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Psychometric evaluation of the problem areas in diabetes (PAID) scale among people with type 2 diabetes in Ethiopia: a tool validation study

BMC Research Notes volume 18, Article number: 154 (2025) Cite this article

Abstract

Objective

to assesses the psychometric properties of the Problem Area in Diabetes (PAID) scale for Ethiopian patients with type 2 diabetes.

Results

The confirmatory factor analysis for the Ethiopian Problem Area in Diabetes (Eth-PAID) scales demonstrated good model fit to the one, two, three, and four factor structures. The one-factor model Eth-PAID-20 scale showed acceptable internal consistency (α = 0.82), but the “Diabetes distress” subscale of two, three, and four-factor structures partially satisfied the internal consistency (ranged α = 0.74-77). The Eth-PAID-20 scale correlated negatively with self-care efficacy (r = 0.131, P = 0.06) and positively with Fasting Blood Sugar (FBS) level (r = 0.02, P = 0.86), which implies poor convergent validity. Moreover, “lack of confidence,” “food-related problem,” and “support-related problem” subclasses of two, three, and four-factor models showed very weak convergent validity. Discriminative validity revealed that female patients (30.16 ± 13.11), t = − 2.73, p = 0.007, d = 0.4) and patients who lived alone (28.05 ± 12.98), t = 2.542, p = 0.021, d = 0.5) had significantly higher distress scores in Eth-PAID-20 as one factor model.

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Introduction

Diabetes distress (DD) is the negative emotional response linked to diabetes due to persistent self-care practices and long-term complications [1,2,3]. Severe DD affects one in four people with type 1, one in five with insulin-treated type 2, and one in ten with non-insulin-treated type.2 [4]. The most frequently reported problem areas among people with type 1 and type 2 diabetes are “worries about the future and getting serious complications” and “guilt and anxiety when diabetes management goes off track [5, 6].

Severe DD is linked to poor medication adherence, poor glycemic control, low self-efficacy, and unhealthy dietary and exercise behaviors [7]. Therefore, the ADA and IDF recommend clinicians regularly and effectively assess patients’ emotional distress using tools like the validated problem area in diabetes (PAID) scale [8, 9].

The PAID scale is a diabetes-specific tool that measures change in patients’ psychosocial and emotional states related to diabetes [10]. It is a 20-item self-reported instrument [11]. and the original PAID has been developed for various cultural contexts and translated from English into several languages globally. For example it was translated into Korean [12].,Spanish [13, 14],Dutch [15],, Mandarin [16], Icelandic [17],Singaporean [18],Portuguese [19],Swedish [20], Turkish [21], Arabic [22], Persian [23] and Swahili [24] languages.

A 5-item version of the PAID scale has been prepared recently, and its psychometric property evaluation has been performed in some countries [12, 25,26,27]. Although the tool is valid for identifying DD across countries, its cross-cultural validity has not been established yet.

The dimensionality of the PAID scale was not explored in the original PAID scale, which was developed as a single-factor structure with 20 items [11, 28]. Studies have identified contradictory results or confirmed the original one-factor structure [16, 28]. and other studies have identified multiple factor structures [15, 17, 20]. For example, in the Netherlands/USA, four sub-dimensions were identified, including negative emotions, treatment problems, food-related problems, and lack of social support [15], and in Iran, three sub-dimensions were identified: psychological distress in relation to diabetes management, depression-related problems, and treatment barriers [23].

However, a Greek study revealed a subclass of diabetes-related emotional problems, food-related problems, and social-support-related problems [29], the Turkish version yielded a two-factor structure, identifying diabetes distress-related factors and support-related issues [21]. but a PAID tool validation study among African American women with type 2 diabetes revealed a two-factor structure that included a lack of confidence and negative emotional consequences [30]. A one-factor Chinese version of the PAID was identified in people with type 2 diabetes [16].

Several studies were done to validate the PAID scale, primarily using EFA; however, CFA is considered more suitable for identifying the underlying structure of a scale [31]. and the study population are either people with type 1 or type 2 diabetes or both with variable cultural backgrounds. Though the PAID scale is validated using different language versions, in western countries there is no translated, culturally adapted, and psychometrically validated version in Tigrigna, a language spoken in two countries (Ethiopia and Eritrea). Moreover, there is no published article of a study done to assess its validity and reliability, which calls for translation and cross-cultural validation of the PAID scale. Therefore, this study examined the psychometric properties of the PAID scale for patients with type 2 diabetes in Ethiopia.

