Psychometric evaluation of the Problem Areas in Diabetes (PAID) survey in Southern, rural African American women with Type 2 diabetes
© Miller and Elasy; licensee BioMed Central Ltd. 2008
Received: 23 August 2007
Accepted: 22 February 2008
Published: 22 February 2008
The Problem Areas in Diabetes (PAID) survey is a measure of diabetes-related stress for which reported use has been in largely Caucasian populations. Our purpose was to assess the psychometric properties of the PAID in Southern rural African American women with Type 2 diabetes.
A convenience sample of African American women (N = 131) ranging from 21–50 years of age and diagnosed with Type 2 diabetes were recruited for a survey study from two rural Southern community health centers. Participants completed the PAID, Center for Epidemiological Studies-Depression Scale (CES-D), and the Summary of Diabetes Self-Care Activities Scale (SDSCA). Factor analysis, Cronbach's coefficient alpha, and construct validation facilitated psychometric evaluation.
A principle component factor analysis of the PAID yielded two factors, 1) a lack of confidence subscale, and 2) a negative emotional consequences subscale. The Lack of Confidence and Negative Emotional Consequences subscales, but not the overall PAID scale, were associated with glycemic control and body mass index, respectively. Relationships with measures of depression and diabetes self-care supported construct validity of both subscales. Both subscales had acceptable (alpha = 0.85 and 0.94) internal consistency measures.
A psychometrically sound two-factor solution to the PAID survey is identified in Southern, rural African American women with Type 2 diabetes. Lack of confidence in and negative emotional consequences of diabetes self-care implementation provide a better understanding of determinants of glycemic control and weight than an aggregate of the two scales.
Type 2 diabetes is a leading cause of death for African American women . Epidemiological evidence indicates that glycemic control in this patient group is suboptimal and that they suffer disproportionately from diabetes-related complications .
Though tight glycemic control is viewed as a primary indicator of favorable diabetes outcomes , a myriad of factors, including attention to diet, monitoring of blood glucose, medication, and physical activity , contribute to a patient's success in achieving desirable glycemic control. Additionally, psychological distress can negatively impact a patient's adherence to these necessary self-care regimens [5, 6].
The Problem Areas in Diabetes (PAID) survey was developed as a measure of diabetes-related stress that could be useful in measuring the association between psychological adjustment to diabetes and adherence to self-care behaviors . This 20-item survey uses a Likert-scale format to assess the degree to which diabetes management and/or feelings about diabetes are problematic to patients. To date, research application of the PAID has been mostly in Caucasian, urban populations [8, 9] and, to a lesser extent, urban African Americans [1, 10]. Our goal was to assess the reliability and validity of the PAID in Southern, rural African American women with Type 2 diabetes.
This study was part of a larger survey investigation to characterize diabetes self-care activities in Southern, rural African American women with Type 2 diabetes. Participants were recruited from two rural community health centers in a southern state. Both centers serve predominately African American patients. Eligible participants were 1) African American females, 2) with a clinical diagnosis of Type 2 diabetes for a minimum of 6 months, and 3) between 21 and 50 years of age. Participants were identified from a diabetes database and sent invitation letters or referred by nurses during appointments. Follow-up phone calls were used when patients had not responded to letters after 2 weeks. Newspaper ads and flyers were also used for recruitment. The Meharry Medical College Institutional Review Board approved the survey and the administration procedures.
Demographic characteristics were obtained using a self-report survey. Body mass index (BMI) was calculated from self-reported height and weight entries. The most recent hemoglobin A1c (HbA1c) readings within the last year were collected via chart extractions after all surveys were complete.
Problem Areas in Diabetes (PAID) scores were calculated using a five-point Likert-scale with options ranging from "0-not a problem" to "4-serious problem". Summing all item scores and multiplying by 1.25 resulted in an overall PAID score. A minimum score of 0 indicated no diabetes-related distress. A maximum score of 100 indicated significant diabetes-related distress. Previously, high internal consistency of PAID was reported (Cronbach's alpha = 0.95) and factor analyses revealed a single global emotional distress factor . Evidence of construct validity has been reported based on correlations to related measures, including diabetes coping scales . Additionally, discriminant validity has been reported, including comparisons of PAID scores between Type 1 and 2 diabetes patients .
The Center for Epidemiological Studies Depression Scale (CES-D)  was used as a measure of depression. Scores were based on patients' responses to 20 statements assessing behavior and feelings within the last week. Response options ranged from "0-rarely/none of the time" to "3-most/all of the time". Summing all item scores resulted in a final score, with a score of 60 indicating significant depression.
