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VOLUME 13 NUMBER 1 • JULY 2016
RESEARCH ARTICLE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Validity and reliability of the Zambian version of the
Problem Areas in Diabetes (PAID) scale: a triangulation
with cognitive interviews
GIVEN HAPUNDA, AMINA ABUBAKAR, FRANS POUWER, FONS VAN DE VIJVER
Correspondence to: Given Hapunda
Department of Psychology, University of Zambia, Lusaka, Zambia; Department
of Culture Studies, Tilburg University, Tilburg, the Netherlands
e-mail:
given.hapunda@unza.zmAmina Abubakar
Department of Culture Studies, Tilburg University, Tilburg, The Netherlands;
Neuroassessment Centre for Geographic Medicine Research, Kilifi, Kenya,
Department of Psychology, Lancaster University, Lancaster, UK
Frans Pouwer
Department of Medical and Clinical Psychology, Tilburg University, Tilburg,
The Netherlands
Fons van de Vijver
Department of Culture Studies, Tilburg University, Tilburg, The Netherlands;
Work Well Unit, North–West University, Potchefstroom, South Africa; School
of Psychology, University of Queensland, Brisbane, Australia
S Afr J Diabetes Vasc Dis
2016;
13
: 4–12
Abstract
This study aimed to examine the psychometric properties
of the Zambian version of the Problem Areas in Diabetes
(PAID) scale and to determine the levels of diabetes-specific
emotional distress in Zambian people with diabetes. A total of
157 Zambians living with type 1 and 2 diabetes completed the
20-item PAID, self-care inventory (SCI), fear for hypoglycaemia
scale (HFS) andthemajordepression inventory (MDI) instudy1.
In addition to exploratory factor analysis (EFA), reliability and
validity tests were also conducted. In study 2, eight patients
participated in cognitive interviews, in order to evaluate
the extent to which participants were able to comprehend
the scale items. EFA showed that a one-factor solution was
the best interpretable solution and the PAID was a valid
and reliable measure. Cognitive interviews showed that the
participants were able to comprehend question intent, while
a few faced some challenges with the meaning of words such
as ‘anxious’ and ‘physician’, and with comprehension of some
items. The Zambian version of the PAID is a reliable and valid
measure to assess diabetes-specific distress. These Zambian
participants with diabetes expressed high levels of diabetes-
specific distress, and some items needed to be simplified or
clarified to enhance comprehensibility.
Keywords:
validity, reliability, diabetes, cognitive interviews,
Problem Areas in Diabetes, Zambia
Introduction
Diabetes has become a major public health concern globally and
sub-Saharan African (SSA) has not been spared. An estimated
15 million people in SSA are living with diabetes.
1
In Zambia alone,
approximately 437 570 people are known to have diabetes, although
this is potentially a gross underestimation of the magnitude of the
problem, since many diabetes cases remain undiagnosed and the
healthcare institutions do not keep systematic records of those who
go for care. The number of people with undiagnosed diabetes in
Zambia is estimated at 221 000.
1
Evidence from mainly European and North American studies has
shown that being diagnosed with either diabetes mellitus type 1
(TIDM) or type 2 (T2DM) can be daunting and demanding, and its
treatment and care may impact on work, interpersonal relationships,
social functioning, as well as the physical and emotional well-being
of patients.
2-5
Psychosocial distress not only burdens patients but
can also hamper adequate self-care behaviours, consequently
compromising glycaemic control.
4,6,7
Depression has also been reported to be a common problem
in people with diabetes, which is associated with suboptimal
HbA
1c
levels, higher mortality rates and impaired quality of life.
8-14
Diabetes-specific emotional distress appears to mediate the
relationship between depression and glycaemic control.
15
Hence,
it is not surprising that depressive symptoms and diabetes-specific
emotional distress are highly correlated; both affect glycaemic
control and quality of life, among others.
15
Addressing diabetes-
specific emotional distress could presumably simultaneously
improve depressive mood and help improve health outcomes of
patients with diabetes mellitus.
Having diabetes mellitus in Zambia differs from having diabetes
in Europe or the USA. Access to care is often problematic, and
cost of insulin and/or syringes is high, especially in rural areas.
16
Furthermore, as found in an earlier study in Zambia, certain
cultural beliefs prevail that may impede the functioning of diabetes
patients, such as ‘a girl with diabetes cannot have children’ or
‘diabetes complications such as foot ulcers result from witchcraft’.
17
Given this array of issues specific to Zambia and Africa, a study of
diabetes-specific emotional distress is needed in Zambia.
To be able to adequately monitor the levels of diabetes-specific
emotional stress, there is a need to have adequately developed
and standardised measures for monitoring and identifying those
experiencing distress. The Problem Areas in Diabetes (PAID) scale is a
widely used measure to monitor diabetes-related distress. The PAID
has been translated and used to assess diabetes-specific emotional
problems in many countries, such as Brazil, China, Iceland, Iran, the
Netherlands, Norway, Sweden, Turkey and the USA.
3,6,7,18-24
Given this wide use, its administration to various age groups,
good psychometric properties and clinical utility, this measure has
the potential to fill the gap in assessment measures in the diabetes
population in Africa. However, its factor structure has been found
to differ across studies. For instance, some studies reported the
scale to be composed of one,
3,20
two,
6
three,
7
and four factors or
scales.
18,19