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Table of Contents
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 150-154

Psychometric properties of diabetes attitude measurement scale among patients with Type 2 diabetes

Assistant Professor, Government College of Nursing, Alappuzha, Kerala, India

Date of Submission30-May-2019
Date of Decision12-May-2020
Date of Acceptance13-May-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Athirarani Muraleedharan Rohini
Muralee Gopalam, TC 2/990 (2), KPRA A59 (2), Koonamkulam Lane, Medical College PO, Thiruvananthapuram - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_131_20

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Attitude towards the disease is an important determinant of better outcomes in patients with diabetes. It has wide-ranging effects on drug compliance, dietary modifications, self-care and frequency of follow-up. There was no tool in the local language to assess attitude towards disease among diabetes patients comprehensively. The present study intended to assess the psychometric properties of Diabetes Attitude Measurement Scale (DAMS) among patients with Type 2 diabetes mellitus. A purposive sample of 242 individuals with diabetes was included for validation purpose. A 30-item questionnaire, to identify the attitude towards the diabetes was developed in the local language, by selecting items through literature search, expert opinions and qualitative methods such as in-depth interview and focus group discussions. Item reduction was done by expert opinion based on the endorsement rate and pilot testing and the items were reduced to 22. The psychometric property of the tool was assessed by factor analysis among 242 patients with Type 2 diabetes mellitus. The final questionnaire had 16 items questionnaire with internal consistency reliability of 0.77 and cumulative variance of 60%. DAMS has adequate psychometric properties to identify attitude towards disease among patients with Type 2 diabetes. The most important clinical implication of tool is that it can be incorporated for the assessment of determinants of glycaemic control.

Keywords: Attitude, reliability, type 2 diabetes, validity

How to cite this article:
Rohini AM. Psychometric properties of diabetes attitude measurement scale among patients with Type 2 diabetes. Indian J Cont Nsg Edn 2020;21:150-4

How to cite this URL:
Rohini AM. Psychometric properties of diabetes attitude measurement scale among patients with Type 2 diabetes. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Aug 1];21:150-4. Available from: https://www.ijcne.org/text.asp?2020/21/2/150/309848

  Introduction Top

Attitude is a construct that represents an individual's degree of like or dislike for a statement. The Theory of Reasoned Action provides a framework which denotes that attitude is a critical factor towards an attainment of a goal by mediating knowledge into practice.[1] Attitude is a distal variable which acts through the proximal variables such as medication adherence, dietary modification, physical activity and frequency of blood sugar examination and follow up. Therefore, attitude has an influence on the achievement of glycaemic control.[2]

Attitude has a dynamic influence on behaviour. Stone et al.[3] defined attitude as a mental and neural state of readiness, organised through experiences, exerting a directive influence on the individual's response to all objects and situations with which it is related.[4] Diabetes is foremost a self-managed disease; treatment and prevention of acute and long-term complications are largely a function of the patient's decisions on a daily basis. Understanding the behaviour of persons towards their problems requires knowing of their attitudes about it.[2] Several studies have demonstrated the importance of patients' attitudes and beliefs on health behaviour in Diabetes. The patient's positive attitude has been found to be a factor in patient response to treatment recommendations.[5],[6]

Need for the study

This work originated from the concern that attitude is a major construct affecting the health seeking behaviour of the patient. In Type 2 diabetes mellitus, attainment of glycaemic control is the therapeutic goal because optimal glycaemic control is crucial for the prevention of complications. Attitude towards the disease is a major factor affecting compliance, diet control and regularity of blood sugar estimation, physical activity and follow-ups. The literature search through online and manual search revealed that there are few tools in foreign languages which are too complex to be comprehended by the local people. There are no culturally and conceptually equivalent tools in regional language to measure attitude towards diabetes among patients with Type 2 diabetes mellitus. A culture-specific tool if developed would help in assessing the attitude of the clients so that remedial measures would be planned to enhance desirable attitude. Thus the investigator has posed the objective to develop a questionnaire to measure the psychometric properties of the scale to measure the attitude towards the disease among patients with Type 2 diabetes mellitus.

Objective of the study

The present study intended to assess the psychometric properties of Diabetes Attitude Measurement Scale (DAMS) among patients with Type 2 diabetes mellitus.

  Methodology Top

A descriptive study was used for validation of questionnaire. Adults of more than 18 years with Type 2 diabetes mellitus residing in Thiruvananthapuram district, Kerala, were included in the study.