Methods

Design, setting and sampling

A cross-sectional study was conducted at Ayder and Mekelle hospitals among 210 people with type 2 diabetes in Ethiopia. Participants were selected through a systematic random sampling strategy. The study involved participants over 18 years old, diagnosed with type 2 diabetes, and stayed with diabetes for at least a year. The sample size was calculated using a person-to-item ratio of 10:1 [32]., PAID scale with 20 items and an additional 5% sample was added to achieve a refusal rate. Data from all participants (including illiterates) were collected using interviewer-administered questionnaires via two nurses from August to December 2021.

Study measures and scales

The study’s questionnaire comprised two parts. Part one included demographic characteristics and clinical factors. Part two included the Tigrigna versions of the Ethiopian (Eth-PAID) [28, 33]. and Perceived Diabetes Self-Management Scale (PDSMS) scales [34]. The original PAID scale consists of 20 items [28, 33]., psychometrically robust [35] and a reliable tool with a Cronbach’s α of 0.95 [36].

Each item was scored on a 5-point Likert scale ranging from “not a problem” (score of 0) to “serious problem” (score of 4) [10]. All 20 scores are added and multiplied by 1.25, resulting in a total score of 0–100 points. Higher scores indicate high distress (cutoff ≥ 40) [28, 33, 37, 38]. PAID-5 also developed as one factor structure with items 3, 6, 12, 16, and 19 pooled out from the original PAID-20. The possible total scores of the PAID-5 range from 0 to 20, again with higher scores implying greater emotional distress [25].

Moreover, patients were asked to rate their confidence in diabetes self-efficacy using the PDSMS scale (8 items), and each item was scored on a 5-point Likert-type scale. The response categories were “strongly disagree” (1), “disagree” (2), “neutral” (3), “agree” (4), and “strongly agree” (5). The four items of the scale were negative questions. Therefore, these 4 items were reverse scored. The total PDSMS score ranges from 8 to 40, with higher scores indicating more confidence in self-managing one’s diabetes [39].

The English versions of the PAID-20 and PDSMS were translated into the Tigrigna language through the forward-and-backward translation technique to prepare the Ethiopian version PAID-20 (Eth-PAID) [40]. Weight (in kg), height (in cm), FBS test and BP measurement results were taken from the patients’ medical records. Hypertension is defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg [41]. In this study, BMI was classified into two categories (< 25 and ≥ 25) [42], and controlled fasting blood sugar is a fasting blood sugar level of ≤ 130 mg/dl [43].

Statistical analysis

Data analyses were performed using SPSS V.18.0 and AMOS V.26.0. The Eth-PAID-20 and Eth-PAID-5 scales were tested for both reliability and validity. A series of confirmatory factor analyses (CFA) was done to investigate five previously established factorial structures after sampling adequacy and data suitability for CFA were checked through Kaiser Meyer Olkin (KMO ≥ 0.5) and Bartlett’s test of sphericity, respectively [44].

Model fit was evaluated by examining goodness-of-fit indices on the basis of the previously proposed five-factor structures: one factor of the original and the Chinese PAID [16, 28]. two-factor of the Turkish and USA PAID [21, 30], three-factor of the Greek PAID [29] and four-factor of the Dutch PAID [15].

The model fit indices include χ²(P), df, a goodness-of-fit index (GFI), the comparative fit index (CFI), the root mean squared error of approximation (RMSEA), the standardized root mean square residual (SRMR), the ratio of the χ² value to the df (CMIN/DF), and the normed fit index (NFI) [45, 46]. The model was considered to fit the data when the following criteria were satisfied: RMSEA < 0.08, CFI > 0.95, GFI > 0.90, SRMR < 0.08, CMIN/DF < 3.0, and NFI > 0.95 [46, 47].

Reliability was estimated by calculating the internal consistency; Cronbach’s alpha (α) coefficient was used, and a coefficient of approximately ≥ 0.70 was considered acceptable [48,49,50]. A floor and ceiling effect was determined and defined as being present if > 15% of the participants scored at the minimum (total score = 0) and/or maximum (total score = 100) level, respectively [51].

CFA with the maximum likelihood estimation method was done to examine the construct validity of the Eth-PAID scales because CFA is an acceptable method for assessing construct validity [52].

In this study, Pearson’s correlations between the Eth-PAID scales, PDSM scale, and FBS level were performed to assess the convergent validity of the scales, and coefficients in the range of 0–0.19 were regarded as very weak, 0.2–0.39 as weak, 0.40–0.59 as moderate, 0.6–0.79 as strong, and 0.8–1 as very strong correlation [53].

