Cited by 664Diabetes Management and EducationPsychometric Methodologies and TestingHealth Education and Validation

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

Welch, Garry W, Jacobson, Alan M, Polonsky, William H·1997·Diabetes Care

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Abstract

OBJECTIVE: 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. RESEARCH DESIGN AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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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BackgroundMethodInfluential
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Method
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Method
Impact of “Conversation Map™” tools on understanding of diabetes by Spanish patients with type 2 diabetes mellitus: A randomized, comparative study
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Method
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Method
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Background
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“in addition to the Brazilian, Taiwanese, and Polish versions of the PAID (13, 20, 23, 32).”
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Self-citation
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Method
History of mild hypoglycaemia does not affect the prevalence of diabetes-related distress in people with diabetes
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Background
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“For example, both the PAID and Diabetes Distress Scale (DDS) are highly valid and reliable instruments for measuring diabetes distress.(15,47) However, use of the PAID was necessitated by the parent study’s protocol.”
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Liraglutide versus Sitagliptin in a 24-week, Multicenter, Open-label, Randomized, Parallel-group Study in Japanese Type 2 Diabetes Mellitus Patients Responding Inadequately to a Sulfonylurea and/or One or Two Other Oral Antidiabetic Drugs (JDDM 33)
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Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the problem areas in diabetes (PAID) questionnaire
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“It should be noted, lastly, that the cut-off was established in Western populations (one standard deviation above the mean) [2, 43] and may not be universally applicable.”
Background
Capturing Diabetes-Related Distress and Burden From the Perspective of Patients With Type 1 or Type 2 Diabetes: Protocol for an Explorative Mixed Methods Study
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“The Problem Areas in Diabetes scale [26] includes 20 items to assess different areas of diabetes-related emotional distress.”
Background
Evaluation of Self-Care Practices and Emotional Distress Among People with Type 2 Diabetes Mellitus in Dar Es Salaam, Tanzania
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“However, participants were experiencing severe diabetes distress ( > 40) (Welch et al., 1997).”
Background
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“In Deutschland ist seit vielen Jahren der Fragebogen „Problem Areas in Diabetes“ (PAID) zur Messung von Diabetesbelastungen gut etabliert [5, 31].”
Background
Microbiome composition and central serotonergic activity in patients with depression and type 1 diabetes
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“In short, participants completed the depression module of the “Patient Health Questionnaire (PHQ)-9 [32, 33], the “Prob-lem Areas in Diabetes” scale (PAID [34, 35]), the 12-item SSCS variant of the “Trier inventory for chronic stress” (TICS [36, 37]).”
Background
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“Psychodiabetic KIT supports a diagnosis of coping styles, perception of self-influence on diabetes course and a more reliable diagnosis of depression and anxiety, than the one WHO-5 and PAID used as screening tools for depression.”
Method
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“reported that the total score of the PAID scale was higher in the patients with type 1 diabetes than those with type 2 diabetes (12).”
Background
Frequência de sofrimento emocional é elevada em pessoas com diabetes assistidas na atenção primária
Goes, J. A., Rodrigues, K. F., de Avila, A. C., Geisler, A., Maieski, A., Nunes, C. R. D. O., da Silveira, J. L. G. C., & Helena, E. T. D. S. (2020) · Revista Brasileira de Medicina de Família e Comunidade · doi:10.5712/rbmfc15(42)2078 · Cited by 7
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“95), and the PAID had moderate to high correlation with other relevant measures of coping and distress.(46,47) The PAID has been validated to be sensitive to changes associated with educational and psychosocial interventions.”
BackgroundMethodInfluential
Association Between a Low Carbohydrate Diet, Quality of Life, and Glycemic Control in Australian Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Pilot Study
Paul, J., Jani, R., Davoren, P. M., & Knight-Agarwal, C. R. (2021) · JMIR Research Protocols · doi:10.2196/25085 · Cited by 6