The Summary of Diabetes Self-Care Activities Scale (SDSCA)  was used to measure various diabetes self-care activities. Using a continuous scale ranging from "0 to 7 days", each participant indicated the number of days in a week that she engaged in 1) eating a generally healthy diet (general diet-2 items), 2) eating a diet high in fruits/vegetables and low in high fat foods (specific diet-2 items), 3) physical activity for at least 30 minutes (1 item), 4) a specific exercise (1 item), 5) glucose self-monitoring (2 items), 6) foot inspections (2 items), and 7) taking recommended medications (1 item). For self-care categories with at least 2 items (all except the "physical activity", "specific exercise", and "medication", questions), item scores were averaged resulting in an overall score for each self-care activity (i.e. general diet, specific diet, glucose self-monitoring, and foot inspections). Scores ranged from 0 (no weekly participation in a diabetes self-care activity) to 7 (participation in a diabetes self-care activity every day of the week).
All surveys were self-administered (paper and pencil) to individual patients or patient groups (ranging from 2 to 25 people). Administration took place in a designated room at the collaborating community health centers under the direct supervision of either the principal investigator or research coordinator. Patients received a $20 gift certificate for participation. Survey completion times ranged from 20 minutes to 40 minutes.
To examine the internal structure of the PAID, we performed principal component factor analysis to examine the pattern of loadings for evidence of a 1-factor solution that supports the current use of the PAID as a single scale  or the possibility of an alternate factor solution. We utilized both a scree plot and a minimum eigenvalue of 1.5 to guide extracting factors in subsequent analysis. Orthogonal and oblique rotations were explored to best approximate simple structure when extracting more than one factor. Item-loadings of 0.40 or greater were the criterion used to guide interpretation of rotated factor loadings. Reliability was assessed using Cronbach's coefficient alpha. For internal consistency testing, we accepted an alpha of ≥0.75. To evaluate the construct validity of the PAID, we performed several correlation analyses using the Pearson product-moment correlation coefficient (r). For correlation with the CES-D, we hypothesized that higher scores on the PAID (either as a one or two factor solution) would be positively associated (r = ~0.5) with higher scores on the CES-D. We hypothesized low to moderate (r = 0.10–0.30) negative correlations with SDSCA subscales. We further tested validity of the PAID using correlations between the PAID and patient age, BMI, and HbA1c and expected low to moderate (r = 0.10–0.30) correlations.
All data were analyzed using STATA Version 7 (STATA Corporation, College Station, TX).
39.4 ± 8.2
Income greater than 20 K (%)
Some college or above (%)
Average duration of diabetes (years)
6.1.0 ± 5.6
9 ± 2.4
35.5 ± 8.6
Item Loadings for Items in PAID Subscales
Factor 1* Loadings-Lack of Confidence Subscale
Factor 2† Loadings-Negative Emotional Consequences Subscale
1. Not having clear and concrete goals for your diabetes care?
2. Feeling discouraged with your diabetes treatment plan?
3. Not "accepting" your diabetes?
4. Feeling unsatisfied with your diabetes physician?
5. Feeling that diabetes is taking up too much of your mental and physical energy everyday?
6. Feeling alone with your diabetes?
7. Feeling that your friends and family are not supportive of your diabetes management efforts?
8. Feeling scared when you think about living with diabetes?
9. Uncomfortable social situations related to your diabetes care (e.g., people telling you what to eat)?
10. Feelings of deprivation regarding food and meals?
11. Feeling depressed when you think about living with diabetes?
12. Not knowing if your mood or feelings are related to your diabetes
13. Feeling overwhelmed by your diabetes?
14. Worrying about low blood sugar reactions?
15. Feeling angry when you think about living with diabetes?
16. Feeling constantly concerned about food and eating?
17. Worrying about the future and the possibility of serious complications?
18. Feelings of guilt or anxiety when you get off track with your diabetes management?
19. Coping with complications of diabetes?
20. Feeling "burned out" by the constant effort needed to manage diabetes?
Pearson correlations between scores on the PAID, Lack of Confidence in Self-Care Implementation Subscale, and Emotional Consequences of Self-Care Implementation and scores on the CES-D, SDSCA subscales, and demographic and clinical factors.