Discriminant validity is the ability of an instrument to detect a difference between different groups of participants who are both clinically relevant and statistically significant [54,55,56]. It was determined by computing the effect size for known groups. In this study, effect sizes of 0.2 (small), 0.5 (moderate), and 0.8 (large) were used as cutoff points or references [57]. We analyzed discriminative validity using the independent t-test (Welch’s test) and Cohen’s d effect size. A significance level of 0.05 was used in all analyses.

Results

Participant characteristics

A total of 200 patients with type 2 diabetes were involved in this study. The measure of sampling adequacy was 0.781 (P < 0.001). Participants’ mean age, diabetes duration, BMI, and FBS value were 56.17 ± 9.57 years, 7.72 ± 6.39 years, 25.2 ± 3.9, and 168.39 ± 57.04%, respectively. Of all participants, 51%, 75%, 38.0%, and 79.5% were males, married, not employed, and attending formal education, respectively. 55% of participants had normal weight, and 93.5% lived with family. Furthermore, only 57 patients (28.5%) had good glycemic control, 71.0% were taking OHA, 78.5% had a diabetes duration of < 10 years, 55.0% had hypertension, and 61.0% were less confident in diabetes self-management practices. (Table 1).

Table 1 Demographic and clinical characteristics of the study participants (n = 200)
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Mean score of Eth-PAID-20 and Eth-PAID-5 items

The mean value for the Eth-PAID-20 was 27.68 ± 12.75 (ranging 5–68), and the mean score for the Ethiopian (Eth-PAID-5) was 8.85 ± 3.82 (ranging 0–19). Among all 20 items, the highest score item was item 19, “Coping with complications of diabetes” (2.12 ± 1.24), whereas the lowest score item was item 14, “Not accepting of diabetes” (0.79 ± 1.27). (Table 2).

Table 2 PAID and PAID-5 mean scores on items and sub dimensions for the samples (n = 200)
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Factor structure of Eth-PAID-20 and Eth-PAID-5

The PAID-20 and PAID-5 have been previously reported in various studies as having a one-factor structure [16, 25, 28)], two-factor structure [12, 30], three-factor structure [29] and four-factor structure [15]. On the basis of these findings, five alternative factor structures were compared for the goodness-of-fit indices via CFA. (Table 3)

Table 3 Constructs of established models of PAID from previous studies
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Model goodness of fit and construct validity

The construct validity of the Eth-PAID-20 and Eth-PAID-5 was evaluated using the CFA method. The fit estimates for a one-factor model based on the original version (PAID-20) were good: CMIN/DF = 1.325, GFI = 0.925, RMR = 0.051, RMSEA = 0.040, and CFI = 0.951. All items were significantly loaded on the construct of diabetes-related distress, ranging from 0.095 to 0.703 (P = 0.05). All of the goodness of fit indices of the one-factor structure were significant at the p < 0.05 level, and the standardized factor loadings ranged from 0.095 to 0.703. The two-, three-, and four-factor structures produced findings similar to those of the one-factor structure. Overall, the CFAs showed good fits for all of the evaluated factor structures. For the short-form Eth-PAID-5, the one-factor structure showed that excellent goodness-of-fit indices: CMIN/DF = 2.106, GFI = 0.992, RMR = 0.059, RMSEA = 0.075, CFI = 0.975, and NFI = 0.958. The standardized loadings in the one-factor model of the Eth-PAID-5 ranged from − 1.25 to -0.02. (Table 4).

Table 4 CFA: Goodness-of-fit statistics for the Eth-PAID and Eth-PAID-5 models and standardized loadings
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Reliability

The Eth-PAID-20 scale had very low floor and ceiling effects, with 0.5% of the participants scoring at the floor and 1% of the participants scoring at the ceiling; however, the original PAID-20 scale had 5.4% of the participants scoring at the floor and none at the ceiling.

The Cronbach’s alpha for the Eth-PAID-20 item as one-factor structure was 0.82, which implies acceptable internal consistency reliability and indicates that the scale is reliable for measuring diabetes related distress. When Eth-PAID-20 was structured as a two-factor structure, as reported in previous studies [21, 30], the Cronbach’s alpha was greater than the criterion value of 0.70 for the “diabetes-related distress” subscale only. However, when the Eth-PAID-20 scale was structured as three factors [29], the Cronbach’s alpha of “social support” was 0.52, indicating unsatisfactory internal consistency reliability. When Eth-PAID-20 was structured as four dimensions [15], the Cronbach’s alphas were 0.74 (emotions), 0.61 (food), 0.52 (social support) and 0.31 (treatment). The Cronbach’s alpha value of the Eth-PAID-5 as a one-factor structure was 0.510, revealing unsatisfactory internal consistency reliability. (Table 5).