Questionnaire development

The study was planned and conducted in the peripheral training units of a tertiary care teaching hospital in south India. The items for the tool were generated from literature, expert opinions and qualitative methods such as in-depth interview and focus group discussion. Focus group discussions were conducted among men and women with Type 2 diabetes mellitus. The homogeneity of the focus group was ensured by separate discussion with men and women. In-depth interviews were conducted among employed men and employed women with Type 2 diabetes, and close relatives of patients with Type 2 diabetes. At the end of this process, a pool of 60 items was generated. These items were subjected to item analysis with the help of expert review, peer review and respondent review. The process of item analysis involved item selection, item reduction, item wording and item sequencing. The items were reduced to 30. Through this process, items were assessed for its conceptual and cultural equivalence. The next step was the selection of response category. A five point Likert scale was chosen and the response categories were strongly agree, agree, neutral, disagree and strongly disagree. The scoring was from five to one. The 30-item scale was pre-tested and piloted. After the series of pre-testing final refined scale retained 22 items. The tool was named as DAMS. The psychometric properties of the tool were established by factor analysis. For factor analysis, the 22-item tool was administered to a convenient sample of 242 adult patients above the age of 18 years with Type 2 diabetes. The data obtained were entered into Excel and imported to statistical software R for analysis of the data.

  Results Top

Sample characteristics

The mean age of patients with Type 2 diabetes participated in the study is 61.91 (standard deviation [SD]: 9.6) years. Majority were females 70.2% and 91.32% of the participants were married. 59.6% of the participants were from rural and 4.96% from coastal area. Majority of the participants belonged to upper middle class (66.11%) and 8.3% to upper class. 42.15% of the patients were with more than 5 years' duration of diabetes, and 2.47% was with <5 years of diabetes. More than half i.e., 60% of the participants had co-morbidly.

Item analysis

There were 22 items and 5 response categories in the questionnaire. The items in the scale were coded from A1 to A22. The mean, SD and graphical representation were done for each item. The skewness and kurtosis of each item were assessed. There were marginal skewness and kurtosis for all items.

Item-endorsement index

The entire item from A1 to A22 has an endorsement rate of 10%–90%. All the response categories of items were chosen by the participants, and the distribution pattern was almost normally distributed so none of the items were deleted at this stage. Thus, all the items were put in for factor analysis.

Reliability estimation

During the analysis, 6 items with negative correlation were deleted. The correlation matrix given in [Table 1] shows the final subscales I, II and III with inter item correlation. It was assessed using Pearson product moment correlation. Except for the item A4 to A1 and A5 to A4 in subscale 1 with correlation <0.2, all the other items had the required correlation of more than 0.2, none of the items in the subscale was not correlated more than. 08 and this indicate that there were no collinearity of items.
Table 1: Inter item correlation matrix subscales

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Average inter item correlation

The average inter-item correlation of subscale I, II and III was 0.75, 0.81 and 0.69, respectively. All the subscales had the desirable correlation.

Internal consistency reliability

The internal consistency reliability was estimated after a single administration of the questionnaire by calculating the coefficient of alpha, Cronbach's alpha for the total items and was found to be 0.77 95% confidence interval (CI) 0.73–0.80.

Test retest reliability

Test–retest reliability was 0.88 (95% CI 0.71–0.95), when the questionnaire was re administered within a period of 2 weeks.

Validity estimation

Expert reviews at different levels in the initial developmental phase i.e., item selection, item wording, forward and backward translations had ensured the face and content validity. Construct validity measures how well the tool measures the attitude of patients with Type 2 diabetes regarding the disease. It was done with the administration of refined tool to a sample of 242 patients with Type 2 diabetes mellitus. The data obtained were subjected to factor analysis. Kaiser–Mayer-Olkin value 0.860, a value of more than 0.5, which indicated that the sample size was adequate. Significant Bartlett's test ensured that the data were amenable for factor analysis. Principal component factor analysis was done to extract the initial factors. An orthogonal rotation of the initial factor structure was done by varimax method. Eigen value shows the amount variance in data explained by each factor. Cumulative variance explained is 59.54 ≈ 60% of the variability [Table 2].
Table 2: Eigen values and variance

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[Figure 1] shows the Scree plot. It is the graph of the Eigen values. It should be more than 1 and denotes the number of useful factors. Principal Component Analysis yielded 4 components with Eigen Value more than 1.
Figure 1: Scree plot

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[Table 3] presents the communality of the items; it is the total amount of variance an original variable shares with all other variable. The maximum communality is 0.792 and minimum is 0.395, thus all the items possessed the acceptable communality of around 0.40.
Table 3: Communalities of items in the diabetes attitude measurement scale

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Rotated component factor loading matrix for selected items under each component with all the variables in three subscales have the factor loading value of more than 0.35, hence ascertains the construct validity. Items in the final questionnaire in three domains are shown in [Table 4].
Table 4: Rotated component-factor loading matrix

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The final 16-item DAMS, which has desirable reliability and validity and the final tool is shown in [Table 4].

