Primary Care Diabetes 16 (2022) 703–708

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Primary Care Diabetes

journal homepage: www.journals.elsevier.com/primary-care-diabetes

Type 2 Diabetes Stigma Assessment Scale (DSAS-2): Cultural and linguistic

adaptation and psychometric assessment of the Arabic version
Hamzah Alzubaidi a, b, 1, *, Kevin Mc Namara c, d, 2, Catarina Samorinha b, 3, Ward Saidawi b, 4,
Vincent L. Versace e, 5, Jane Speight f, g, 6
a
Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, United Arab Emirates
b
Sharjah Institute for Medical Research, University of Sharjah, PO Box 27272, Sharjah, United Arab Emirates
c
School of Medicine, Deakin University, 75 Pigdons Rd, Waurn Ponds, Victoria 3216, Australia
d
Centre for Population Health Research, Deakin University, Burwood, Victoria 3125, Australia
e
School of Medicine, Deakin Rural Health, Deakin University Faculty of Health, 75 Pigdons Rd, Waurn Ponds, Victoria 3216, Australia
f
Deakin University, School of Psychology, Geelong, Victoria, Australia
g
The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Aims: To culturally and linguistically adapt the Type 2 Diabetes Stigma Assessment Scale (DSAS-2) into Arabic
Diabetes Mellitus and assess its psychometric properties.
Type 2 Methods: Following forward-backward translation of the DSAS-2, the Content Validity Index (CVI) was assessed.
Social stigma
Cognitive debriefing and pilot testing were conducted with adults with T2DM. The Arabic DSAS-2 was included
Validation study
Psychometrics
in a multi-center, cross-sectional study (N = 327) Arabic-speaking adults with type 2 diabetes. Psychometric
Surveys and questionnaires analyses included exploratory and confirmatory factor analysis (EFA/CFA), internal consistency reliability, and
convergent validity.
Results: The Arabic DSAS-2 was considered appropriate, with an excellent CVI (0.98). Unforced EFA revealed a
satisfactory three-factor structure, indicating the same subscales as the original instrument (’Treated differently’,
’Blame and judgment’, ‘Self-stigma’). EFA for three factors showed good indicators (KMO=0.924; Bartlett’s test
of sphericity χ2 = 4063.709, df=171, p < 0.001). Internal consistency was satisfactory for both the three-factor
structure (α = 0.91, α = 0.88, and α = 0.88, respectively) and the single factor (α = 0.94). CFA results were
inconclusive. Although fit indices improved for the single-factor model, compared to the three-factor, they
remained inadequate. The total scale demonstrated satisfactory convergent validity with self-esteem.
Conclusions: The Arabic DSAS-2 has excellent reliability and acceptable validity, supporting a three-factor
structure as well as the use of a total score.

1. Introduction global average of 9.3 %.[1,2]. In several Arabic-speaking countries, such

as Kuwait, Saudi Arabia, and the United Arab Emirates (UAE), the
Type 2 diabetes mellitus (T2DM) continues to be a major global prevalence of diabetes has soared above regional and global estimates,
health problem. In 2019, the prevalence of diabetes in the Middle East and increases are expected in the coming decades [2].
and Northern Africa was 12.8 %, which is substantially higher than the Around one third of adults with T2DM experience considerable

* Corresponding author at: Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, 7165585812, United Arab Emirates.
E-mail addresses: halzubaidi@sharjah.ac.ae (H. Alzubaidi), kevin.mcnamara@deakin.edu.au (K.M. Namara), csamorinha@sharjah.ac.ae (C. Samorinha),
wsaidawi@sharjah.ac.ae (W. Saidawi), vincent.versace@deakin.edu.au (V.L. Versace), jspeight@acbrd.org.au (J. Speight).
1
ORCID: 0000–0001-5122–271X
2
ORCID: 0000–0001-6547–9153
3
ORCID: 0000–0002-6662–0347
4
ORCID: 0000–0003-0558–4765
5
ORCID: 0000–0002-8514–1763
6
ORCID: 0000–0002-1204–6896

