The Autonomy and Relatedness Inventory: An Analysis of the Psychometric Properties in Persons with Type 2 Diabetes

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Al-Dwaikat, Audai Hayajneh, Haitham Khatatbeh, Ibrahim Alasqah This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6993605/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Aug, 2025 Read the published version in BMC Psychology → Version 1 posted 10 You are reading this latest preprint version Abstract Background Social support is essential for the self-management of type 2 diabetes mellitus (T2DM), no specific measure of the quality of social support has been designed and tested for people with T2DM. Having a validated questionnaire that is culturally and linguistically appropriate in this field would nurture research in this area and contribute to better patient health outcomes. Aims This study investigated the psychometric features of the Autonomy in Relatedness Inventory (ARI) among individuals with T2DM in Jordan. Methodology: We used a secondary dataset on self-management and outcomes of individuals with T2DM to examine the psychometric properties of the ARI. The ARI's items' overall reliability was assessed using internal consistency (Cronbach's alpha). Exploratory Factor Analysis (EFA) was used to evaluate the validity of the ARI. Confirmatory factor analysis (CFA) was performed using structural equation modeling (SEM) to test the yielded factors. Results The ARI demonstrated high reliability (Cronbach’s alpha value was 0.90) and validity in T2DM patients. Convergent validity of the ARI was established. The findings showed that ARI was strongly correlated with functional social support ( r = 0.61, p < .001), in addition to negative correlations with depression ( r = -0.26, p < .001), anxiety ( r = -0.18, p < .001), and stress ( r = -0.24, p < .001). Regarding the factor structure of ARI, two latent factors were determined using a scree plot and EFA. Conclusion ARI provides a psychometrically sound method for measuring autonomy and relatedness in T2DM patients in Jordan. diabetes mellitus type 2 self-management psychometrics social support autonomy relatedness Figures Figure 1 Impact The findings provide researchers and clinicians with a robust tool to evaluate social and psychological dimensions essential for effective self-management. The ARI empowers researchers to explore the concept of social support that enhances self-management behaviors, fostering better health outcomes and reducing the burden of T2DM on patients and healthcare systems. Introduction Social support plays a critical role in chronic illness management, being linked to improved self‑management behaviors, psychological well‑being, and clinical outcomes in conditions such as cardiovascular disease, hypertension, and T2DM (Bustamante et al., 2018 ; Byrd et al., 2022 ; Hardman et al.,2020; Nyaaba et al., 2019 ; Vest et al., 2013 ). In T2DM specifically, instrumental assistance, emotional encouragement, and informational support facilitate daily disease management and are associated with better glycemic control and quality of life (Baek et al., 2014 ; Vest et al., 2013 ; Wang et al., 2022 ). However, the source and quality of support modulate these benefits. Support from spouses or healthcare professionals often yields more favorable outcomes compared to support from non‑spousal family or friends, underscoring the importance of relationship quality (Canevello & Crocker, 2010 ; Gabriel Navar et al., 2014; Strom & Egede, 2012 ). High‑quality support, characterized by empathy, respect, and responsiveness, attenuates depression, distress, and diabetes‑related burden, above and beyond mere availability of assistance (Baek et al., 2014 ; Canevello & Crocker, 2010 ; Hessler et al., 2012 ). By definition, social support entails two dimensions: social network, structure of support, and functional supportive behaviors exhibited by members of the social network (Drageset, 2021 ). Quality of social support is another dimension that contributes to the outcomes of people receiving support (Canevello & Crocker, 2010 ). The quality of social support is inferred through the evaluation of relationships with social network members (Linares et al., 2015 ) or satisfaction with the support received (Williams et al., 2004 ). In the literature on diabetes, social support is used as a general concept when its impact on the type 2 diabetes mellitus (T2DM) population has been studied (Strom & Egede, 2012 ; Watkins et al., 2013 ). Furthermore, most studies on the influence of social support on the clinical outcomes of people with T2DM have focused solely on the function of social support (Bing-Jonsson et al., 2018). The quality of social support has not been fully assessed in individuals with T2DM (Al-Dwaikat & Hall, 2017 ). Al-Dwaikat and Hall's study further highlighted that research on T2DM outcomes primarily utilized measures of the functional dimension of social support, with a significant lack of focus on assessing the quality of social support within this population (Al-Dwaikat & Hall, 2017 ). While measures like the Medical Outcomes Study Social Support Survey (MOS‑SSS) (Sherbourne & Stewart, 1991 ) capture overall functional support, they do not distinguish autonomy encouragement from empathic connection, constructs central to motivation and well‑being according to self‑determination theory (Deci & Ryan, 2000 ) and relational support models. The Autonomy and Relatedness Inventory (ARI) is grounded in self-determination theory (SDT) and relational models of support, which emphasize the fundamental human needs for autonomy and relatedness in social contexts (Deci & Ryan, 2000 ; Reis et al., 2000 ). SDT posits that perceptions of autonomy support and empathetic relation foster intrinsic motivation and well-being, while relational models highlight how supportive interpersonal behaviors, such as emotional availability and respect for personal perspectives, neutralize stress and promote health outcomes. The ARI was designed to capture these two dimensions by assessing supportive behaviors and relational quality, in addition to items that detect response biases due to negative phrasing. Embedding the ARI within these theoretical frameworks enhances its conceptual clarity and justifies its use in populations with chronic illness, such as T2DM, where social support significantly influences self-management and psychological well-being (Qi et al., 2021 ; Uchino, 2009 ). The ARI is a valid and reliable measure of the quality of intimate relationships (Al-Dwaikat et al., 2021 ; Hall & Kiernan, 1992 ; Linares et al., 2015 ). The ARI is a psychometrically sound tool for assessing the quality of intimate relationships among pregnant women (Hall & Kiernan, 1990). Thus, to better understand the impact of social support on T2DM outcomes, it is important not only to assess the function of social support but also to use a psychometrically sound measure of social support quality that evaluates the nature of the relationship between people who receive support and those who provide that support. Although the quality of the relationships was found to improve the outcomes of persons with T2DM (Al-Dwaikat et al., 2020 ), no specific measure was tested within this population. To address these gaps, this study applies the ARI to a clinical sample of adults with T2DM. We aimed to (1) determine the ARI’s latent structure by employing exploratory and confirmatory factor analyses; (2) evaluate internal consistency reliability for the overall scale and subscales; and (3) establish construct validity through analyses of convergent validity and discriminant validity. To evaluate the construct validity of the ARI, we selected the MOS-SSS and the DASS‑21 as comparative measures based on theoretical alignment. The MOS-SSS captures perceived availability of general social support and is expected to be positively correlated with ARI scores. By extending ARI validation to a T2DM context, we aim to provide researchers and clinicians with a psychometrically robust tool for assessing the quality of interpersonal support, a key determinant of diabetes self‑management and psychological health. Methods Study Design and Setting This study was a secondary analysis of cross-sectional data obtained as part of an exploratory study of the mediating effects of self-management on the outcomes of people with T2DM (Al-Dwaikat et al., 2021 ). A convenience sample of 339 patients with T2DM was recruited from a university-affiliated outpatient clinic located in a medium-sized city in Northern Jordan. Written informed consent was obtained from all participants before they completed the questionnaire. The Institutional Review Board (IRB) was obtained from the Jordan University of Science and Technology IRB Review Board (IRB No: IRB#: 572/2018). Clients were included in the study if they were aged 18 years or older, diagnosed with T2DM, and were able to understand the study procedures. Participants were interviewed to collect data on the quality of their intimate relationships, self-efficacy, depression, anxiety, and stress. Demographic data were obtained from interviews. The results of this study were reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (Cuschieri, 2019 ). Measures Demographic Data and Clinical History The following demographic data were collected