Diabetes-related emotional distress in adults: Reliability and validity of the Norwegian versions of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS)

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Abstract

Background

Regular assessment of diabetes-related emotional distress is recommended to identify high-risk people with diabetes and to further prevent negative effects on self-management. Nevertheless, psychological problems are greatly under diagnosed. Translating and testing instruments for psychosocial assessment across languages, countries and cultures allow for further research collaboration and enhance the prospect of improving treatment and care.

Objectives

To examine the psychometric properties of the Norwegian versions of the Problem Areas in Diabetes Scale and the Diabetes Distress Scale.

Design

Cross-sectional survey design.

Settings

A sample comprising adults with diabetes (response rate 71%) completed the Problem Areas in Diabetes Scale and the Diabetes Distress Scale, which were translated into Norwegian with standard forward–backwards translation.

Participants

The study included 292 participants with type 1 (80%) and type 2 diabetes (20%) aged 18–69 years, 58% males, mean diabetes duration 17.3 years (11.6), mean HbA1c 8.2% (1.6).

Methods

We used exploratory factor analysis with principal axis factoring and varimax rotation to investigate the factor structure and performed confirmatory factor analysis to test the best fit of a priori-defined models. Convergent and discriminate validity were examined using the Short Form-36 Health Survey, Hospital Anxiety and Depression Scale and demographic and disease-related clinical variables. We explored reliability by internal consistency and test–retest analysis.

Results

Exploratory factor analysis supported a four-factor model for the Diabetes Distress Scale. Confirmatory factor analysis indicated that the data and the hypothesized model for the Diabetes Distress Scale fit acceptably but not for the Problem Areas in Diabetes Scale. Greater distress assessed with both instruments correlated moderately with lower health-related quality of life and greater anxiety and depression. The instruments discriminated between those having additional health conditions or disabilities, foot problems or neuropathy. Women and participants with higher HbA1c levels reported significantly higher diabetes-related emotional distress.

Conclusions

The Norwegian versions of the Problem Areas in Diabetes Scale and the Diabetes Distress Scale have satisfactory psychometric properties and can be used to map diabetes-related emotional distress for diagnostic or clinical use. The Diabetes Distress Scale also contributes to identifying sub-domains of distress and seems promising for use in clinical trials.

Introduction

The continued gap between clinical results and treatment goals (Eeg-Olofsson et al., 2007, Cooper et al., 2009) has led to increased awareness of the relationships between treatment outcomes and diabetes-related emotional distress and depressive symptoms. Many people living with diabetes do not reach recommended treatment goals despite new and better oral medication, better insulin and improved technologies for insulin delivery. Regular assessment of disease-specific emotional distress is recommended to identify high-risk people with diabetes and to further prevent negative effects on diabetes management (Fisher et al., 2009). Some people with diabetes need help to present their individual concerns and to address essential emotional problems in order to be able to increase their self-care efforts. Nevertheless, both mild and serious psychological problems are greatly under diagnosed among people with diabetes (Pouwer et al., 2006).

The Problem Areas in Diabetes Scale (PAID) (Polonsky et al., 1995, Welch et al., 1997, Welch et al., 2003) and the Diabetes Distress Scale (DDS) (Polonsky et al., 2005) are commonly used for mapping diabetes-related problem areas and emotional distress. They were developed in the United States and are also translated and validated for use in some European populations (Snoek et al., 2000, Sigurðardóttir and Benediktsson, 2008). Both instruments display good psychometric properties and are used for clinical screening and in research. The PAID items were solicited from 10 health care providers at the Joslin Diabetes Clinic and from patients’ comments into an item pool, resulting in a final measure after piloting of 20 items (Polonsky et al., 1995). The DDS is more conceptually driven and draws items from four pre-established domains of diabetes-related distress (Polonsky et al., 2005). Snoek et al. (2000) maintain that international psychosocial research in diabetes could benefit from standardized instruments to promote further international comparison of results.

Translating and testing instruments for psychosocial assessment across languages, countries and cultures allow for further research collaboration and enhance the prospect of improving treatment and care. Valid and reliable instruments to map disease-related emotional distress and to discriminate between levels of diabetes-related emotional problems and those who are clinically depressed are needed. Furthermore, the availability of sound instruments is important in order to compare results from different behavioral and psychosocial interventions in diabetes (Peyrot and Rubin, 2007). To our knowledge including both PAID and DDS in the same study allowing for consideration of the properties of both instruments in the same sample, have not previously been described internationally.

In the present study, we examine the psychometric properties of the Norwegian versions of the PAID and the DDS instruments and hypothesized that the PAID and DDS scores would be negatively associated with self-rated health-related quality of life (Short Form-36 Health Survey (SF-36)) and positively associated with general anxiety and depression levels (Hospital Anxiety and Depression Scale (HADS)) as variants of the same construct, and would discriminate diabetes-related emotional distress at a group level.

Section snippets

Design and sample

We invited everyone with type 1 or 2 diabetes, visiting an endocrinology outpatient clinic at a larger University Hospital in Western Norway between October 2008 and February 2009 to participate in this cross-sectional survey study. Inclusion criteria were aged 18–69 years, diagnosed with diabetes for at least 1 year and able to complete a Norwegian questionnaire. The patients were informed about the purpose of the study and the possibility to withdraw at any time. They gave written consent and

Results

The study included 292 Norwegian adults with type 1 (80%) and type 2 diabetes (20%) aged 18–69 years (Table 1). The nonparticipants (n = 119) did not differ in mean age (42.3 years vs. 43.0 years, P = 0.66), sex (male 168 vs. 77 and female 124 vs. 42, P = 0.18) or HbA1c (8.2% vs. 8.5%, P = 0.09).

Discussion

The availability of standardized instruments across languages, countries and cultures enhances the prospect of comparing results from multinational and cross-cultural research. The results from the current study suggest that the Norwegian versions of PAID and DDS have satisfactory psychometric properties to map individual levels of diabetes-related emotional distress among people with diabetes for diagnostic or clinical use. The instruments can discriminate distressed subjects and might be

Conclusion

The Norwegian versions of PAID and DDS seem to be valid and reliable and contribute uniquely in assessing diabetes-related emotional distress. Both instruments have satisfactory psychometric properties to map individual levels of distress among people with diabetes for diagnostic or clinical use. For the use of these instruments in clinical trials the DDS might have some advantages as it also contributes to identifying sub-domains of distress.

Acknowledgements

Bergen University College and the Western Norway Health Authority Trust kindly supported this research. We thank the patients for participating and nurses at the endocrinology outpatient clinic, Ingvild Hernar, Kari Horn, Elisabeth Iversen, Berit M. Tarlebø and Elin Irrborg, for enthusiastic participating in data collection.

Contributions: MG, BR, AH, MIV contributed to study design, MG contributed to data collection; MG, TWL, BK contributed to data analysis and MG, AH, MIV, TWL, BK, BR

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