https://doi.org/10.1016/j.pcd.2022.08.004
Received 17 October 2021; Received in revised form 21 June 2022; Accepted 5 August 2022
Available online 11 August 2022
1751-9918/© 2022 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
H. Alzubaidi et al.
emotional burdens related directly to their condition, known as diabetes
distress [3]. This can stem from an emotional response to the diagnosis
of T2DM, being overwhelmed by the extensive self-management activ­
ities, fear of diabetes-related complications, feelings of guilt or shame, or
lack of social networks and support [3–5]. Feelings of guilt or shame are
also associated with health-related stigma, defined as a negative social
judgment related to having a condition or a feature of a condition, or its
management that leads to exclusion, rejection, blame, stereotyping, and
status loss, or the perception thereof [6]. There is a substantial body of
evidence documenting that adults with T2DM experience stigma related
to diabetes [7–10].
Diabetes-related stigma may manifest in several ways. Negative so­
cietal stereotypes are exemplified by the perception that the onset of
T2DM is due to a ‘character flaw’ (e.g. being lazy, fat, gluttonous, or
lacking in intelligence) [6]. Stigma can also be evident through differ­
ential treatment. For example, a survey in the United Kingdom found
that one-sixth of adults with type 2 diabetes reported being discrimi­
nated against by their employers because of their diabetes diagnosis
[10]. In another qualitative study, participants described limitations in
child adoption, travel, professional advancement, exclusion, and lost
friendships [6]. Furthermore, stigma can be internalized through feel­
ings of self-blame, [6] devaluation and shame [11]. Stigma occurs when
the stereotyped negative views about the development of the disease by
the society are incorporated by the stigmatized person and become part
of their self-concept [12]. Adults with T2DM have reported several
sources of stigma, including family members, friends, and colleagues
who display judgmental attitudes, interfere with their choices, or
display otherwise unhelpful, annoying or discouraging behaviors [6].
Similarly, healthcare professionals can cause stigmatization by using
discouraging language, excessively focusing on what is ‘wrong’, or
implying that people with T2DM do not know how, or are unmotivated,
to take appropriate care of their diabetes [6,9]. Some adults with T2DM
report that the media propagate negative stereotypes.[6] Of additional
concern is that many people who do not have diabetes and healthcare
professionals believe that diabetes is not stigmatized or that there is
minimal or no stigma surrounding this condition [8,13]. Among adults
with diabetes, stigma has been associated with increased diabetes
distress, anxiety and depressive symptoms, lower engagement in
self-management activities, reluctance to initiate insulin, decreased
self-efficacy and quality of life, and less supportive social networks [7,9,
14–16].
Several international organizations have called for immediate action
to address diabetes-related stigma. For example, the International Dia­
betes Federation has made it a priority to implement educational ini­
tiatives and conduct relevant research; [17] Diabetes Australia, the
American Diabetes Association and the American Association of Dia­
betes Educators have published position statements and reports
encouraging health care professionals to be aware of the language they
use when discussing diabetes with patients [9,18]. Most recently, Dia­
betes New Zealand and Diabetes Australia have highlighted the preva­
lence and impact of diabetes stigma in their national campaigns [19].
Diabetes-related stigma among Arabic-speaking communities has
garnered increasing attention recently. There is a small body of quali­
tative research in which stigma was evident through discussions be­
tween adults with T2DM and their healthcare professionals [20–22]. A
dominant view of diabetes in Arabic communities is that T2DM is a
genetic weakness that reflects negatively on the individual and their
family due to its heritable characteristic [21,22]. Arabic-speaking peo­
ple with T2DM have reported that they are unlikely to disclose their