Table 5 Internal-consistency reliability, and convergent validity of the Eth-PAID and Eth-PAID-5 (n = 200)
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Convergent validity

The correlations between one, two, three, and four factors of the Eth-PAID scale and other measures of interest (PDSM scale and FBS level) were determined. The overall score of the PDSM scale was 27.68 ± 12.56 (range = 9–38). The person-product correlation coefficient of Eth-PAID-20 as a one-factor scale was found to be very low but not statistically significant (r=-0.131, p = 0.06). These findings indicate that an increase in diabetes-related distress leads to lower perceived self-management competency among type 2 diabetes patients. (Table 5)

In most cases, the Pearson’s correlation coefficients of each subscale of the Eth-PAID-20 scale related to the PDSM scale showed very low correlations. However, the subscale of “treatment-related problems” was markedly weakly and negligibly correlated (r = -0.002, p = 0.98). There was also a weak negative correlation between the Eth-PAID-5 score and PDSM scale score (r=-0.138, p = 0.05), reflecting poor convergent validity (Table 5). The Eth-PAID-20 scale as a one-factor structure was positively but very weakly correlated with the FBG level (r = 0.02, p = 0.86). Moreover, all subscales of Eth-PAID-20 were markedly weakly and negligibly correlated with the FBS level, with the exception of “treatment-related problems” in the four factor structures. The Eth-PAID-5 score was positively but very weakly correlated with the FBG level (r = 0.07, p = 0.34), indicating poor convergent validity. (Table 5)

Discriminative validity

The independent t-test of the Eth-PAID-20 scale as a single-factor structure revealed that there was a significant difference between males (25.30 ± 11.19) and females (30.16 ± 13.11), t = − 2.73, p = 0.007, Cohen’s d = 0.4); similarly, participants who lived with family (28.05 ± 12.98) had significantly higher PAID scores than participants who lived alone (22.38 ± 7.27), t = 2.542, p = 0.021, Cohen’s d = 0.5), which reflects small and medium effects, respectively. (Table 6)

Table 6 Discriminate validity of the Eth-PAID and Eth-PAID-5 by demographic and clinical factors (n = 200)
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For the Eth-PAID-20 scale with two, three, and four factor structures, only the mean scores of the subscales “negative emotional consequences,” “diabetes-related emotional problems,” and “treatment-related problems” significantly differed in terms of gender and living arrangement, and Cohen’s effect size (d) was small for all subscales except one, ranging from 0.4 to 0.6.

There was no significant difference in the Eth-PAID-5 score between males (8.47 ± 3.55) and females (9.24 ± 4.06), t = − 1.43, p = 0.153, Cohen’s d = 0.2), but there was a significant difference between living with family (8.94 ± 3.89) and living alone (7.53 ± 2.18), t = 2.095, p = 0.051, Cohen’s d = 0.4), reflecting a small effect. Overall, the discriminative validity of the Eth-PAID-5 was satisfactory. (Table 6)

Discussion

In this study, psychometric evaluation of the Eth-PAID-20 and PAID-5 scales was performed. In this study, the one-factor structure of the Eth-PAID-20 scale exhibited good reliability and validity, similar to findings from similar studies [16, 18, 21,22,23,24, 58]. However, the Eth-PAID-5 is not psychometrically robust, which is different from the findings of previous studies [12, 25,26,27].

In this study, a factorial structure of the Eth-PAID scale was identified via CFA based on one-, two-, three-, or four-factor structure tests and revealed good fit indices after model modification with the covariance of error terms.

In this study, the subscale “Treatment-related problems” (items 1, 2, and 15) in the four-factor structure of the Eth-PAID-20 produced the lowest Cronbach’s alpha of 0.31, which implies relative heterogeneity among these three items [59], and the items were ambiguous or the participants were not familiar with or cared about the items [60]. Similarly, an unsatisfactory Cronbach’s alpha was also found for this subscale in the Brazilian (0.60) and Korean (0.52) versions [12, 19]. However, satisfactory internal consistency reliability was observed in studies from Egypt, the U.S., and the Netherlands [15, 22].

This poor reliability might have occurred for two reasons. First, participants’ inability to understand items 1 and 2 may have resulted in measurement error, which decreased the Cronbach’s alpha. Second, item 15 (“feeling unsatisfied with your diabetes physician”) had a very low score (0.89 ± 1.42) because the majority of the patients answered this question with “not a problem” [61]. Similar scores for item 15 were found in participants from Greece (0.36 ± 0.61) [29], Taipei (0.04 ± 0.27) [16] and Korea (0.30 ± 0.73) [12].