“Study phase 2b–subsequent validation: online Australian diabetes-specific quality of life, MOS SF-36, DQOL, and PAID-20 questionnaires completed by adults with type 1 diabetes mellitus (n=100).”
BackgroundMethodInfluential
Assessing cultural appropriateness of patient-reported outcome measures for Aboriginal people with diabetes: study protocol
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“• Problem Areas in Diabetes: The 20-item Problem Areas in Diabetes Scale evaluates emotional stress, such as anger, worry, depressed mood, guilt, and fear in persons living with diabetes [42,43].”
BackgroundInfluential
Advanced Insulin Management program reduces A1C levels and regimen-related distress without weight gain in patients with type 1 diabetes mellitus
Fish, L. H., Wetzler, H. P., Davidson, J. L., Ofstead, C. L., & Johnson, M. L. (2008) · Insulin · doi:10.1016/s1557-0843(08)80017-6 · Cited by 6
Health-related quality of life of patients with type 2 diabetes mellitus in primary care in Spain: self-reported and proxy assessment using the EQ-5D
Boye, K. S., Yurgin, N., Dilla, T., et al. (2007) · Journal of Medical Economics · doi:10.3111/200710041058 · Cited by 6
What are disease perceptions and subjective treatment goals of insulin treated diabetic patients?
Lächelt, S. (2005) · Swiss Medical Weekly · doi:10.4414/smw.2005.11008 · Cited by 6
Enhancing Diabetes Self-Management: Motivational Enhancement Therapy
Britt, E. (2008) · UC Research Repository (University of Canterbury) · doi:10.26021/7701 · Cited by 6
Health outcomes of telemonitoring of patients with type-2 diabetes mellitus: One-year results from a randomized controlled trial (Optimizing care of Patients via Telemedicine In Monitoring and aUgmenting their control of diabetes Mellitus)
Lee, C. S., Tyagi, S., Koh, Y. L. E., Gong, P. P., Ang, S. B., Koh, G. C., & Tan, N. C. (2024) · Journal of Telemedicine and Telecare · doi:10.1177/1357633x241261733 · Cited by 6
Evaluating the mySugr diabetes app: A randomised controlled trial exploring changes in HbA1c and psychological outcomes in adults with type 1 diabetes
Singh, A. A., Babbott, K. M., Young, S., Wu, Z., & Serlachius, A. S. (2025) · Primary care diabetes · doi:10.1016/j.pcd.2025.07.002 · Cited by 7
Test–retest reliability and measurement error of the WHO-5 Well-being Index and the Problem Areas in Diabetes questionnaire (PAID) used in telehealth among patients with type 1 diabetes
Schougaard, L. M. V., Laurberg, T., Lomborg, K. E., Hansen, T. K., Hjøllund, N. H., & Jensen, A. L. (2022) · Journal of Patient-Reported Outcomes · doi:10.1186/s41687-022-00505-3 · Cited by 5
“Moreover, we selected PAID which is a 20-item disease-specific questionnaire measuring diabetes distress, for example, feeling scared about living with diabetes, feelings of deprivation regarding food and meals, and worrying about low blood sugar reactions [14].”
BackgroundMethodInfluential
Factores psicosociales en la diabetes mellitus tipo1 y su relación con el riesgo de desarrollar trastornos alimentarios en la infancia y la adolescencia
Sancanuto, C., Tébar, F. J., Jiménez‐Rodríguez, D., & Morante, J. J. H. (2014) · Avances en Diabetología · doi:10.1016/j.avdiab.2014.08.001 · Cited by 5
The Importance of Screening for Mild Depression in Adults with Diabetes
Wilhelm, K. A., Reddy, J., Crawford, J., Robins, L., Campbell, L. V., & Proudfoot, J. G. (2017) · Translational Biomedicine · doi:10.21767/2172-0479.1000101 · Cited by 5
“This may be because the association between depression and glycaemic control is mediated by several pathways [21] and/or the impact of depression on glycaemic control can vary with other concurrent stressors and needs [20].”
Background
Three approaches to glucose monitoring in non-insulin treated diabetes: a pragmatic randomized clinical trial protocol
Young, L., Buse, J. B., Weaver, M. A., Vu, M. B., Reese, A., Mitchell, C. M., Blakeney, T., Grimm, K. F., Rees, J. R., & Donahue, K. E. (2017) · BMC Health Services Research · doi:10.1186/s12913-017-2202-7 · Cited by 5
Feasibility and acceptance of a virtual multidisciplinary care programme for patients with type 2 diabetes during the COVID-19 pandemic
Hernández-Jiménez, S. C., García-Ulloa, A. C., Alcántara-Garcés, M. T., Urbina-Arronte, L. E., Lara-Sánchez, C., Velázquez-Jurado, H., & for the Group of Study CAIPaDi (2021) · Therapeutic Advances in Endocrinology and Metabolism · doi:10.1177/20420188211059882 · Cited by 5
Programme Grants for Applied Research
Library, N. J. (2012) · Cited by 5
Identification of patient-centered outcomes among African American women with type 2 diabetes
Miller, S. T., Akohoue, S. A., & Brooks, M. A. (2014) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2014.09.049 · Cited by 5
Standards of Care and Treatment in Diabetes
Dugan, J. A. (2016) · Physician Assistant Clinics · doi:10.1016/j.cpha.2016.08.004 · Cited by 5
Medication Intake, Perceived Barriers, and Their Correlates Among Adults With Type 1 and Type 2 Diabetes: Results From Diabetes MILES – The Netherlands
Hogervorst, S., Adriaanse, M. C., Hugtenburg, J. G., Bot, M., Speight, J., Pouwer, F., & Nefs, G. (2021) · Frontiers in Clinical Diabetes and Healthcare · doi:10.3389/fcdhc.2021.645609 · Cited by 5