diabetes in social gatherings, [20] and their healthcare professionals
worry that stigma could be a barrier to accepting the diabetes diagnosis
and accessing appropriate care, including mental healthcare, taking
medications, and engaging in other self-management activities [20–22].
In Arabic-speaking communities, quantitative research is now
needed to assess the prevalence of diabetes-related stigma and the
associated factors using valid, reliable and specific instruments [23].
704
Primary Care Diabetes 16 (2022) 703–708
The Type-2 Diabetes Stigma Assessment Scale (DSAS-2) is a valid and
reliable self-report measure of diabetes-related stigma with good psy­
chometric properties [13]. It was developed in English, and consists of
19 items across three domains: treated differently, blame and judgment,
and self-stigma [13]. This study aimed to produce a culturally-adapted
Arabic translation of DSAS-2 and to assess its psychometric properties.
2. Methods
2.1. Translation and cross-cultural adaptation of the DSAS-2
This work followed the guidelines for the cross-cultural adaptation of
self-reported measures.3 First, the English version of the DSAS-2 was
translated into Arabic by two independent professional certified trans­
lators. The two versions were compared carefully and synthesized into
one consensus Arabic version (reconciliation). This Arabic version was
then back-translated into English. Members of the research team, health
professionals, and the translators discussed the Arabic version in com­
parison with the original English questionnaire, and no changes in the
meaning and structure of the items were detected. Thus, a pre-final
version of the questionnaire was developed for field testing.
The Content Validity Index (CVI) was assessed by a panel of five
independent experts, including two academics in the field of behavioral
medicine and three physicians (one diabetologist and two internal
medicine specialists). The CVI was calculated based on the common
formula to assess practical relevance, language clarity, and essentiality
[24]. Each item was evaluated on a three-point rating scale ranging from
one (not clear/pertinent) to three (very clear/pertinent).
The pre-final Arabic DSAS-2 was tested through cognitive in­
terviews/debriefing iteratively in a sample of participants recruited
from the target population in which the instrument will be used [25].
Through the “think aloud” cognitive interviewing method, [26] partic­
ipants were explicitly asked to "think aloud" as they answered the survey
questions to understand their comprehension of the question, recall
ability of information, and sensitivity/social desirability. Additionally,
the “verbal probing technique” was used in which the interviewer asked
for other specific information relevant to the question or the specific
answer to one item [26].
The Arabic DSAS-2 was then pilot tested in individuals of the target
population (Arabic-speaking adults with T2DM). This process examined
the face and content validity of the questionnaire, and the intelligibility
of the items.
2.2. Study participants and procedures
Patients were recruited from 13 hospitals, three diabetes centers, and
five primary healthcare centers in Sharjah, Dubai, and Ajman. Adults
(aged >18 years) with T2DM, who were fluent in Arabic, and resident in
the UAE were invited to participate in the study by research assistants
while waiting for their routine clinic appointments. Those who agreed to
participate signed an informed consent form and self-completed a
structured paper-pencil format questionnaire.
2.3. Sample size
The sample size calculation was based on the rule of thumb, which is
to recruit at least 10 participants per item of the instrument [25]. In this
case, since the DSAS-2 has 19 items, a minimum sample of 190 in­
dividuals was required. The calculated sample size was increased by 20
% to allow for potential missing data, making the final minimum sample
required N = 228 participants.
2.4. Measures
The survey included four sections: (i) the Arabic version of the Type
2 Diabetes Stigma Assessment Scale (DSAS-2), a 19-item tool to measure
H. Alzubaidi et al. Primary Care Diabetes 16 (2022) 703–708

