Abstract
Objectives
We aimed to (a) culturally and linguistically adapt the Type 1 Diabetes Stigma Assessment Scale (DSAS-1) from English (for Australia) into Danish and (b) examine psychometric properties of the measure among Danish adults with type 1 diabetes.
Methods
We performed a forward–backward translation, face validity interviews with experts and cognitive debriefing of the Danish version (DSAS-1 DK) with ten adults from the target group. The DSAS-1 DK was then completed by 1594 adults with type 1 diabetes. Electronic clinical records provided age, diabetes duration, diabetes-related complications, and glycemic control [glycated hemoglobin (HbA1c)]. We examined internal consistency, construct validity and structural validity of the DSAS-1 DK using exploratory and confirmatory factor analysis in a cross-validation design.
Results
The translated measure was found acceptable by the experts and target group, with only minor adaptations required for the Danish context. The DSAS-1 DK structure was best represented by a three-factor model representing the subscales ‘Treated Differently,’ ‘Blame and Judgement,’ and ‘Identity Concern’ (α = 0.88–0.89). The results also provided some support for calculation of a total score (19-item scale; α = 0.75). The subscales and total scale demonstrated satisfactory convergent and discriminant validity. Good structural validity was demonstrated for the three-factor model for four out of five indices [normed χ 2 = 4.257, goodness-of-fit index (GFI) = 0.923, root mean square error of approximation (RMSEA) = 0.065, standardized root mean square residual (SRMSR) = 0.0567, comparative fit index (CFI) = 0.93].
Conclusion
The DSAS-1 DK has a confirmed three-factor structure, consistent with the original Australian English version. The measure is now validated and available to advance research into the stigma perceived and experienced by adults with type 1 diabetes in a Danish context.
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References
Young-Hyman D, et al. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(12):2126–40.
Nicolucci A, et al. Diabetes attitudes, wishes and needs second study (DAWN2): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med. 2013;30(7):767–77.
Weiss MG, Ramakrishna J. Stigma interventions and research for international health. Lancet. 2006;367(9509):536–8.
Mahajan AP, et al. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. Aids. 2008;22(Suppl 2):S67–79.
Jacoby A, Snape D, Baker GA. Epilepsy and social identity: the stigma of a chronic neurological disorder. Lancet Neurol. 2005;4(3):171–8.
Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16–20.
Browne JL, et al. I’m not a druggie, I’m just a diabetic’: a qualitative study of stigma from the perspective of adults with type 1 diabetes. BMJ Open. 2014;4(7):e005625.
Browne JL, et al. Measuring type 1 diabetes stigma: development and validation of the Type 1 Diabetes Stigma Assessment Scale (DSAS-1). Diabet Med. 2017;34(12):1773–82.
Schabert J, et al. Social stigma in diabetes: a framework to understand a growing problem for an increasing epidemic. Patient. 2013;6(1):1–10.
Browne JL, V.A., Mosley K, Speight J. Development and validation of the Type 1 and Type 2 Diabetes Stigma Assessment Scales (DSAS-1 and DSAS-2), in American Diabetes Association 76th Scientific Sessions, New Orleans; 2016.
Acquadro C, et al. Literature review of methods to translate health-related quality of life questionnaires for use in multinational clinical trials. Value Health. 2008;11(3):509–21.
Acquadro C, et al. Linguistic validation manual for patient-reported outcomes (PRO) instruments. Lyon: MAPI Research Institute; 2004.
Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw-Hill, Inc; 1994.
Polonsky WH, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18(6):754–60.
McGuire BE, et al. Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1. Diabetologia. 2010;53(1):66–9.
Rosenberg M. Conceiving the self. New York: Basic Books; 1979.
Nathan DM, Turgeon H, Regan S. Relationship between glycated haemoglobin levels and mean glucose levels over time. Diabetologia. 2007;50(11):2239–44.
Sacks DB, et al. Position statement executive summary: guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care. 2011;34(6):1419–23.
Terwee CB, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34–42.
Floyd FJ, Widaman KF. Factor analysis in the development and refinement of clinical assessment instruments. Psychol Assess. 1995;7:286–99.
Thurstone LL. The calibration of test items. Am Psychol. 1947;2(3):103.
Brown TA. Confirmatory factor analysis for applied research. 2nd ed. New York: The Guilford Press; 2015.
Hooper D, Coughlan J, Mullen M. Structural equation modelling: guidelines for determining model fit. Electron J Bus Res Methods. 2008;6(1):53–60.