during the interviews: age, age at diagnosis, sex, marital status, educational level, employment status, type of health insurance, and income. Clinical history data were obtained regarding smoking history, other morbidities, diabetes medications, and diabetes education history. The Autonomy in Relatedness Inventory The primary purpose of the ARI is to assess the quality of the relationship between intimate dyads. In this context, an intimate refers to the individual most significant to the respondent, who could be a family member, friend, or other significant person (Hall & Kiernan, 1990). The 32-item measure was developed by Hall ( 1983 ), drawing from Schaefer and Edgerton’s ( 1979 ) Marital Autonomy and Relatedness Inventory (Schaefer & Edgerton, 1979 ) and supplementing it with an additional eight items (Hall & Kiernan, 1990). The 32-item measure has eight subscales, with four items for each subscale, that were designed to capture positive and negative dimensions of the primary intimate relationship; the subscales include Acceptance, Relatedness, Support, Listening, Autonomy, Control, Hostile Control, and Detachment/Rejection (Hall & Kiernan, 1990). Before completing the ARI, participants were asked to identify their most significant relationship (e.g., family member, friend, or partner), which served as the referent for all item responses. Each of the 32 ARI items was rated on a 5-point Likert scale ranging from 1 (“ Not at all like him/her ”) to 5 (“ Very much like him/her ”), describing the behavior of the identified intimate person. Negatively worded items were reverse-coded before scoring. The total ARI score was calculated by summing responses across all 32 items (after reverse coding), then subtracting 32 to create a standardized cumulative score ranging from 0 to 128. Higher total scores reflect a more positive perception of the quality of the intimate relationship. For subscale scores, items were grouped based on their empirical factor loadings (as defined in the final factor structure). Subscale scores were calculated by summing the relevant items within each factor (after reverse coding where applicable). This approach aligns with previous applications of the ARI and enhances the interpretability of autonomy-related and method-related factors. Both discriminant and convergent validities of the ARI were supported, and the Cronbach’s alphas for the subscales ranged from .53 to .76 in a sample of 213 women describing their relationships with spouses (Hall & Kiernan, 1990). In addition, non-English-speaking women supported the construct validity of the ARI was supported in non-English-speaking women (Linares et al., 2015 ). In two different samples of 214 and 100 women, Cronbach’s alphas for the total scale were .94 and .92, respectively (Hall et al., 1987 ; Linares et al., 2015 ). The ARI items were factored into two dimensions: Support/Positive Regard and Dominance/Control, which were moderately correlated (Hall & Kiernan, 1990). Medical Outcomes Study-Social Support Scale (MOS-SSS) In this study, the MOS-SSS developed by Sherbourne and Stewart ( 1991 ) was used to assess social support among study participants. This scale was intended to evaluate various aspects of support, including emotional, informational, tangible, affectionate, and positive social interactions. The participants responded to 19 Likert-scale items to evaluate their perceived level of support. Scores ranged from 0 to 100, with higher scores indicating greater support. Sherbourne and Stewart reported strong psychometric properties for the MOS-SSS, with a Cronbach’s α coefficient of .97 for the total scale (Sherbourne & Stewart, 1991 ). In this study, Cronbach’s α coefficient for the total scale was also high (.95). Depression, Anxiety, and Stress Scale (DASS-21) The psychological burden of T2DM was assessed using the DASS-21 (Lovibond & Lovibond, 1995 ). This scale measures the negative emotional states of depression, anxiety, and stress experienced during the week before the completion of the questionnaire. Each subscale comprised seven items, with scores calculated by summing the responses to these items. The DASS-21 has demonstrated established validity and reliability, with Cronbach’s α coefficients of .94, .87, and .91 for the depression, anxiety, and stress subscales, respectively (Antony et al., 1998). In this study, the Cronbach’s α coefficients for depression, anxiety, and stress were .81, .78, and .82, respectively. Statistical Analysis Descriptive statistics (mean [M], standard deviation [SD], percentage, and frequency) were used to report the sample characteristics and responses. Psychometric analysis primarily focuses on the internal consistency for reliability, construct validity, and Exploratory Factor Analysis (EFA). The internal consistency reliability coefficient (Cronbach's α) was computed for the overall scale, and item-total correlations were checked. To be retained in the instrument, each item must demonstrate a commonality of at least 0.4 (Myers et al., 2015 ). The ARI was administered as part of the original data collection protocol targeting adults with T2DM. No secondary data sources were used; all scale items were directly obtained to validate the ARI in this clinical sample. A sample size of N = 200 (≥ 5 respondents per item) ensured adequate statistical power for EFA and CFA analyses (MacCallum et al., 1999 ). Before factor analyses, item-level distributions were examined: skewness and kurtosis values for each ARI item fell within acceptable bounds (± 2.0), supporting the assumption of univariate normality. Additionally, a scree plot was examined to ascertain the appropriate number of factors that best fit the data (Cattell, 1966 ). All statistical analyses were performed using Jamovi version 2.3 (The Jamovi Project, 2024 ), which utilizes the lavaan package for structural equation and factor analyses (Rosseel, 2012 ). Before exploratory factor analysis (EFA), data were screened for missing values. Sampling adequacy was evaluated using the Kaiser-Meyer-Olkin (KMO) statistic and Bartlett’s sphericity test. For subsequent analysis, a KMO value of at least 0.6 and a significant Bartlett’s test were considered necessary (Hutcheson & Sofroniou, 1999 ). In addition, confirmatory factor analysis (CFA) was used, utilizing structural equation modeling (SEM), to test the validity of the factor structure yielded by the EFA. The convergent and discriminant validities of the ARI were assessed by exploring its correlation with the MOS-SSS and the DASS-21, evaluating the Average Variance Extracted (AVE), and comparing each factor’s AVE to the squared correlation between factors. Results Table 1 shows that most participants were married (56.6%) and female (92.3%) with high school or higher education (67.7%). The mean age was 59.6 (SD = 11.1), and the mean age at diagnosis was 48.09 (SD = 10.43). Reliability Internal Consistency Cronbach’s alpha coefficients were computed for the entire 30-item ARI scale and each factor using Jamovi’s Reliability Analysis module. The full scale demonstrated excellent internal consistency (α = .90). Factor 1 (Positive/Support; 20 items) showed high reliability (α = .97), and Factor 2 (Negative/ Control; 8 items) exhibited acceptable reliability (α = .79). Validity Face and Content Validity To establish content validity, the items of the ARI were reviewed by a panel of five experts in psychology, diabetes care, and psychometric assessment. Panel members evaluated each item for relevance, clarity, and appropriateness for individuals with T2DM. The content validity appeared to be appropriate for patients with T2DM. For face validity, the instrument was tested with a sample of 10 adults diagnosed with T2DM. Participants were asked to provide feedback on item clarity, comprehension, and perceived relevance. Based on their responses, minor revisions to wording were made to improve clarity and contextual fit for the T2DM population. Exploratory Factor Analysis Results (Forced TwoFactor Solution) An exploratory factor analysis (EFA) was conducted on the 30-item Autonomy and Relatedness Inventory (ARI) after excluding items ARI24 and ARI28 because these two items did not load on any factor, using minimum residual extraction with oblimin rotation. Reverse-coded items (ARI2, ARI4, ARI6, ARI10, ARI14, ARI18, ARI20, ARI22, ARI26, ARI28, and ARI30) were included in their recoded form since they are negatively worded items. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was outstanding (KMO = .95), and Bartlett’s test of sphericity was significant, χ² (496) = 6,299, p < .001, indicating suitability for factor analysis. Based on theoretical considerations and model parsimony, a two-factor solution (Fig. 1 was forced. Table 2 summarizes the rotated factor loadings and uniqueness estimates for each item (loadings < |.30| suppressed). Factor 1 (Support/Positive) includes all positively worded items that reflect supportive behaviors and emotional availability, such as " Talks over his/her problems with me" , " Respects my opinions ", " Encourages me to follow my own interests ", and " Considers my point of view ". High loadings on these items (≥ .46) indicate a clear dimension of perceived autonomy support and relational quality provided by the important person. Factor 2 (Dominance/Control) includes reverse‑coded items that describe controlling or critically blaming behaviors, such as " Is always trying to change me " (RARI2), " Argues back no matter what I say ", " Makes fun of me ", and " Acts as though I am in the way ". Primary loadings on these items (≥ .38) suggest a methodological factor capturing response style associated with negatively phrased items rather than a substantive psychological construct. This forced two‑factor solution describes substantive perceptions of autonomy and relatedness support from methodological artifacts due to item wording, aligning with the ARI’s underlying theory. Thus, these results should be confirmed by this structure by CFA. Confirmatory Factor Analysis In addition to chai-sequare (χ²), degree of freedom (df), Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), NNFI (Bentler–Bonett Non‑normed Fit Index), Relative Noncentrality Index (RNI), Normed Fit Index (NFI), Relative Fit Index (RFI), Incremental Fit Index (IFI), Parsimony Normed Fit Index (PNFI), Standardized Root Mean Squared Residual (SRMR), and Root Mean Squared Error Approximate (RMSEA) (with 90% confidence Interval [CI] and p‑value) were included to comprehensively evaluate model adequacy. Table 3 shows that the goodness-of-fit indices of this model were an acceptable fit between the proposed model with the two subscales and their latent factors or items. The CFI = .0999, TLI = 0.999, NNFI = .0999, RMSEA fit index = 0.080, 90% C. I (0.073–0.088), and SRMR = 0.035. This indicates good convergent validity of items to their two proposed latent factors. All indices meet recommended thresholds, confirming the robustness of the two‑factor CFA model. Convergent and Discriminant Validity Average Variance Extracted (AVE) was calculated for each factor. Factor 1 achieved an AVE of .68, and Factor 2 had an AVE of .39, indicating acceptable convergent validity for Factor 1 (AVE > .50) and marginal for Factor 2 (Fornell & Larcker, 1981 ). Discriminant validity was assessed using the Fornell–Larcker criterion, comparing each factor’s AVE to the squared correlation between factors (r = .32, r² = .10). Both AVE estimates exceed the squared inter-factor correlation (0.10), indicating satisfactory discriminant validity. To assess concurrent validity, we examined Pearson correlations between total ARI scores and scores on the MOS-SSS. As expected, ARI demonstrated a strong positive correlation with perceived social support ( r = .614, p < .001). Convergent validity was further supported by significant negative correlations between ARI and measures of psychological distress: depression ( r = –.255, p < .001), anxiety ( r = –.181, p < .001), and stress ( r = –.244, p < .001) (see Table 4 ). Discussion This study examined the construct validity, internal consistency, and reliability of ARI. Overall, the values of Cronbach’s alpha demonstrated high internal consistency for the ARI among individuals diagnosed with T2DM. This finding suggests that the ARI is a reliable measure of the quality of relationships, that is, social support. The reliability obtained in this study indicates that ARI items assess the same underlying construct. This result is similar to that obtained by Linares et al ( 2015 ). However, the results showed that some of the ARI items had low item-total correlations. Such findings can be attributed to several factors. For instance, the wording of these items may be unclear or vague, and these items may be trickier or more difficult to respond to than others. Ultimately, these factors may cause incorrect or inconsistent responses and lead to low item-total correlations for the corresponding items (Stomme & Wills, 2004). The other aim of this study was to evaluate the factor structure of ARI in patients with T2DM. Based on the scree plot and both EFA and CFA results, two latent factors were forced after the removal of the items that did not load into a factor. This indicates that ARI assesses two distinct yet interconnected constructs that were found in the original study (Hall & Kiernan, 1990). This result can be used to further assess the quality of relationships among people diagnosed with T2DM. Furthermore, it could be used to explore and target specific constructs, which can lead to improved understanding of the variables related to social support among people with T2DM. Additionally, future research could use these two latent factors to study the relationships between the constructs of ARI and other variables, such as glycemic control and psychological well-being of people with T2DM. The final aim was to evaluate the construct validity of the ARI in T2DM patients. The AVE values for both factors demonstrate the convergent validity of the ARI items to their latent factors. In addition, convergent validity was demonstrated by the significant correlations between the ARI and MOS-SSS, depression, anxiety, and stress. Discriminant validity was supported by AVE estimates exceeding the squared inter-factor correlation, confirming that each factor captures a distinct construct. These findings support the results of a previous study examining the construct validity of the ARI (Linares et al., 2015 ). The results of this study on the convergent and discriminant validities of ARI indicate that the items on the scale are harmonious with the underlying latent components that they are supposed to evaluate. Together, these findings indicate that the ARI is a reliable and valid instrument for assessing perceived autonomy and relatedness support in individuals with T2DM, and that methodological artifacts due to item wording can be effectively modeled. Future research should use confirmatory approaches in independent samples, consider item rewording to minimize response bias, and explore the ARI’s predictive utility for diabetes self‑management and psychological well‑being. Limitations Although this study showed that the ARI is a psychometrically sound measure to be used for persons with T2DM, the results are promising but require further replication and refinement. This study has several limitations. First, it utilizes a secondary dataset of a convenient and relatively small sample, limiting the generalizability of the findings. Second, because the study was limited to northern Jordan, it is uncertain whether the findings are generalizable to other areas of Jordan, as well as other Arabic-speaking countries. Finally, the ARI may be not culturally appropriate. The cultural appropriateness of assessing intimate relationships in Arabic-speaking populations may be challenging, as they may have unique relational norms and disclosure barriers. Future studies with larger and more heterogeneous samples are recommended to address these limitations. Furthermore, future studies should further investigate the psychometric properties of the ARI among individuals with T2DM. Conclusion In conclusion, the ARI offers a promising, valid, and reliable method for assessing the quality of relationships among individuals diagnosed with T2DM. The ARI demonstrated strong internal consistency and convergent validity. This is especially significant, given that T2DM is one of the leading causes of morbidity and mortality worldwide. This study has valuable implications for both research and practice. First, the availability of such tools will allow researchers to easily study the quality of relationships in individuals with T2DM, considering that the quality of the relationships will be directly related to the self-management and psychological well-being of individuals with T2DM (Al-Dwaikat et al., 2023 ). This is crucial because autonomy and relatedness are associated with several important outcomes in people with T2DM, including glycemic control, quality of life, and self-management behaviors. Implications of The Study The ARI provides clinicians and researchers with a robust tool to explore the intimate relationship dynamics of individuals with T2DM. In addition, recognizing the importance of autonomy and relatedness in managing T2DM, healthcare systems can incorporate assessments of relationship quality into routine care. Furthermore, the ARI can help identify individuals with T2DM who might have challenging or poor relationship quality. Finally, the ARI can be utilized in studies examining how changes in the quality of the relationships impact T2DM self-management and outcomes. It also opens avenues for comparative studies among persons with different demographic and clinical backgrounds. Abbreviations ARI Autonomy and Relatedness Inventory T2DM Type 2 Diabetes Mellitus EFA Exploratory Factor Analysis CFA Confirmatory Factor Analysis SEM Structural Equation Modeling SDT Self-Determination Theory MOS-SSS Medical Outcomes Study–Social Support Survey DASS-21 Depression, Anxiety, and Stress Scale – 21 items KMO Kaiser–Meyer–Olkin (Measure of Sampling Adequacy) RMSEA Root Mean Squared Error of Approximation SRMR Standardized Root Mean Squared Residual CFI Comparative Fit Index TLI Tucker–Lewis Index NNFI Non-Normed Fit Index (Bentler–Bonett) RNI Relative Noncentrality Index NFI Normed Fit Index RFI Relative Fit Index IFI Incremental Fit Index PNFI Parsimony Normed Fit Index AVE Average Variance Extracted IRB Institutional Review Board STROBE Strengthening the Reporting of Observational Studies in Epidemiology checklist Declarations Acknowledgements: The Researchers would like to thank the Deanship of Graduate Studies and Scientific Research at Qassim University for financial support (QU-APC-2025). Author contributions: Conceptualization: TA, AH, HK, and IA. Formal analysis: TA and AH. Project administration: IA. Methodology: TA, AH, and HK. Investigation: TA, AH, and IA. Resources: TA, HK, and IA. Visualization: TA, AH, and HK. Draft-writing: TA, AH, HK, and IA. Validation: AH, HK, and IA. All authors read and agreed to the final version of the manuscript. Funding: A Faculty Research Grant from the Jordan University of Science and Technology supported this study. Data availability: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate: This study was approved by the Institutional Review Board (IRB) of Jordan University of Science and Technology (Approval No: 572/2018). 