Lack of Confidence in Self-Care Implementation
Emotional Consequences of Self-care Implementation
Lack of Confidence in Self-Care Implementation
Emotional Consequences of Self-care Implementation
General Diet (SDSCA)-2 items
Physical Activity (SDSCA)-1 item
Exercise (SDSCA)-1 item
Glucose Monitoring (SDSCA)-2 items
Foot Inspections (SDSCA)-2 items
Taking Medications-1 item
Correlations of the Lack of Confidence and Emotional Consequences subscales and the PAID with select demographic and clinical characteristics were used to examine predictive validity. Age was significantly negatively correlated with the each subscale and the PAID. Glycemic control, as measured by HbA1c, was significantly correlated (in a positive direction) with only the Lack of Confidence subscale. Body mass index was positively correlated with each of the subscales and the PAID. However, the association was only statistically significant with the Emotional Consequences subscale.
This is the first study to quantitatively evaluate the psychometric attributes of the highly utilized PAID survey in Southern, rural African American women with Type 2 diabetes. While the original 1-factor solution previously described performed well, a 2-factor solution revealed clearer correlations between psychological distress and glycemic control and BMI, two critical indicators for diabetes-related health outcomes.
Therefore, our 2-factor solution allowed us to identify important correlates of HbA1c and BMI in Southern, rural African American women with Type 2 diabetes, ones that would not have emerged using the 1-factor PAID solution alone. Our work represents first steps in identifying relevant emotional factors for diabetes self-management and, ultimately, glycemic control among rural African American women with Type 2 diabetes. To the extent that our 2 subscales reliably and accurately correlate with Hba1C and BMI among this patient population, future work should focus on defining best methods for improving patient confidence in self-care activities that pose the most significant challenges and helping patients manage the emotional consequences of implementing self-care plans.
Our study has some limitations. Cognitive response interviews were not conducted. The addition of this method would have enhanced our ability to understand how patients perceived the meaning of individual PAID items. Our demographic questionnaire did not discriminate between patients receiving insulin via shots or pump. Therefore, our study results do not take into account differences attributable to distinct methods of insulin delivery and, possibly, adjustment issues. Another possible limitation was the potential for patients to respond to PAID questions in a manner that they felt was socially desirable (i.e. reporting that "feeling scared when you think about living with diabetes" was not a problem when indeed it was a significant one). Though impractical relative to minimizing patient fatigue during questionnaire administration, the additional administration of a social desirability questionnaire along with the PAID and other questionnaires would have been helpful in determining whether this was indeed true for this study . Also, our most significant study results were found in a sample of obese patients with poorly controlled diabetes. Since our study only included rural, female patients, it is not clear the extent to which gender and locale alone correlated with these specific clinical characteristics. A more heterogeneous study sample would have been helpful in this regard. From a psychometric perspective, it was apparent from our factor analysis results that 3 of the PAID items loaded well (≥ 0.40) on both the Lack of Confidence and Emotional Consequences subscales. Since it was not our goal to modify the PAID items and, hence, possibly enhance factor loading clarity, we assigned these 3 items to the Emotional Consequences subscale based on three critical factors: 1) slightly superior loadings (with the exception of item 9 where loadings were equal); 2) face validity, and 3) better theoretical cohesiveness relative to our construct validity conceptualization. Finally, while it is appropriate and common practice to report correlations between 1- and 2-item SDSCA subscales and other scales, subscales with more items might lend to more robust and discriminating results.
The greatest strengths of our study were findings that lack of confidence in diabetes self-care implementation and the negative emotional consequences of self-care implementation were associated with Hba1c and BMI, respectively. Though the correlations that support these findings were modest, the clinical importance of identifying emotions that might impact glycemic control and body weight among Southern, rural African American women with Type 2 diabetes adds tremendous value to these novel findings. Other major strengths of this study were related to our recruitment efforts. We were able to recruit African American patients, a group that is typically perceived to be "hard to reach" relative to study recruitment (). Additionally, we were able to recruit patients from rural locales, a success that is invaluable for involving geographically underserved populations in research ().
A psychometrically sound two-factor solution to the PAID survey is identified in Southern, rural African American women with Type 2 diabetes. Lack of confidence in and negative emotional consequences of diabetes self-care implementation provide a better understanding of determinants of glycemic control and weight than an aggregate of the two scales. Further work is needed to replicate these findings and, subsequently, design interventions that to improve the lives of Southern, rural African American women with Type 2 diabetes.
This study was supported by grants from the National Institutes of Health, National Center for Research Resources (1 R25 RR017577-01), National Institutes of Health, National Center on Minority Health and Health Disparities (5 P20 MD000516-03), and National Institutes of Health, National Institute of Diabetes and Digestive, and Kidney Diseases (3 P60 DK020593-26S1). The sponsors had no role in study design; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.
The authors wish thank the administrative and clinical staff at Delta Health Center (Mound Bayou, MS) and Greater Meridian Health Clinic (Meridian, MS) for their support during all phases of this project.
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