“Diabetes-specific emotional distress was assessed with the validated 20-item Problem Areas in Diabetes scale (PAID; total score range: 0– 100), in which higher scores indicate greater severity of diabetesspecific emotional distress (22).”
Method
The Japanese version of Problem Areas in Diabetes Scale: a clinical and research tool to assess emotional functioning among people with diabetes
Hayashino, Y., Goto, M., Yamamoto, T., Tsujii, S., & Ishii, H. (2023) · Diabetology International · doi:10.1007/s13340-023-00661-x · Cited by 5
Feasibility of a Manualized Occupation-Based Diabetes Management Intervention
Carandang, K. M., & Pyatak, E. A. (2018) · American Journal of Occupational Therapy · doi:10.5014/ajot.2018.021790 · Cited by 7
Health Outcome Measures for Diabetes Mellitus: A Review
Bhatt, J. K., Thomas, S., & Nanjan, M. J. (2012) · Applied Research in Quality of Life · doi:10.1007/s11482-012-9168-8 · Cited by 5
Diabetes or Impaired Glucose Tolerance
Lara, C., de Leon, S. P., Foncerrada, H., et al. (2007) · Diabetes Care · doi:10.2337/dc06-2379 · Cited by 5
“The specific variables studied were knowledge about the disease (2), compliance with treatment (2), quality of life (3), emotional functioning (3,4), coping mechanisms (4), and glucose control.”
Background
Diabetesbezogene Belastungen
Paust, R., Krämer-Paust, R. R., & Jansen, B. (2013) · Springer eBooks · doi:10.1007/978-3-642-29908-7_9 · Cited by 5
Psychological Impact of DAFNE Training in Adults with Type 1 Diabetes
Engel, L. (2009) · Figshare · Cited by 5
Psychological distress in Aotearoa New Zealand adults with type 1 diabetes
McClintock, J. M., Chepulis, L. M., Blackmore, T., Fraser, S. K., & Paul, R. G. (2024) · Journal of Health Psychology · doi:10.1177/13591053241289189 · Cited by 5
“Diabetes distress was determined by the Problem Areas in Diabetes Scales (PAID; Welch et al., 1997), a 20 item scale where patients indicate the extent to which each item is a problem on a 5-point scale ranging from 0 (not a problem) to 4 (serious problem).”
A scoping review exploring research investigating the influence of carbohydrate counting on eating behaviour and/or disordered eating in type 1 diabetes.
Rigby, K., Iturbe, I., Candler, T., Anderson, R., Hamilton-Shield, J., & Hinton, E. (2025) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2025.112068 · Cited by 6
The utility of Problem Areas in Diabetes (PAID) scale amongst patients with Type 2 diabetes (T2DM)
Thomas, L., Asha, H. S., Amalraj, R. E., Prakash, R., Abraham, P., & Thomas, N. (2021) · Journal of Family Medicine and Primary Care · doi:10.4103/jfmpc.jfmpc_1891_20 · Cited by 4
Health‐related quality of life assessment in health economic analyses involving type 2 diabetes
Smith, H., James, S., Brown, F., Gaca, M., O'Neal, D. N., Tran‐Duy, A., Devlin, N. J., Kelly, R., & Ekinci, E. I. (2024) · Diabetic Medicine · doi:10.1111/dme.15418 · Cited by 4
“Two HRQoL tools were tailored to the unique stressors faced by people with type 2 diabetes: the Problem Areas In Diabetes (PAID) scale 47 and the Diabetes Distress Scale (DDS).”
Psychometric Evaluation of the Chinese Version of the Diabetes Coping Measure Scale
Huang, M., Courtney, M. D., Edwards, H. E., et al. (2009) · Journal of Nursing Scholarship · doi:10.1111/j.1547-5069.2009.01306.x · Cited by 4
Assessment of a Multidisciplinary Intervention in Patients With BMI ≥35 kg/m2 and Recently Diagnosed Type 2 Diabetes
García-Ulloa, A. C., Landa-Anell, V., Melgarejo-Hernández, M. A., Villegas-Narvaez, A., Urbina-Arronte, L. E., Hernández-Jiménez, S. C., & CAIPaDi Study Group (2019) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2018-01148 · Cited by 4
Determinants of successful diabetes self-management behaviors among women of Arab descent with Type 2 Diabetes
Alanazi, M. R. (2020) · Primary care diabetes · doi:10.1016/j.pcd.2020.10.009 · Cited by 4
Interpreting Patient-Reported Outcome Measures
Meadows, K. (2021) · Philosophy of Medicine · doi:10.5195/philmed.2021.66 · Cited by 4
Psychosocial and Educational Implications of Diabetic Foot Complications
Weinger, K., & Smaldone, A. M. (2007) · Humana Press eBooks · doi:10.1007/978-1-59745-075-1_24 · Cited by 4
Cohort profile: the ‘Biomarkers of heterogeneity in type 1 diabetes’ study—a national prospective cohort study of clinical and metabolic phenotyping of individuals with long-standing type 1 diabetes in the Netherlands
Aanstoot, H., Varkevisser, R. D. M., Aanstoot, H., Dekker, P., Birnie, E., Boesten, L. S. M., Brugts, M. P., Brugts, M. P., Geelhoed-Duijvestijn, P. H. L. M., Geelhoed-Duijvestijn, P. H. L. M., et al. (2024) · BMJ Open · doi:10.1136/bmjopen-2023-082453 · Cited by 4
Working with Challenging Patients in Diabetes Treatment
Ritholz, M. D. (2008) · Humana Press eBooks · doi:10.1007/978-1-60327-208-7_13 · Cited by 4
TYPE 2 DIABETES MELLITUS;
Malik, J. A., Mumtaz, T., & Sa, H. (2018) · The Professional Medical Journal · doi:10.29309/tpmj/2014.21.05.2553 · Cited by 4
Patient Satisfaction with Professional Continuous Glucose Monitoring in a Diverse Family Medicine Clinic: A Pilot Study
Hougas, J. E., Nichol, H. R., & Schafer, K. M. (2022) · INNOVATIONS in pharmacy · doi:10.24926/iip.v13i2.4784 · Cited by 3