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APA PsycTests. https://doi.org/10.1037/t01004-000 MacCallum RC, Widaman KF, Zhang S, Hong S. Sample size in factor analysis. Psychol Methods. 1999;4(1):84–99. https://doi.org/10.1037/1082-989X.4.1.84 . Myers ND, Jin Y, Ahn S, Celimli S, Zopluoglu C. Rotation to a partially specified target matrix in exploratory factor analysis in practice. Behav Res Methods. 2015;47(2):494–505. https://doi.org/10.3758/s13428-014-0486-7 . Nyaaba GN, Stronks K, Meeks K, Beune E, Owusu-Dabo E, Addo J, de-Graft Aikins A, Mockenhaupt F, Bahendeka S, Klipstein-Grobusch K, Smeeth L, Agyemang C. Is social support associated with hypertension control among Ghanaian migrants in Europe and non-migrants in Ghana? The RODAM study. Intern Emerg Med. 2019;14(6):957–66. https://doi.org/10.1007/s11739-019-02075-7 . Qi X, Xu J, Chen G, Liu H, Liu J, Wang J, Zhang X, Hao Y, Wu Q, Jiao M. Self-management behavior and fasting plasma glucose control in patients with type 2 diabetes mellitus over 60 years old: multiple effects of social support on quality of life. Health Qual Life Outcomes. 2021;19(1):254. https://doi.org/10.1186/s12955-021-01881-y . Reis HT, Clark MS, Holmes JG. Perceived partner responsiveness as an organizing construct in the study of intimacy and closeness. In: Fletcher GJ, Clark MS, editors. Blackwell handbook of social psychology: Interpersonal processes. Blackwell; 2000. pp. 367–89. Rosseel Y. lavaan: An R Package for Structural Equation Modeling. J Stat Softw. 2012;48(2):1–36. https://doi.org/10.18637/jss.v048.i02 . Schaefer ES, Edgerton M. (1979). Marital Autonomy and Relatedness Inventory (Unpublished doctoral dissertation). University of North Carolina, Chapel Hill, NC. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705–14. https://doi.org/10.1016/0277-9536(91)90150-b . Stommel M, Wills C. (2004). Clinical research: Concepts and principles for advanced practice nurses. Strom JL, Egede LE. The impact of social support on outcomes in adult patients with type 2 diabetes: a systematic review. Curr Diab Rep. 2012;12(6):769–81. https://doi.org/10.1007/s11892-012-0317-0 . The Jamovi Project. (2024). Jamovi (Version 2.3) [Computer software]. https://www.jamovi.org Uchino BN. Understanding the Links Between Social Support and Physical Health: A Life-Span Perspective With Emphasis on the Separability of Perceived and Received Support. Perspect Psychol Sci. 2009;4(3):236–55. https://doi.org/10.1111/j.1745-6924.2009.01122.x . Vest BM, Kahn LS, Danzo A, Tumiel-Berhalter L, Schuster RC, Karl R, Taylor R, Glaser K, Danakas A, Fox CH. Diabetes self-management in a low-income population: impacts of social support and relationships with the health care system. Chronic Illn. 2013;9(2):145–55. https://doi.org/10.1177/1742395313475674 . Wang J, Zou R, Wu N, Fu H, He Y, Crawford P, Kane E, Dai J. Depressive symptoms, social support, and health-related quality of life: A community-based study in Shanghai, China. Compr Psychiatr. 2022;113:152292. https://doi.org/10.1016/j.comppsych.2021.152292 . Watkins YJ, Quinn LT, Ruggiero L, Quinn MT, Choi YK. Spiritual and religious beliefs and practices and social support's relationship to diabetes self-care activities in African Americans. Diabetes Educ. 2013;39(2):231–9. https://doi.org/10.1177/0145721713475843 . Williams P, Barclay L, Schmied V. Defining social support in context: a necessary step in improving research, intervention, and practice. Qual Health Res. 2004;14(7):942–60. https://doi.org/10.1177/1049732304266997 . Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files ARITables06.21.25.docx Cite Share Download PDF Status: Published Journal Publication published 31 Aug, 2025 Read the published version in BMC Psychology → Version 1 posted Editorial decision: Revision requested 02 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviews received at journal 27 Jul, 2025 Reviewers agreed at journal 27 Jul, 2025 Reviewers agreed at journal 17 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor invited by journal 04 Jul, 2025 Editor assigned by journal 01 Jul, 2025 Submission checks completed at journal 01 Jul, 2025 First submitted to journal 27 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6993605","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486461981,"identity":"24f237c1-a23d-4178-841d-509b8499f33d","order_by":0,"name":"Tariq N. Al-Dwaikat","email":"","orcid":"","institution":"Jordan University of Science and Technology Faculty of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Tariq","middleName":"N.","lastName":"Al-Dwaikat","suffix":""},{"id":486461982,"identity":"b9a6dd14-7b54-4eb6-93c0-24768addb243","order_by":1,"name":"Audai Hayajneh","email":"","orcid":"","institution":"Jordan University of Science and Technology Faculty of Nursing","correspondingAuthor":false,"prefix":"","firstName":"Audai","middleName":"","lastName":"Hayajneh","suffix":""},{"id":486461983,"identity":"e5d377be-84c8-4944-bb9c-5bcac4083fea","order_by":2,"name":"Haitham Khatatbeh","email":"","orcid":"","institution":"Yarmouk University","correspondingAuthor":false,"prefix":"","firstName":"Haitham","middleName":"","lastName":"Khatatbeh","suffix":""},{"id":486461986,"identity":"b5220304-775a-4815-96ea-74f72aaf0777","order_by":3,"name":"Ibrahim Alasqah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACNgYGxgMghgF7A4hiJkoLA0QLzwEitTDAtUgkEKmFj4H5wYEff6zlzSUfb5NgqLBObOA//ICAw9gMDva2pRvunJ1WJsFwJj2xQSLNgIAWBoMDvA2HGTfczjGTYGw7DNTCQEgL+4eDf/4ctt9w8wxQyz+gFv7jHwho4TE4zMN2OHHDDR6glgagFoYcArYw8xQclm1LT95wJq3YIuFYunGbRE4BXi3y7e0bH775Y2274fjhjTc+1FjL9vMf34BXCzQiwKQBQwIDJHKJAVAto2AUjIJRMAqwAQBmUUVR8N726wAAAABJRU5ErkJggg==","orcid":"","institution":"Qassim University","correspondingAuthor":true,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Alasqah","suffix":""}],"badges":[],"createdAt":"2025-06-27 17:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6993605/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6993605/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40359-025-03374-9","type":"published","date":"2025-08-31T15:57:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87267268,"identity":"0eae0124-d348-4602-b3c2-93e0ac01c2de","added_by":"auto","created_at":"2025-07-22 08:06:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19949,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eScree Plot\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6993605/v1/d0849a2b51b4993b526c809a.jpg"},{"id":90344887,"identity":"141fd008-b073-41bf-b18b-8efb8d7d2984","added_by":"auto","created_at":"2025-09-01 16:07:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":740283,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6993605/v1/23bbd715-f36c-4688-9cef-5baf907003c0.pdf"},{"id":87267271,"identity":"7ad0ab98-11db-410e-852f-3d5f9e6fa4d5","added_by":"auto","created_at":"2025-07-22 08:06:05","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":25589,"visible":true,"origin":"","legend":"","description":"","filename":"ARITables06.21.25.docx","url":"https://assets-eu.researchsquare.com/files/rs-6993605/v1/9fea59d41a3ceffc8f29448e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Autonomy and Relatedness Inventory: An Analysis of the Psychometric Properties in Persons with Type 2 Diabetes","fulltext":[{"header":"Impact","content":"\u003cul\u003e\n \u003cli\u003eThe findings provide researchers and clinicians with a robust tool to evaluate social and psychological dimensions essential for effective self-management.\u003c/li\u003e\n \u003cli\u003eThe ARI empowers researchers to explore the concept of social support that enhances self-management behaviors, fostering better health outcomes and reducing the burden of T2DM on patients and healthcare systems.