DAMS consists of 16 items with 3 discrete subscales covering of diseases aspects (7 items), social aspects (5 items) and mental aspects (4 items). The responses were categorised into 5 point Likert scale such as strongly agree, agree, neutral, disagree and strongly disagree. The score ranges from 16 to 80. The sub-domains address the attitudes towards diseases and its treatment, social aspects in the context of diabetes and an individual's emotional aspects to deal with diabetes. Higher the score demotes a positive attitude towards the diseases.

  Discussion Top

Attitude is a major determinant of patient's compliance towards treatment regimen and there by the glycaemic control. The assessment of patient's attitude towards diseases is a neglected area of research in India. It is essential to develop valid tool to tap the contextual element regarding various aspects of attitude. Reliability and validity are measures to identify of how well an instrument works. Reliability indicates how closely the results of repeated measurements of the same concept agree and validity means that the concept measured is actually the one the researcher intended.[7] This study resulted in 16-item DAMS with 3 discrete subscales with appreciable reliability. The endorsement rates of items were 10%–90%. All the subscales had desirable internal consistency reliably (0.75, 0.81 and 0.69). The reliability was evaluated through Interquartile Range (ICR), Cronbach's alpha: 0.7728, which is greater than the acceptable level of 0.7. The validity was assessed through factor analysis. Finally selected items under three subscales have the factor loading value of more than 0.35, hence ascertain the construct validity. The retained factors explain around 60% of the total variance and seem to be a desirable property of the instrument. The items of this questionnaire were conceived to represent the domains of diseases related, social and mental aspects.

  Conclusion Top

Based on the analysis of the psychometric properties, it can be concluded that the 16-item DAMS is a reliable and valid tool for use among patients with Type 2 diabetes mellitus. The DAMS can be used in diabetes clinics for assessing the attitude of the patients towards the disease. This tool can be utilised in studies requiring the measurement of attitude of patients towards diabetes. Health-care providers should be motivated to identify the specific factors pertinent to each individual with Type 2 diabetes to achieve optimal glycaemic control. Equality in health services requires an individual assessment of each patient's resources, expectations and life situation to find the right treatment indicating that further research is needed to explore in this regard.


The author is thankful to Dr. Rema Devi. C, Retired associate professor from Government College of Nursing, Thiruvananthapuram, Dr. Remadevi, Social scientist, Clinical epidemiology research and training centre, Medical college, Prof. Prasanna Kumari. Y, Former Joint Director of Nursing Education, Dr. Sathidevi, Professor, Department of Anatomy, Government Medical College, Thrissur and all the faculty of Clinical Epidemiology Research and Training Centre, Government Medical College, Thiruvananthapuram.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fishbein M, Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley.; 1975. Available from: https://www.researchgate.net/publication/247743775_The_Theory_of_ Reasoned_Action. [Last accessed on 2020 Dec 03].  Back to cited text no. 1
Abolghasemi R, Sedaghat M. The patient's attitude toward type 2 diabetes mellitus, a qualitative study. J Relig Health 2015;54:1191-205.  Back to cited text no. 2
Stone M, Pound E, Pancholi A, Farooqi A, Khunti K. Empowering patients with diabetes: A qualitative primary care study focusing on South Asians in Leicester, UK. Fam Pract 2005;22:647-52.  Back to cited text no. 3
Hunt LM, Pugh J, Valenzuela M. How patients adapt diabetes self-care recommendations in everyday life. J Fam Pract 1998;46:207-15.  Back to cited text no. 4
Al-Maskari F, El-Sadig M, Al-Kaabi JM, Afandi B, Nagelkerke N, Yeatts KB. Knowledge, attitude and practices of diabetic patients in the United Arab Emirates. PLoS One 2013;8:e52857.  Back to cited text no. 5
Kpekura S, Ninnoni JP, Nuvor SV. Knowledge and attitude of patients with diabetes in government hospitals in the Upper West Region of Ghana. Int J Community Med Public Health 2018;5:3788-95.  Back to cited text no. 6
Giesen D, Meertens V, Vis-Visschers R, Beukenhorst D. Questionnaire Development. The Hague, Heerlen, Netherlands: Netherlands :Statistics Netherlands; 2012. Available from: http://mis.kp.ac.rw/admin/admin_panel/kp_lms/files/digital/ Selective%20Books/Research%20Publications/Questionaire%20 developmentart.pdf. [Last accessed on 2020 May 12].  Back to cited text no. 7


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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