire, a Cronbach's alpha of .46 was calculated; low reliability coefficients are considered adequate, particularly in early stages of research studies (Nunnally, 1969).


The Hispanic community is a growing minority population in Northeast, Ohio. The preferred language of this population is Spanish or a combination of Spanish and English. The development of evaluation instruments in a native language that fits the sub-group contributed to the success of the diabetes education program.

Translation of evaluation instruments requires involvement of community representatives, evaluation specialists, a translator who represents the language of the population, and health professionals. The growing number of Hispanics with diabetes needs to be addressed by collecting accurate data. Health care professionals can benefit by providing educational programs that meet the needs of the public.

Although a knowledge, attitude, and behavior questionnaire was completed by participants, data from this population of seniors may best be collected through focus groups or one-on-one with a translator in the homes of the participants. The majority of the participants surveyed had a 7th-grade education. Reducing the length of the questionnaire may also be beneficial. In view of the growth of the Hispanic population and the need for diabetes education, the evaluation instrument has relevance for health care professionals and organizations that work with the population. Extension educators can provide a leadership role in partnership with other health care professionals in promoting this diabetes education program within the Hispanic community.


National Alliance for Hispanic Health. (2001). A primer for cultural proficiency: toward quality health services for Hispanics. Retrieved March 6, 2004, from

Hispanic Community Forum and Federation for Community Planning. (1991). Hispanic health, knowledge, attitudes and practice project: An analysis of Hispanic residents. Cleveland, OH: Author.

Lipton, R. B., Losey, L. M. Giachello A., Mendez J., & Girotti, M. H. (1998). Attitudes and issues in treating Latino patients with type 2 diabetes: Views of healthcare providers. The Diabetes Educator, 24 (1), 67-71.

Nunnally, J. C. (1967). Psychometric theory. New York: McGraw-Hill.