Gerbing DW, Anderson JC. An updated paradigm for scale development incorporating unidimensionality and its assessment. J Mark Res. 1988;25(2):186–92.
Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model. 1999;6(1):1–55.
Levine T. Confirmatory factor analysis and scale validation in communication research. Commun Res Rep. 2005;22(4):335–8.
O’Rourke N, Hatcher L. A step-by-step approach to using SAS for factor analysis and structural equation modeling. 2nd ed. Cary: SAS Institute Inc; 2013.
Bagozzi RP, Yi Y. On the evaluation of structural equation models. J Acad Mark Sci. 1988;16(1):74–94.
Fornell C, Larcker DF. Structural equation models with unobservable variables and measurement error: algebra and statistics. J Mark Res. 1981;18:39–50.
Björnsson CH. Læsbarhed. København Gad; 1971.
Hair JF, et al. Multivariate data analysis. 5th ed. Upper Saddle River: Prentice-Hall, Inc; 1998.
Ventura AD, et al. Diabetes MILES-2 2016 survey report. The Australian Centre for Behavioural Research in Diabetes: Diabetes Victoria, Melbourne; 2016.
Joensen LE. Psychosocial health in type 1 diabetes. A study of bio-psycho-social interactions and the investigation of conceptual framework for social support targeting adults with type 1 diabetes. Faculty of health and medical sciences. University of Copenhagen, Frederiksberg Trykkeri; 2014.
IDF. International charter of rights and responsibilities of people with diabetes. 2014. [cited 2017 April 27]. https://www.idf.org/about-diabetes/charter-of-rights.html. Accessed Dec 2017.
Acknowledgements
We thank all the study participants for volunteering their time and insights. We acknowledge Dr. Kylie Mosely, who contributed to the development of the original DSAS-1 (English version, for Australia) and to the concept elaboration document enabling linguistic adaptation. We acknowledge Dr. Birgit Gemal (a native Danish-speaking psychologist fluent in English), who provided independent advice to the DSAS-1 developers during the translation process. We acknowledge Dr. Sonia Zafar who undertook the backward translation of the DSAS-1 DK. The DSAS-1 DK as well as the original DSAS-1 are available free of charge to academic researchers, clinicians and students for use in non-commercially funded research. Potential users are advised to email info@acbrd.org.au to enquire about or access the latest version of the questionnaire (including instructions for administering the measure) and scoring guidance.
Funding
This work was supported by an unrestricted grant from Innovation Fund Denmark (Grant no. 4135-00019B). JS and JLB are supported by core funding provided to the Australian Centre for Behavioural Research in Diabetes from Diabetes Victoria and Deakin University.
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Contributions
The cultural and linguistic validation protocol was prepared by UMH with feedback from all authors. UMH, KO and IW translated the DSAS-1 from English to Danish and designed the survey, which included the DSAS-1 DK. JLB, ADV and JS developed the original DSAS-1 in English (for Australia), provided a concept elaboration document to inform the translation, and provided feedback on the translation reconciliations prior to finalizing the new language version. UMH conducted data analyses, which were reviewed by ADV, KO and JLB. UMH prepared the first draft of the manuscript, and all authors provided feedback and revisions on the first and subsequent drafts. All authors approved the final submitted manuscript. JLB, as senior author, takes overall responsibility for the content of the article.
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Ethical approval
The study was registered with the Danish Data Protection Agency (j.nr. SDC-2015-033 DiA/I-Suite nr. 03813). According to the Committees on Health Research Ethics in the Capital Region of Denmark, the study does not require ethical approval, as it does not implicate the use of human biological materials (jr.nr. forespørgsel H-15015747/2015).
Informed consent
In the invitation to take part in the survey, participants were informed about the purpose of the study and informed that by proceeding to the survey and completing it they provided consent. They were also informed that no personally identifiable data would be disclosed.
Conflict of interest
ADV, JS and JLB are employed at the Australian Centre for Behavioural Research in Diabetes, which owns the copyright of the DSAS-1 in all its language versions. UMH, IW, and KO have no conflict of interest to declare.
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Hansen, U.M., Willaing, I., Ventura, A.D. et al. Stigma Perceived and Experienced by Adults with Type 1 Diabetes: Linguistic Adaptation and Psychometric Validation of the Danish Version of the Type 1 Diabetes Stigma Assessment Scale (DSAS-1 DK). Patient 11, 403–412 (2018). https://doi.org/10.1007/s40271-017-0289-x
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DOI: https://doi.org/10.1007/s40271-017-0289-x