With respect to convergent validity, the present study revealed that Eth-PAID-20, as a one-factor structure, was negatively correlated with the PDSM scale (r = -0.131, 0.033) and positively correlated with FBS levels (r = 0.02, 0.432), which indicates that when diabetes-related stress increases, the PDSM score decreases and the FBS level increases, as expected. Overall, the present study revealed a very weak correlation of Eth-PAID-20 with the PDSM scale and the FBS level, which emphasizes very weak convergent validity.

Previous studies have demonstrated that PAID-20, as a one-factor structure, showed moderate correlations with the CES-D (r = 0.58–0.45), GAD-7 (r = 0.50), overall life satisfaction (r = 0.46), perceived health status (r = -0.35), K10 (r = 0.53), DHP-PD (r = 0.56), and ADDQoL (r = -0.54) [12, 21, 22, 30].

Similarly, the total PAID-20 score was strongly correlated with the perceived burden of diabetes (0.60), PHQ-9 score (r = 0.71), and WHO-5 score (r = − 0.69) but weakly correlated with the HbA1c level (r = 0.11), DES-28 score (r = − 0.21), and frequency of SMBG (r = 0.13) [16, 18, 22, 28]. However, there is limited evidence showing the relationships of PAID-20 with the PDSM Scale and the FBS level.

In this study, the effects of gender and living arrangement on the Eth-PAID-20 score based on one-, two-, three-, and four-factor structures were also investigated and showed that there were small-to-moderate effect sizes.

The effect size of Eth-PAID-20 as one factor structure was d = 0.39, indicating a small effect and implying satisfactory discriminant validity, which is supported by studies from Korea [12], the US/Dutch [28], Turkey [21] and Brazil [19]. However, a study from Singapore reported that the PAID-20 scale did not distinguish between patients from different demographic groups, except for education, household income, and housing type, which had small to moderate effect sizes [18].

Limitation of the study

This study has several limitations that warrant consideration. Firstly, the study conducted with small sample size which could affect the reliability and validity of the test results. Secondly, the test-retest reliability of the Ethiopian version was not assessed. Thirdly, data collection may introduce the possibility of social desirability bias, where participants may have over-reported or under-reported in some sensitive questions.

Conclusions

Eth-PAID-20 scale is a reliable and valid instrument for assessing diabetes distress among Ethiopian patients with type 2 diabetes. The results indicate that the Eth-PAID-20 has good psychometric properties, with satisfactory factorial construct, convergent, discriminative validity, and internal consistency. This implies clinicians should consider adopting the instrument to screen diabetes distress in clinical care settings and research, and future studies should give priority to a broader population in order to improve the generalizability of the PAID scale.

Data availability

The data set will be available from the corresponding author upon request.

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Acknowledgements

The authors of this study acknowledge the Ayder comprehensive specialized hospital (ACSH) and Mekelle general hospital (MGH) for granting permission for data collections. Moreover, we would like to extend our thanks to the ACSH and MGH staffs at the diabetes unit/referral clinic for their support and the participants for kindly providing the required information, supervisors and data collectors.

Funding

There is no funding or grant source for this study.

Author information

Authors and Affiliations

  1. School of Nursing, College of Health Sciences, Mekelle University, Mekelle city, Tigray region, Ethiopia

    Kalayou K. Berhe & Haftu B. Gebru

  2. School of Nursing, Department of Clinical Nursing, Muhimbli University of Health and Allied Sciences, (MUHAS), Dar es Salaam, Tanzania

    Lilian T. Mselle

Authors
  1. Kalayou K. Berhe
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  2. Lilian T. Mselle
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  3. Haftu B. Gebru
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Contributions

KK: conceived and designed the study, analyzed the data and drafted the manuscript under continuous supervision of my PhD advisors. LM, and HB, participate in the analysis and interpretation of data, and contributed to the review of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kalayou K. Berhe.

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Ethical approval and consent

Ethical approval to conduct the study was obtained from the Institutional Review Board (IRB) of Mekelle University (Ref No. IRB: MU-IRB 1866/2021). The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from literate participants. Verbal informed consent was obtained from illiterate participants and informed consent was obtained from their legal guardians All the data were kept anonymously in a safe and secure place to maintain confidentiality, and benefits were assured throughout the study period.

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The authors declare no competing interests.

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Berhe, K.K., Mselle, L.T. & Gebru, H.B. Psychometric evaluation of the problem areas in diabetes (PAID) scale among people with type 2 diabetes in Ethiopia: a tool validation study. BMC Res Notes 18, 154 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13104-025-07238-8

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BMC Research Notes

ISSN: 1756-0500

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