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eSocial support plays a critical role in chronic illness management, being linked to improved self‑management behaviors, psychological well‑being, and clinical outcomes in conditions such as cardiovascular disease, hypertension, and T2DM (Bustamante et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Byrd et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Hardman et al.,2020; Nyaaba et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Vest et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). In T2DM specifically, instrumental assistance, emotional encouragement, and informational support facilitate daily disease management and are associated with better glycemic control and quality of life (Baek et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Vest et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, the source and quality of support modulate these benefits. Support from spouses or healthcare professionals often yields more favorable outcomes compared to support from non‑spousal family or friends, underscoring the importance of relationship quality (Canevello \u0026amp; Crocker, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Gabriel Navar et al., 2014; Strom \u0026amp; Egede, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). High‑quality support, characterized by empathy, respect, and responsiveness, attenuates depression, distress, and diabetes‑related burden, above and beyond mere availability of assistance (Baek et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Canevello \u0026amp; Crocker, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Hessler et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBy definition, social support entails two dimensions: social network, structure of support, and functional supportive behaviors exhibited by members of the social network (Drageset, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Quality of social support is another dimension that contributes to the outcomes of people receiving support (Canevello \u0026amp; Crocker, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The quality of social support is inferred through the evaluation of relationships with social network members (Linares et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) or satisfaction with the support received (Williams et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). In the literature on diabetes, social support is used as a general concept when its impact on the type 2 diabetes mellitus (T2DM) population has been studied (Strom \u0026amp; Egede, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Watkins et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Furthermore, most studies on the influence of social support on the clinical outcomes of people with T2DM have focused solely on the function of social support (Bing-Jonsson et al., 2018).\u003c/p\u003e\u003cp\u003eThe quality of social support has not been fully assessed in individuals with T2DM (Al-Dwaikat \u0026amp; Hall, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Al-Dwaikat and Hall's study further highlighted that research on T2DM outcomes primarily utilized measures of the functional dimension of social support, with a significant lack of focus on assessing the quality of social support within this population (Al-Dwaikat \u0026amp; Hall, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). While measures like the Medical Outcomes Study Social Support Survey (MOS‑SSS) (Sherbourne \u0026amp; Stewart, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1991\u003c/span\u003e) capture overall functional support, they do not distinguish autonomy encouragement from empathic connection, constructs central to motivation and well‑being according to self‑determination theory (Deci \u0026amp; Ryan, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) and relational support models.\u003c/p\u003e\u003cp\u003eThe Autonomy and Relatedness Inventory (ARI) is grounded in self-determination theory (SDT) and relational models of support, which emphasize the fundamental human needs for autonomy and relatedness in social contexts (Deci \u0026amp; Ryan, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Reis et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). SDT posits that perceptions of autonomy support and empathetic relation foster intrinsic motivation and well-being, while relational models highlight how supportive interpersonal behaviors, such as emotional availability and respect for personal perspectives, neutralize stress and promote health outcomes.\u003c/p\u003e\u003cp\u003eThe ARI was designed to capture these two dimensions by assessing supportive behaviors and relational quality, in addition to items that detect response biases due to negative phrasing. Embedding the ARI within these theoretical frameworks enhances its conceptual clarity and justifies its use in populations with chronic illness, such as T2DM, where social support significantly influences self-management and psychological well-being (Qi et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Uchino, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The ARI is a valid and reliable measure of the quality of intimate relationships (Al-Dwaikat et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Hall \u0026amp; Kiernan, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1992\u003c/span\u003e; Linares et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The ARI is a psychometrically sound tool for assessing the quality of intimate relationships among pregnant women (Hall \u0026amp; Kiernan, 1990).\u003c/p\u003e\u003cp\u003eThus, to better understand the impact of social support on T2DM outcomes, it is important not only to assess the function of social support but also to use a psychometrically sound measure of social support quality that evaluates the nature of the relationship between people who receive support and those who provide that support. Although the quality of the relationships was found to improve the outcomes of persons with T2DM (Al-Dwaikat et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), no specific measure was tested within this population.\u003c/p\u003e\u003cp\u003eTo address these gaps, this study applies the ARI to a clinical sample of adults with T2DM. We aimed to (1) determine the ARI\u0026rsquo;s latent structure by employing exploratory and confirmatory factor analyses; (2) evaluate internal consistency reliability for the overall scale and subscales; and (3) establish construct validity through analyses of convergent validity and discriminant validity. To evaluate the construct validity of the ARI, we selected the MOS-SSS and the DASS‑21 as comparative measures based on theoretical alignment. The MOS-SSS captures perceived availability of general social support and is expected to be positively correlated with ARI scores. By extending ARI validation to a T2DM context, we aim to provide researchers and clinicians with a psychometrically robust tool for assessing the quality of interpersonal support, a key determinant of diabetes self‑management and psychological health.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis study was a secondary analysis of cross-sectional data obtained as part of an exploratory study of the mediating effects of self-management on the outcomes of people with T2DM (Al-Dwaikat et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). A convenience sample of 339 patients with T2DM was recruited from a university-affiliated outpatient clinic located in a medium-sized city in Northern Jordan. Written informed consent was obtained from all participants before they completed the questionnaire. The Institutional Review Board (IRB) was obtained from the Jordan University of Science and Technology IRB Review Board (IRB No: IRB#: 572/2018). Clients were included in the study if they were aged 18 years or older, diagnosed with T2DM, and were able to understand the study procedures. Participants were interviewed to collect data on the quality of their intimate relationships, self-efficacy, depression, anxiety, and stress. Demographic data were obtained from interviews. The results of this study were reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist (Cuschieri, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eDemographic Data and Clinical History\u003c/h2\u003e\u003cp\u003eThe following demographic data were collected during the interviews: age, age at diagnosis, sex, marital status, educational level, employment status, type of health insurance, and income. Clinical history data were obtained regarding smoking history, other morbidities, diabetes medications, and diabetes education history.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThe Autonomy in Relatedness Inventory\u003c/h3\u003e\n\u003cp\u003eThe primary purpose of the ARI is to assess the quality of the relationship between intimate dyads. In this context, an intimate refers to the individual most significant to the respondent, who could be a family member, friend, or other significant person (Hall \u0026amp; Kiernan, 1990). The 32-item measure was developed by Hall (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1983\u003c/span\u003e), drawing from Schaefer and Edgerton\u0026rsquo;s (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1979\u003c/span\u003e) Marital Autonomy and Relatedness Inventory (Schaefer \u0026amp; Edgerton, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1979\u003c/span\u003e) and supplementing it with an additional eight items (Hall \u0026amp; Kiernan, 1990). The 32-item measure has eight subscales, with four items for each subscale, that were designed to capture positive and negative dimensions of the primary intimate relationship; the subscales include \u003cem\u003eAcceptance, Relatedness, Support, Listening, Autonomy, Control, Hostile Control, and Detachment/Rejection\u003c/em\u003e (Hall \u0026amp; Kiernan, 1990).