VOLUME 13 NUMBER 1 • JULY 2016
SA JOURNAL OF DIABETES & VASCULAR DISEASE
This measure has not been evaluated and validated in the
African context to date. Therefore, the aim of the present study
was to examine psychometric properties of the PAID scale in
Zambian people with diabetes and to determine the levels of
diabetes-specific emotional distress in that group.
The study comprised two sets of data: quantitative data to test the
validity and reliability of the PAID scale (study 1), and a cognitive
interview to assess the adequacy, comprehensibility and cultural
appropriateness of the PAID among the urban sample (study 2).
The study sample comprised out-patients with either T1DM
or T2DM from major hospitals in Lusaka, Ndola, Kitwe and
Livingstone. Patients were classified as T1DM or T2DM based on
what was indicated on the patients’ hospital record cards. Patients
were invited to participate in the study if they were at least 12
years old and were diagnosed at least six months before the study.
In total, 157 patients signed the consent form, or with permission
from guardians, assent was obtained from participants under 18
years of age. Recruitment was done over a one-year period.
Of the 157 participants, 80 were female (51%). We did not
find significant differences in gender composition of the patients.
Mean age was 39 ± 17 years with ages ranging from 12 to 68
years. Of the total sample, 115 (73%) were adults and 42 (27%)
were adolescents. Table 1 shows the detailed demographic
characteristics of the participants. Demographic variables included
Demographic characteristics of 157 participants with type 1
and type 2 diabetes
Age, mean (SD)
39 ± 17
Age range (years)
Type of diabetes,
Unknown (but either type 1 or 2)
BMI mean (SD)
5–7th grade (primary school)
8–12th grade (secondary school)
Marital status (adults
age, gender, educational level, properties and services owned by
families of the participants, and type of diabetes. In addition, the
body mass index of the participants was recorded.
The PAID is a 20-item self-report measure used to assess
diabetes-specific emotional distress in a wide age group,
a range of feelings such as diabetes-related anger, fear, depression,
worry and guilt. Items can be responded to on a scale from 0 (not
a problem) to 4 (serious problem). An overall score for PAID can be
calculated by adding all of the item scores and multiplying by 1.25,
which gives a total score ranging from 0 to 100. Higher scores
indicate more distress. The reported Cronbach’s alpha for the PAID
scale was 0.84 to 0.96.
The hypoglycaemia fear survey (HFS) consists of 26 items. HFS
comprises two scales assessing ‘worries about hypoglycaemia’ and
‘hypoglycaemia-related behaviours’. The items are rated on a five-
point scale ranging from 1 (never) to 5 (very often). The Cronbach’s
alpha of 0.90 suggests high internal consistency.
The 13-item self-care inventory (SCI) is a self-report measure
used to assess patients’ perceptions of their adherence to diabetes
self-care recommendations over the previous one to two months.
Individuals rate themselves on a five-point Likert scale that reflects
on how well they have followed recommendations for self-care
during the past month (i.e. 1 = ‘never do it’ to 5 = ‘always do this as
recommended, without fail’). Higher scores indicate more optimal
diabetes self-care. Cronbach’s alpha for the SCI was 0.84 for T1DM
and 0.85 for T2DM.
The major depression inventory (MDI) is a 12-item self-report
questionnaire used to assess depression. Items of the MDI ask
the patient to rate how long in the past two weeks each of the
symptoms of the depressive syndrome was present on a six-point
scale ranging from 0 = ‘not at all’ to 5 = ‘all the time’. It can be used
as an instrument measuring severity of depression with a range
from 0 to 50. The internal consistency of the MDI appeared to be
good, as indicated by Cronbach’s alphas of 0.89 and 0.94.
Zambia is a multi-lingual country with five main languages
and English is the official language. Measures were administered
in English and in two local languages, Nyanja and Bemba. Back
translations were done by two native speakers in each language
who were fluent in the other language and English. The translators
met, together with the first author to discuss the translation in each
language and the differences between forward and back translation
versions. The goal was to maximise both linguistic and psychological
equivalence. The final translation was piloted on six adolescents
with type 1 diabetes and feedback on their understanding of the
items was obtained.
Demographic characteristics in the total sample were examined using
descriptive statistics. Missing data from the PAID were determined as
missing completely at random(MCAR) and replacedusing expectation
maximisation/maximum likelihood (EM) in SPSS. To assess the factor
structure of the PAID, exploratory factor analysis was conducted; we
used direct oblique rotation (direct oblimin), Keiser–Mayer–Olkin
measure of sampling and Bartlett’s test of sphericity using the
scree plot criterion. Keiser–Mayer–Olkin values of > 0.6 indicate
that data are suitable for conducting a factor analysis.
rotation was used because factors of the PAID were expected to be
moderately correlated. Factor loadings of 0.30 or higher have been
recommended for a sample size of 300 or more.
The reliability was evaluated using data on the type of diabetes
(T1DM and T2DM) and included Cronbach’s alpha and lambda 2