Psychometric Properties of the Problem Areas in Diabetes (PAID) Instrument in Singapore

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Abstract

Background

Emotional distress is an important dimension in diabetes, and several instruments have been developed to measure this aspect. The Problem Areas in Diabetes (PAID) scale is one such instrument which has demonstrated validity and reliability in Western populations, but its psychometric properties in Asian populations have not been examined.

Methods

This was a secondary analysis of data from patients with Type 2 diabetes mellitus recruited through convenience sampling from a diabetes specialist outpatient clinic in Singapore. The following psychometric properties were assessed: Construct validity through confirmatory factor analysis (CFA) and Rasch analysis, concurrent validity through correlation with related scales (Kessler Psychological Distress Scale, Diabetes Health Profile—psychological distress, Audit of Diabetes Dependent Quality of Life), reliability through assessment of internal consistency and floor and ceiling effects, and sensitivity by estimating effect sizes for known clinical and social functioning groups.

Results

203 patients with mean age of 45±12 years were analysed. None of the previously published model structures achieved a good fit on CFA. On Rasch analysis, four items showed poor fit and were removed. The abridged 16-item PAID mapped to a single latent trait, with a high degree of internal consistency (Cronbach ɑ 0.95), but significant floor effect (24.6% scoring at floor). Both 20-item and 16-item PAID scores were moderately correlated with scores of related scales, and sensitive to differences in clinical and social functioning groups, with large effect sizes for glycemic control and diabetes related complications, nephropathy and neuropathy.

Conclusion

The abridged 16-item PAID measures a single latent trait of emotional distress due to diabetes whereas the 20-item PAID appears to measures more than one latent trait. However, both the 16-item and 20-item PAID versions are valid, reliable and sensitive for use among Singaporean patients with diabetes.

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Most cited references 16

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Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life.

K Wyrwich, W Tierney, F D Wolinsky (1999)

This study used the standard error of measurement (SEM) to evaluate intra-individual change on both the Chronic Respiratory Disease Questionnaire (CRQ) and the SF-36. After analyzing the reliability and validity of both instruments at baseline among 471 COPD outpatients, the SEM was compared to established minimal clinically important difference (MCID) standards for three CRQ dimensions. A value of one SEM closely approximated the MCID standards for all CRQ dimensions. This SEM-based criterion was then validated by cross-classifying the change status (improved, stable, or declined) of 393 follow-up outpatients using the one-SEM criterion and the MCID standard. Excellent agreement was achieved for all three CRQ dimensions. Although MCID standards have not been established for the SF-36, the one-SEM criterion was explored in these change scores. Among SF-36 scales demonstrating acceptable reliability and reasonable variance, the percent of individuals within each change category was consistent with those seen in the CRQ dimensions. These results replicate previous findings where a value of one SEM also closely approximated MCIDs for all dimensions of the Chronic Heart Disease Questionnaire among cardiovascular outpatients. The one-SEM criterion should be explored in other health-related quality of life instruments with established MCIDs.

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Assessment of diabetes-related distress.

Ivan Anderson, David C. Schwartz, William H. Polonsky … (1995)

To describe a new measure of psychosocial adjustment specific to diabetes, the Problem Areas in Diabetes Survey (PAID), and to present initial information on its reliability and validity. Before their routine clinic appointments, 451 female patients with type I and type II diabetes, all of whom required insulin, completed a self-report survey. Included in the survey was the PAID, a 20-item questionnaire in which each item represents a unique area of diabetes-related psychosocial distress. Each item is rated on a six-point Likert scale, reflecting the degree to which the item is perceived as currently problematic. A total scale score, hypothesized to reflect the overall level of diabetes-related emotional distress, is computed by summing the total item responses. To examine the concurrent validity of the PAID, the survey also included a series of standardized questionnaires assessing psychosocial functioning (general emotional distress, fear of hypoglycemia, and disordered eating), attitudes toward diabetes, and self-care behaviors. All subjects were assessed for HbA1, within 30 days of survey completion and again approximately 1-2 years later. Finally, long-term diabetic complications were determined through chart review. Internal reliability of the PAID was high, with good item-to-total correlations. Approximately 60% of the subject sample reported at least one serious diabetes-related concern. As expected, the PAID was positively associated with relevant psychosocial measures of distress, including general emotional distress, disordered eating, and fear of hypoglycemia, short- and long-term diabetic complications, and HbA1, and negatively associated with reported self-care behaviors. The PAID accounted for approximately 9% of the variance in HbA1. Diabetes-related emotional distress, as measured by the PAID, was found to be a unique contributor to adherence to self-care behaviors after adjustment for age, diabetes duration, and general emotional distress. In addition, the PAID was associated with HbA1 even after adjustment for age, diabetes duration, general emotional distress, and adherence to self-care behaviors. These findings suggest that the PAID, a brief, easy-to-administer instrument, may be valuable in assessing psychosocial adjustment to diabetes. In addition to high internal reliability, the consistent pattern of correlational findings indicates that the PAID is tapping into relevant aspects of emotional distress and that its particular feature, the measurement of diabetes-related emotional distress, is uniquely associated with diabetes-relevant outcomes. These data are also consistent with the hypothesis that diabetes-related emotional distress, separate from general emotional distress, is an independent and major contributor to poor adherence. Given that the study was limited to female patients using insulin, further examination of the clinical usefulness of the PAID will need to focus on more heterogeneous samples.