\u003c/p\u003e\u003cp\u003e Before completing the ARI, participants were asked to identify their most significant relationship (e.g., family member, friend, or partner), which served as the referent for all item responses. Each of the 32 ARI items was rated on a 5-point Likert scale ranging from 1 (\u0026ldquo;\u003cem\u003eNot at all like him/her\u003c/em\u003e\u0026rdquo;) to 5 (\u0026ldquo;\u003cem\u003eVery much like him/her\u003c/em\u003e\u0026rdquo;), describing the behavior of the identified intimate person. Negatively worded items were reverse-coded before scoring. The total ARI score was calculated by summing responses across all 32 items (after reverse coding), then subtracting 32 to create a standardized cumulative score ranging from 0 to 128. Higher total scores reflect a more positive perception of the quality of the intimate relationship.\u003c/p\u003e\u003cp\u003eFor subscale scores, items were grouped based on their empirical factor loadings (as defined in the final factor structure). Subscale scores were calculated by summing the relevant items within each factor (after reverse coding where applicable). This approach aligns with previous applications of the ARI and enhances the interpretability of autonomy-related and method-related factors.\u003c/p\u003e\u003cp\u003eBoth discriminant and convergent validities of the ARI were supported, and the Cronbach\u0026rsquo;s alphas for the subscales ranged from .53 to .76 in a sample of 213 women describing their relationships with spouses (Hall \u0026amp; Kiernan, 1990). In addition, non-English-speaking women supported the construct validity of the ARI was supported in non-English-speaking women (Linares et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In two different samples of 214 and 100 women, Cronbach\u0026rsquo;s alphas for the total scale were .94 and .92, respectively (Hall et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e1987\u003c/span\u003e; Linares et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The ARI items were factored into two dimensions: Support/Positive Regard and Dominance/Control, which were moderately correlated (Hall \u0026amp; Kiernan, 1990).\u003c/p\u003e\n\u003ch3\u003eMedical Outcomes Study-Social Support Scale (MOS-SSS)\u003c/h3\u003e\n\u003cp\u003eIn this study, the MOS-SSS developed by Sherbourne and Stewart (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1991\u003c/span\u003e) was used to assess social support among study participants. This scale was intended to evaluate various aspects of support, including emotional, informational, tangible, affectionate, and positive social interactions. The participants responded to 19 Likert-scale items to evaluate their perceived level of support. Scores ranged from 0 to 100, with higher scores indicating greater support. Sherbourne and Stewart reported strong psychometric properties for the MOS-SSS, with a Cronbach\u0026rsquo;s α coefficient of .97 for the total scale (Sherbourne \u0026amp; Stewart, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). In this study, Cronbach\u0026rsquo;s α coefficient for the total scale was also high (.95).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDepression, Anxiety, and Stress Scale (DASS-21)\u003c/h2\u003e\u003cp\u003eThe psychological burden of T2DM was assessed using the DASS-21 (Lovibond \u0026amp; Lovibond, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). This scale measures the negative emotional states of depression, anxiety, and stress experienced during the week before the completion of the questionnaire. Each subscale comprised seven items, with scores calculated by summing the responses to these items. The DASS-21 has demonstrated established validity and reliability, with Cronbach\u0026rsquo;s α coefficients of .94, .87, and .91 for the depression, anxiety, and stress subscales, respectively (Antony et al., 1998). In this study, the Cronbach\u0026rsquo;s α coefficients for depression, anxiety, and stress were .81, .78, and .82, respectively.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics (mean [M], standard deviation [SD], percentage, and frequency) were used to report the sample characteristics and responses. Psychometric analysis primarily focuses on the internal consistency for reliability, construct validity, and Exploratory Factor Analysis (EFA). The internal consistency reliability coefficient (Cronbach's α) was computed for the overall scale, and item-total correlations were checked. To be retained in the instrument, each item must demonstrate a commonality of at least 0.4 (Myers et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe ARI was administered as part of the original data collection protocol targeting adults with T2DM. No secondary data sources were used; all scale items were directly obtained to validate the ARI in this clinical sample. A sample size of N\u0026thinsp;=\u0026thinsp;200 (\u0026ge;\u0026thinsp;5 respondents per item) ensured adequate statistical power for EFA and CFA analyses (MacCallum et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Before factor analyses, item-level distributions were examined: skewness and kurtosis values for each ARI item fell within acceptable bounds (\u0026plusmn;\u0026thinsp;2.0), supporting the assumption of univariate normality.\u003c/p\u003e\u003cp\u003eAdditionally, a scree plot was examined to ascertain the appropriate number of factors that best fit the data (Cattell, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1966\u003c/span\u003e). All statistical analyses were performed using Jamovi version 2.3 (The Jamovi Project, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), which utilizes the lavaan package for structural equation and factor analyses (Rosseel, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Before exploratory factor analysis (EFA), data were screened for missing values. Sampling adequacy was evaluated using the Kaiser-Meyer-Olkin (KMO) statistic and Bartlett\u0026rsquo;s sphericity test. For subsequent analysis, a KMO value of at least 0.6 and a significant Bartlett\u0026rsquo;s test were considered necessary (Hutcheson \u0026amp; Sofroniou, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). In addition, confirmatory factor analysis (CFA) was used, utilizing structural equation modeling (SEM), to test the validity of the factor structure yielded by the EFA. The convergent and discriminant validities of the ARI were assessed by exploring its correlation with the MOS-SSS and the DASS-21, evaluating the Average Variance Extracted (AVE), and comparing each factor\u0026rsquo;s AVE to the squared correlation between factors.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows that most participants were married (56.6%) and female (92.3%) with high school or higher education (67.7%). The mean age was 59.6 (SD\u0026thinsp;=\u0026thinsp;11.1), and the mean age at diagnosis was 48.09 (SD\u0026thinsp;=\u0026thinsp;10.43).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ch2\u003eReliability\u003c/h2\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n \u003ch2\u003eInternal Consistency\u003c/h2\u003e\n \u003cp\u003eCronbach\u0026rsquo;s alpha coefficients were computed for the entire 30-item ARI scale and each factor using Jamovi\u0026rsquo;s Reliability Analysis module. The full scale demonstrated excellent internal consistency (\u0026alpha;\u0026thinsp;=\u0026thinsp;.90). Factor 1 (Positive/Support; 20 items) showed high reliability (\u0026alpha;\u0026thinsp;=\u0026thinsp;.97), and Factor 2 (Negative/ Control; 8 items) exhibited acceptable reliability (\u0026alpha;\u0026thinsp;=\u0026thinsp;.79).\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eValidity\u003c/h2\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003ch2\u003eFace and Content Validity\u003c/h2\u003e\n \u003cp\u003eTo establish content validity, the items of the ARI were reviewed by a panel of five experts in psychology, diabetes care, and psychometric assessment. Panel members evaluated each item for relevance, clarity, and appropriateness for individuals with T2DM. The content validity appeared to be appropriate for patients with T2DM. For face validity, the instrument was tested with a sample of 10 adults diagnosed with T2DM. Participants were asked to provide feedback on item clarity, comprehension, and perceived relevance. Based on their responses, minor revisions to wording were made to improve clarity and contextual fit for the T2DM population.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eExploratory Factor Analysis Results (Forced TwoFactor Solution)\u003c/h2\u003e\n \u003cp\u003eAn exploratory factor analysis (EFA) was conducted on the 30-item Autonomy and Relatedness Inventory (ARI) after excluding items ARI24 and ARI28 because these two items did not load on any factor, using minimum residual extraction with oblimin rotation. Reverse-coded items (ARI2, ARI4, ARI6, ARI10, ARI14, ARI18, ARI20, ARI22, ARI26, ARI28, and ARI30) were included in their recoded form since they are negatively worded items. The Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure of sampling adequacy was outstanding (KMO\u0026thinsp;=\u0026thinsp;.95), and Bartlett\u0026rsquo;s test of sphericity was significant, \u0026chi;\u0026sup2; (496)\u0026thinsp;=\u0026thinsp;6,299, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, indicating suitability for factor analysis.