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VOLUME 13 NUMBER 1 • JULY 2016
RESEARCH ARTICLE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
associations between body mass index, socio-economic status,
glycaemic control and self-care with depression.
37-41
Overall, the cognitive interviews demonstrate that our
respondents were able to comprehend the scale items and to
link them to the scale category. Four items (‘feeling constantly
burned out by constant effort to manage diabetes’, ‘not having
a clear and concrete goal for managing diabetes care’, ‘coping
with complications of diabetes’ and ‘feeling diabetes was taking
up too much of your mental and physical energy’, were not well
comprehended by five respondents. The difficulties were beyond
word difficulties or vague concepts, but were the comprehension
of the question intent. Although some of the respondents had
difficulties with the meaning of some words/terms (e.g. anxious,
physician, concrete goals), overall they were able to comprehend
the intent of the questions, with the exception of a few
questions.
Of the main items that influenced the missing values figure,
‘feeling constantly burned out by constant effort to manage
diabetes’ and ‘feeling diabetes is taking up toomuch of your mental
and physical energy’ were also items that patients found difficult
to comprehend. Patients also had problems with the meaning
of the word ‘overwhelmed’ in the item ‘feeling overwhelmed
by your diabetes management’. It is possible that patients were
uncomfortable answering the items ‘feeling constantly concerned
with food’ and ‘not accepting diabetes’, hence leaving them
unanswered by some patients.
Implementing the feedback from respondents on some changes
to key words could improve the strength of the items. In addition,
including items covering patients’ worries on adapting in future
roles such as marriage and work, costs associated with medicine
and worries on discrimination would enrich the Zambian version
of the PAID.
This study is the first to validate an African version of the PAID.
The sample in this study was drawn from three provinces in Zambia,
including adolescents and adults with type 1 and 2 diabetes
mellitus, making the sample heterogeneous and generalisable
with T1DM were on insulin injection therapy, which has been
shown to be physically and mentally challenging. Patients are
required to buy their own strips for blood glucose testing, which
are often unaffordable for most patients. Generally, diabetes
patients get off track with diabetes management and care, which
can cause a sense of guilt and anxiety.
The mean value for the 16 items of the PAID was 33.8 ± 27.2
(it would be 40.3 ± 33 in the case of 20 items) suggesting that the
Zambian participants experienced high levels of diabetes-specific
emotional distress. In the Icelandic participants (T1DM only) the
mean value for the PAID was 28 ± 18, in Swedish participants
(T1DM only) it was 27 ± 18, in the Dutch, 24 ± 19, and in USA
participants, it was 31 ± 23. The results suggest that living with
diabetes in Zambia is perceived as much more stressful compared
to Western Europe and the USA, and that it imposes many
demands on the patients, which may exacerbate diabetes-specific
emotional distress.
These differences in levels of diabetes-specific emotional
distress may reflect differences in access to physical and mental
healthcare, and costs associated with diabetes management.
Another explanation could be cultural differences in the experience
of psychological problems. Graue and colleagues also speculated
that differences in diabetes-specific emotional distress across
countries may be due to cultural differences in the explanation
of psychological problems.
24
Most importantly, definitions and
attributes of depression are dominated by Western cultural
assumptions, which may not reflect the conceptualisation and
treatment of depression in Zambia. To the best of our knowledge
diabetes patients in Zambia are not given any psychosocial help.
Moreover about 48% of our participants indicated that family/
friends were not supportive of diabetes management efforts.
In our study, the PAID scores were positively associated with
fear for hypoglycaemia and depression, and negatively associated
with diabetes self-care. Equally, PAID scores were predicted by
the patients’ depression levels, diabetes self-care and fear of
hypoglycaemia. This was expected, as the literature has shown
Table 8.
Item total correlations of 20 PAID items
Scale mean Scale variance Corrected item Cronbach alpha
Items if deleted if deleted total correlation if item deleted
1. Worrying about future and possible complications
37.83 307.10
0.62
0.87
2. Feeling guilty or anxious when getting off track with your diabetes management
37.83
312.85
0.56
0.87
3. Feeling scared when you think about living with diabetes
38.12
304.65
0.65
0.87
4. Feeling discouraged with diabetes regimens
38.41
305.26
0.65
0.87
5. Worrying about low blood sugar
37.74
317.27
0.47
0.87
6. Feeling constantly burned out by constant effort to manage diabetes
38.08
306.18
0.64
0.87
7. Not knowing if mood/feelings experiencing are related to your blood glucose
37.98
311.06
0.56
0.87
8. Coping with complications of diabetes
38.54
339.95
0.06
0.89
9. Feeling diabetes is taking up too much of your mental and physical energy
37.70
311.74
0.56
0.87
10. Feeling constantly concerned about food
38.50
332.56
0.17
0.88
11. Feeling depressed when thinking about living with diabetes
37.94
305.58
0.65
0.87
12. Feeling angry when you think about living with diabetes
38.50
309.53
0.55
0.87
13. Feeling overwhelmed by your diabetes regimens
39.10
332.15
0.24
0.88
14. Feeling alone with diabetes
38.33
311.81
0.53
0.87
15. Feeling deprived regarding food
38.47
328.89
0.23
0.88
16. Not having a clear and concrete goal for your diabetes care
38.37
323.66
0.33
0.88
17. Uncomfortable interactions around diabetes with friends/family
38.61
313.51
0.52
0.87
18. Not accepting diabetes
38.51
308.00
0.55
0.87
19. Feeling that family/friends are not supportive of diabetes management effort
38.20
306.06
0.60
0.87
20. Feeling unsatisfied with your diabetes physician
38.44
314.39
0.48
0.87