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The Problem Areas in Diabetes Scale. An evaluation of its clinical utility.

G Welch, A Jacobson, W Polonsky (1997)

To evaluate the reliability and concurrent and discriminant validity of the Problem Areas in Diabetes (PAID) scale, a new measure of emotional functioning in diabetes. A battery of questionnaires, including the PAID, was completed by 256 volunteer diabetic outpatients. In our analyses, we examined the PAID's internal structure and compared mean IDDM and NIDDM treatment group scores in regression analyses to explore its discriminant validity. We also evaluated concurrent validity from the correlations between the PAID and diabetes-specific measures of coping and health attitudes and HbA1c. Principal component analyses identified a large emotional adjustment factor, supporting the use of the total score. Significant sizable correlations were found between the PAID and a range of selected health attitudinal measures. There were significant differences (with small-to-moderate effect sizes) in PAID scores between IDDM and NIDDM patients and between IDDM and NIDDM insulin- and tablet-treated subgroups; no differences were found between NIDDM insulin- and tablet-treated subgroups. The study findings provided support for the construct validity of the PAID, including evidence for discriminant validity from its ability to detect differences between IDDM and NIDDM treatment groups expected to differ in the emotional impact of life with diabetes. Future studies should explore the PAID's performance in nonspecialist treatment settings as well as its responsiveness to clinical change.

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Author and article information

Contributors

Fakir M Amirul Islam: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 3 September 2015

Publication date Collection: 2015

Volume: 10

Issue: 9

Electronic Location Identifier: e0136759

Affiliations

[1 ]Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore

[2 ]Center for Quantitative Medicine, Duke NUS Graduate Medical School, Singapore, Singapore

[3 ]Singapore Clinical Research Institute, Singapore, Singapore

[4 ]Department of Psychology, National University of Singapore, Singapore, Singapore

[5 ]Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

[6 ]Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

[7 ]Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore

[8 ]Singapore Institute for Clinical Sciences, A*STAR, Singapore, Singapore

[9 ]Department of Pharmacy, National University of Singapore, Singapore, Singapore

Swinburne University of Technology, AUSTRALIA

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: EYHK KG YSL HLW. Performed the experiments: YLMZ MA. Analyzed the data: KV HLW. Contributed reagents/materials/analysis tools: LSMT DCTB. Wrote the paper: KV JL EST HLW EYHK.

* E-mail: eric_khoo@ 123456nuhs.edu.sg (EYHK); phawhl@ 123456nus.edu.sg (HLW)

Article

Publisher ID: PONE-D-15-16142

DOI: 10.1371/journal.pone.0136759

PMC ID: 4559380

PubMed ID: 26336088

SO-VID: 91d82f7e-49fe-4a24-82e5-68876104eb0e

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

History

Date received : 14 April 2015

Date accepted : 7 August 2015

Page count

Figures: 1, Tables: 3, Pages: 11

Funding

This work was supported by a grant from the Ministry of Education Singapore Academic Research Fund Tier 1 (Grant No. FY2011-FRC3-007). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Custom metadata

Data Availability The DOI associated with the data is as follows: 10.7910/DVN/JO6SKS.

Psychometric Properties of the Problem Areas in Diabetes (PAID) Instrument in Singapore

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Most cited references 16

Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life.

Assessment of diabetes-related distress.

The Problem Areas in Diabetes Scale. An evaluation of its clinical utility.

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