\u003c/p\u003e\n \u003cp\u003eBased on theoretical considerations and model parsimony, a two-factor solution (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e was forced. Table 2 summarizes the rotated factor loadings and uniqueness estimates for each item (loadings \u0026lt; |.30| suppressed). Factor 1 (Support/Positive) includes all positively worded items that reflect supportive behaviors and emotional availability, such as \u0026quot;\u003cem\u003eTalks over his/her problems with me\u0026quot;\u003c/em\u003e, \u0026quot;\u003cem\u003eRespects my opinions\u003c/em\u003e\u0026quot;, \u0026quot;\u003cem\u003eEncourages me to follow my own interests\u003c/em\u003e\u0026quot;, and \u0026quot;\u003cem\u003eConsiders my point of view\u003c/em\u003e\u0026quot;. High loadings on these items (\u0026ge;\u0026thinsp;.46) indicate a clear dimension of perceived autonomy support and relational quality provided by the important person.\u003c/p\u003e\n \u003cp\u003eFactor 2 (Dominance/Control) includes reverse‑coded items that describe controlling or critically blaming behaviors, such as \u0026quot;\u003cem\u003eIs always trying to change me\u003c/em\u003e\u0026quot; (RARI2), \u0026quot;\u003cem\u003eArgues back no matter what I say\u003c/em\u003e\u0026quot;, \u0026quot;\u003cem\u003eMakes fun of me\u003c/em\u003e\u0026quot;, and \u0026quot;\u003cem\u003eActs as though I am in the way\u003c/em\u003e\u0026quot;. Primary loadings on these items (\u0026ge;\u0026thinsp;.38) suggest a methodological factor capturing response style associated with negatively phrased items rather than a substantive psychological construct.\u003c/p\u003e\n \u003cp\u003eThis forced two‑factor solution describes substantive perceptions of autonomy and relatedness support from methodological artifacts due to item wording, aligning with the ARI\u0026rsquo;s underlying theory. Thus, these results should be confirmed by this structure by CFA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eConfirmatory Factor Analysis\u003c/h2\u003e\n \u003cp\u003eIn addition to chai-sequare (\u0026chi;\u0026sup2;), degree of freedom (df), Comparative Fit Index (CFI), Tucker\u0026ndash;Lewis Index (TLI), NNFI (Bentler\u0026ndash;Bonett Non‑normed Fit Index), Relative Noncentrality Index (RNI), Normed Fit Index (NFI), Relative Fit Index (RFI), Incremental Fit Index (IFI), Parsimony Normed Fit Index (PNFI), Standardized Root Mean Squared Residual (SRMR), and Root Mean Squared Error Approximate (RMSEA) (with 90% confidence Interval [CI] and p‑value) were included to comprehensively evaluate model adequacy. Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e shows that the goodness-of-fit indices of this model were an acceptable fit between the proposed model with the two subscales and their latent factors or items. The CFI\u0026thinsp;=\u0026thinsp;.0999, TLI\u0026thinsp;=\u0026thinsp;0.999, NNFI\u0026thinsp;=\u0026thinsp;.0999, RMSEA fit index\u0026thinsp;=\u0026thinsp;0.080, 90% C. I (0.073\u0026ndash;0.088), and SRMR\u0026thinsp;=\u0026thinsp;0.035. This indicates good convergent validity of items to their two proposed latent factors. All indices meet recommended thresholds, confirming the robustness of the two‑factor CFA model.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eConvergent and Discriminant Validity\u003c/h2\u003e\n \u003cp\u003eAverage Variance Extracted (AVE) was calculated for each factor. Factor 1 achieved an AVE of .68, and Factor 2 had an AVE of .39, indicating acceptable convergent validity for Factor 1 (AVE\u0026thinsp;\u0026gt;\u0026thinsp;.50) and marginal for Factor 2 (Fornell \u0026amp; Larcker, \u003cspan class=\"CitationRef\"\u003e1981\u003c/span\u003e). Discriminant validity was assessed using the Fornell\u0026ndash;Larcker criterion, comparing each factor\u0026rsquo;s AVE to the squared correlation between factors (r\u0026thinsp;=\u0026thinsp;.32, r\u0026sup2; = .10). Both AVE estimates exceed the squared inter-factor correlation (0.10), indicating satisfactory discriminant validity.\u003c/p\u003e\n \u003cp\u003eTo assess concurrent validity, we examined Pearson correlations between total ARI scores and scores on the MOS-SSS. As expected, ARI demonstrated a strong positive correlation with perceived social support (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.614, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Convergent validity was further supported by significant negative correlations between ARI and measures of psychological distress: depression (\u003cem\u003er\u003c/em\u003e = \u0026ndash;.255, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), anxiety (\u003cem\u003er\u003c/em\u003e = \u0026ndash;.181, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and stress (\u003cem\u003er\u003c/em\u003e = \u0026ndash;.244, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) (see Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the construct validity, internal consistency, and reliability of ARI. Overall, the values of Cronbach\u0026rsquo;s alpha demonstrated high internal consistency for the ARI among individuals diagnosed with T2DM. This finding suggests that the ARI is a reliable measure of the quality of relationships, that is, social support. The reliability obtained in this study indicates that ARI items assess the same underlying construct. This result is similar to that obtained by Linares et al (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, the results showed that some of the ARI items had low item-total correlations. Such findings can be attributed to several factors. For instance, the wording of these items may be unclear or vague, and these items may be trickier or more difficult to respond to than others. Ultimately, these factors may cause incorrect or inconsistent responses and lead to low item-total correlations for the corresponding items (Stomme \u0026amp; Wills, 2004).\u003c/p\u003e\u003cp\u003eThe other aim of this study was to evaluate the factor structure of ARI in patients with T2DM. Based on the scree plot and both EFA and CFA results, two latent factors were forced after the removal of the items that did not load into a factor. This indicates that ARI assesses two distinct yet interconnected constructs that were found in the original study (Hall \u0026amp; Kiernan, 1990). This result can be used to further assess the quality of relationships among people diagnosed with T2DM. Furthermore, it could be used to explore and target specific constructs, which can lead to improved understanding of the variables related to social support among people with T2DM. Additionally, future research could use these two latent factors to study the relationships between the constructs of ARI and other variables, such as glycemic control and psychological well-being of people with T2DM.\u003c/p\u003e\u003cp\u003eThe final aim was to evaluate the construct validity of the ARI in T2DM patients. The AVE values for both factors demonstrate the convergent validity of the ARI items to their latent factors. In addition, convergent validity was demonstrated by the significant correlations between the ARI and MOS-SSS, depression, anxiety, and stress. Discriminant validity was supported by AVE estimates exceeding the squared inter-factor correlation, confirming that each factor captures a distinct construct. These findings support the results of a previous study examining the construct validity of the ARI (Linares et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The results of this study on the convergent and discriminant validities of ARI indicate that the items on the scale are harmonious with the underlying latent components that they are supposed to evaluate.\u003c/p\u003e\u003cp\u003eTogether, these findings indicate that the ARI is a reliable and valid instrument for assessing perceived autonomy and relatedness support in individuals with T2DM, and that methodological artifacts due to item wording can be effectively modeled. Future research should use confirmatory approaches in independent samples, consider item rewording to minimize response bias, and explore the ARI\u0026rsquo;s predictive utility for diabetes self‑management and psychological well‑being.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eAlthough this study showed that the ARI is a psychometrically sound measure to be used for persons with T2DM, the results are promising but require further replication and refinement. This study has several limitations. First, it utilizes a secondary dataset of a convenient and relatively small sample, limiting the generalizability of the findings. Second, because the study was limited to northern Jordan, it is uncertain whether the findings are generalizable to other areas of Jordan, as well as other Arabic-speaking countries. Finally, the ARI may be not culturally appropriate. The cultural appropriateness of assessing intimate relationships in Arabic-speaking populations may be challenging, as they may have unique relational norms and disclosure barriers.\u003c/p\u003e\u003cp\u003eFuture studies with larger and more heterogeneous samples are recommended to address these limitations. Furthermore, future studies should further investigate the psychometric properties of the ARI among individuals with T2DM.