Authors: Welch, G. W., Jacobson, A. M., & Polonsky, W. H.
Affiliations: Mental Health Unit, Balboa Medical Center San Diego, California
Joslin Diabetes Center (US)
ORCID: Polonsky, William H
Venue: Diabetes Care
Publisher: American Diabetes Association
Published: 1997-05-01
Volume: 20
Issue: 5
Pages: 760-766
ISSN: 0149-5992 (ISSN-L)
1935-5548
DOI: 10.2337/diacare.20.5.760
OpenAlex: W2134365893
Cited by: 664
References: 0
Citations by year: 2026: 20 · 2025: 20 · 2024: 35 · 2023: 37 · 2022: 49 · 2021: 46 · 2020: 35 · 2019: 37 · 2018: 28 · 2017: 33 · 2016: 23 · 2015: 31 · 2014: 32 · 2013: 25 · 2012: 37
FWCI: 0.71
Type: journal article
Language: en
Open access: closed
Locations: Diabetes Care (publishedVersion)
PubMed (publishedVersion)
Funders: National Institutes of Health (5r01dk027845-14)
National Institute of Diabetes and Digestive and Kidney Diseases (DK27845, DK42315, R01DK042315)
Topics: Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
Health Sciences › Nursing › Research and Theory › Health Education and Validation
Keywords: Problem Areas in Diabetes scale, emotional adjustment, type 1 diabetes, type 2 diabetes, discriminant validity, concurrent validity, psychometric properties, coping, health attitudes, insulin-treated diabetes, HbA1c
MeSH terms: Adaptation, Psychological, Adult, Attitude to Health, Demography, Diabetes Mellitus, Diabetes Mellitus, Type 1, Diabetes Mellitus, Type 2, Diet, Diabetic, Education, Emotions, Female, Humans, Hypoglycemic Agents, Insulin, Male, Middle Aged, Surveys and Questionnaires, Socioeconomic Factors, Reproducibility of Results, Discriminant Analysis

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

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