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the ARI offers a promising, valid, and reliable method for assessing the quality of relationships among individuals diagnosed with T2DM. The ARI demonstrated strong internal consistency and convergent validity. This is especially significant, given that T2DM is one of the leading causes of morbidity and mortality worldwide. This study has valuable implications for both research and practice. First, the availability of such tools will allow researchers to easily study the quality of relationships in individuals with T2DM, considering that the quality of the relationships will be directly related to the self-management and psychological well-being of individuals with T2DM (Al-Dwaikat et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This is crucial because autonomy and relatedness are associated with several important outcomes in people with T2DM, including glycemic control, quality of life, and self-management behaviors.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eImplications of The Study\u003c/h2\u003e\u003cp\u003eThe ARI provides clinicians and researchers with a robust tool to explore the intimate relationship dynamics of individuals with T2DM. In addition, recognizing the importance of autonomy and relatedness in managing T2DM, healthcare systems can incorporate assessments of relationship quality into routine care. Furthermore, the ARI can help identify individuals with T2DM who might have challenging or poor relationship quality. Finally, the ARI can be utilized in studies examining how changes in the quality of the relationships impact T2DM self-management and outcomes. It also opens avenues for comparative studies among persons with different demographic and clinical backgrounds.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eARI\u0026nbsp; \u0026nbsp; \u0026nbsp;Autonomy and Relatedness Inventory\u003c/p\u003e\n\u003cp\u003eT2DM\u0026nbsp;Type 2 Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eEFA\u0026nbsp; \u0026nbsp; \u0026nbsp;Exploratory Factor Analysis\u003c/p\u003e\n\u003cp\u003eCFA\u0026nbsp; \u0026nbsp; \u0026nbsp;Confirmatory Factor Analysis\u003c/p\u003e\n\u003cp\u003eSEM\u0026nbsp; \u0026nbsp;\u0026nbsp;Structural Equation Modeling\u003c/p\u003e\n\u003cp\u003eSDT\u0026nbsp; \u0026nbsp; \u0026nbsp;Self-Determination Theory\u003c/p\u003e\n\u003cp\u003eMOS-SSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Medical Outcomes Study–Social Support Survey\u003c/p\u003e\n\u003cp\u003eDASS-21\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Depression, Anxiety, and Stress Scale – 21 items\u003c/p\u003e\n\u003cp\u003eKMO\u0026nbsp; \u0026nbsp;Kaiser–Meyer–Olkin (Measure of Sampling Adequacy)\u003c/p\u003e\n\u003cp\u003eRMSEA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Root Mean Squared Error of Approximation\u003c/p\u003e\n\u003cp\u003eSRMR\u0026nbsp;Standardized Root Mean Squared Residual\u003c/p\u003e\n\u003cp\u003eCFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Comparative Fit Index\u003c/p\u003e\n\u003cp\u003eTLI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tucker–Lewis Index\u003c/p\u003e\n\u003cp\u003eNNFI\u0026nbsp; \u0026nbsp;Non-Normed Fit Index (Bentler–Bonett)\u003c/p\u003e\n\u003cp\u003eRNI\u0026nbsp; \u0026nbsp; \u0026nbsp;Relative Noncentrality Index\u003c/p\u003e\n\u003cp\u003eNFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Normed Fit Index\u003c/p\u003e\n\u003cp\u003eRFI\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Relative Fit Index\u003c/p\u003e\n\u003cp\u003eIFI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Incremental Fit Index\u003c/p\u003e\n\u003cp\u003ePNFI\u0026nbsp; \u0026nbsp;\u0026nbsp;Parsimony Normed Fit Index\u003c/p\u003e\n\u003cp\u003eAVE\u0026nbsp; \u0026nbsp;\u0026nbsp;Average Variance Extracted\u003c/p\u003e\n\u003cp\u003eIRB\u0026nbsp; \u0026nbsp; \u0026nbsp;Institutional Review Board\u003c/p\u003e\n\u003cp\u003eSTROBE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Strengthening the Reporting of Observational Studies in Epidemiology checklist\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe Researchers would like to thank the Deanship of Graduate Studies and Scientific Research at Qassim University for financial support (QU-APC-2025).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u0026nbsp;\u003c/strong\u003eConceptualization: TA, AH, HK, and IA. Formal analysis: TA and AH. Project administration: IA. Methodology: TA, AH, and HK. Investigation: TA, AH, and IA. Resources: TA, HK, and IA. Visualization: TA, AH, and HK. Draft-writing: TA, AH, HK, and IA. Validation: AH, HK, and IA. All authors read and agreed to the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eA Faculty Research Grant from the Jordan University of Science and Technology supported this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Institutional Review Board (IRB) of Jordan University of Science and Technology (Approval No: 572/2018). All methods were performed by relevant guidelines and regulations, including the Declaration of Helsinki and the ethical principles outlined by the journal\u0026rsquo;s editorial policies\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Dwaikat TN, Hall LA. Systematic Review and Critical Analysis of Measures of Social Support Used in Studies of Persons With Type 2 Diabetes. 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Qual Health Res. 2004;14(7):942\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1049732304266997\u003c/span\u003e\u003cspan address=\"10.1177/1049732304266997\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"diabetes mellitus type 2, self-management, psychometrics, social support, autonomy, relatedness","lastPublishedDoi":"10.21203/rs.3.rs-6993605/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6993605/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSocial support is essential for the self-management of type 2 diabetes mellitus (T2DM), no specific measure of the quality of social support has been designed and tested for people with T2DM. Having a validated questionnaire that is culturally and linguistically appropriate in this field would nurture research in this area and contribute to better patient health outcomes.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e\u003cp\u003eThis study investigated the psychometric features of the Autonomy in Relatedness Inventory (ARI) among individuals with T2DM in Jordan.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e\u003cp\u003eWe used a secondary dataset on self-management and outcomes of individuals with T2DM to examine the psychometric properties of the ARI. The ARI's items' overall reliability was assessed using internal consistency (Cronbach's alpha). Exploratory Factor Analysis (EFA) was used to evaluate the validity of the ARI. Confirmatory factor analysis (CFA) was performed using structural equation modeling (SEM) to test the yielded factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe ARI demonstrated high reliability (Cronbach\u0026rsquo;s alpha value was 0.90) and validity in T2DM patients. Convergent validity of the ARI was established. The findings showed that ARI was strongly correlated with functional social support (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), in addition to negative correlations with depression (\u003cem\u003er\u003c/em\u003e= -0.26, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), anxiety (\u003cem\u003er\u003c/em\u003e= -0.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), and stress (\u003cem\u003er\u003c/em\u003e= -0.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Regarding the factor structure of ARI, two latent factors were determined using a scree plot and EFA.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eARI provides a psychometrically sound method for measuring autonomy and relatedness in T2DM patients in Jordan.\u003c/p\u003e","manuscriptTitle":"The Autonomy and Relatedness Inventory: An Analysis of the Psychometric Properties in Persons with Type 2 Diabetes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 08:06:00","doi":"10.21203/rs.3.rs-6993605/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-02T12:47:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-02T07:28:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T03:32:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212071822835092653869753588248842210600","date":"2025-07-28T02:29:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187967095653695299367912262692585471296","date":"2025-07-17T08:00:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T15:38:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-04T09:40:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-02T00:11:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-02T00:11:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-06-27T17:20:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c30f36b-52b9-44df-b963-9d4f2eba44e9","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T16:00:33+00:00","versionOfRecord":{"articleIdentity":"rs-6993605","link":"https://doi.org/10.1186/s40359-025-03374-9","journal":{"identity":"bmc-psychology","isVorOnly":false,"title":"BMC Psychology"},"publishedOn":"2025-08-31 15:57:23","publishedOnDateReadable":"August 31st, 2025"},"versionCreatedAt":"2025-07-22 08:06:00","video":"","vorDoi":"10.1186/s40359-025-03374-9","vorDoiUrl":"https://doi.org/10.1186/s40359-025-03374-9","workflowStages":[]},"version":"v1","identity":"rs-6993605","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6993605","identity":"rs-6993605","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}