three aspects of perceived and experienced diabetes-related stigma, 3.2. Validation study participant characteristics
“blame and judgment”, “treated differently”, and “self-stigma” [13].
Respondents rate their endorsement of statements on a Likert-type scale A total of 327 adults with T2DM (56 % women) completed the sur­
ranging from strongly disagree to strongly agree. Scores are summed to vey. Most participants were aged between 41 and 65 years old (57.2 %),
form three subscales and a total scale score, with higher scores indi­ had an educational level equal to or below high school (53.4 %), were
cating greater diabetes stigma; (ii) diabetes-specific distress was married (78.6 %), and lived with family (87.2 %) (Table 1). Most re­
measured using the five-item Problem Areas in Diabetes (PAID-5) scale spondents reported having been diagnosed with T2DM more than six
[27]. Respondents rate each item on a five-point scale, ranging from years ago (48.8 %).
“not a problem” to “serious problem”. Higher scores represent greater
diabetes distress (range: 5–25); [27] (iii) self-esteem was assessed with 3.3. Acceptability and Response Patterns
the Rosenberg Self-Esteem Scale (RSES), a 10-item scale [28]. Re­
spondents rate each item using a four-point Likert scale, from strongly The means of the responses on all items were between 1.82
agree to strongly disagree. After reversing the inverted items, all are (SD=0.86) in item 18 and 2.85 (SD=1.26) in item 7. No missing data
summed (range: 10–40), with higher scores indicating greater was registered in all items of the scale. Most items were positively
self-esteem; (iv) sociodemographic questions, including gender, educa­ skewed (i.e., most respondents tended to disagree), and five were
tional level, and diabetes history and treatment. negatively skewed (items 4, 5, 6, 15 and 18) (Table 4). The total mean
score was 43.55 (SD=13.95). A floor effect was observed in all items, as
2.5. Data analysis more than 15 % of the participants chose the "strongly disagree" option,
ranging from 15.3 % (item 12) to 39.1 % (item 6).
Descriptive statistics were generated to analyze possible floor and
ceiling effects. To analyze the psychometric characteristics of the Arabic 3.4. Structural validity - Exploratory Factor Analysis
version of the DSAS-2, an exploratory factor analysis (EFA) was per­
formed on the 19 items, using the principal-component analysis with Unforced exploratory factor analysis revealed a three-factor struc­
varimax rotation. The Kaiser-criterion (eigenvalue>1) and scree plot ture, with eigenvalues greater than one, which explained 65 % of the
analysis were used to determine the maximum number of factors. Items variance. The rotated component pattern showed three clear factors,
were disregarded if the factor loading was < 0.4 [25]. Afterward, reli­ with item distribution being the same as the original instrument (Factor
ability and internal consistency were analyzed by examining the 1 - Treated differently - items 1–6; Factor 2 - Blame and judgment - items
inter-item correlation matrix and calculating Cronbach’s alpha (α) for 7–13; and Factor 3 - Self-stigma - items 14–19) [13]. All factor loadings
the subscales and scale emerging from the analysis. were > 0.4 (varying from 0.462 (item 8) to 0.832 (item 3), Table 2). The
Then, a confirmatory factor analysis (CFA) was conducted using the Kaiser-Meyer-Olkin measure of sampling adequacy was 0.924 and Bar­
maximum likelihood estimation to analyze how well the factor structure tlett’s Test of Sphericity was highly significant (χ2 = 4063.709 df=171,
identified in the EFA fits the data collected. A three-factor model with no p < 0.001), demonstrating that the factor analysis was adequate to the
cross-loadings or correlated residuals allowed was tested, and the latent data. A forced factor analysis showed that a one factor solution was also
factors were allowed to correlate. To identify the model, variances of the acceptable. This explained 47 % of the variance and factor loadings
latent variables were fixed at one. A minimal number of modifications to
optimize model fit was allowed. Then, a three-factor model with
Table 1
correlated residuals allowed was tested, and, finally, a single-factor
Participants’ sociodemographic, diabetes and treatment characteristics (N =
model was tested. The goodness of fit indices included comparative fit 327).
indices (CFI), the goodness of fit index (GFI), the root mean square re­
n ( %)
sidual (RMR), the root mean square error of approximation (RMSEA),
and the χ2 value. GFI and CFI values > 0.90, and RMR and RMSEA Gender
Female 183 (56.0)
values < 0.05 indicate that the CFA model is a good fit [29]. Convergent
Male 144 (44.0)
validity was assessed through the Pearson correlation coefficient be­ Age
tween the DSAS-2 and diabetes distress and self-esteem: higher levels of 18–40 84 (25.7)
stigma were expected to be correlated with higher levels of distress and 41–65 187 (57.2)
with lower levels of self-esteem. Correlations closer to r = 1.0 show > 65 56 (17.1)
Educational level
stronger convergent validity. Data were analyzed using the IBM Statis­
≤High school 173 (53.4)
tical Package for the Social Sciences (SPSS) Statistics for Windows, >High school 151 (46.6)
V.27.0, Armonk, NY, USA, and the IBM AMOS V.25.0. Marital status
Married 257 (78.6)
Unmarried 70 (21.4)
2.6. Ethical approval
Working status
Employed 148 (45.5)
This study was approved by the Research Ethics Committee of the Unemployed/retired 177 (54.5)
University of Sharjah (REC-18–03–01–01-S). Living arrangements
Alone 42 (12.8)
With family 285 (87.2)
3. Results Diabetes duration (years since diagnosis)
<1 28 (8.6)
3.1. Content validity 1–3 51 (15.6)
4–6 88 (27.0)
>6 159 (48.8)
The CVI of the Arabic version of the DSAS-2 was excellent (0.98). The
Treatment methods
CVIs by rater were: 0.99 for rater 1, 1.00 for rater 2, 0.98 for rater 3, 0.96 Injectable - insulin 100 (30.9)
for rater 4 and 0.95 for rater 5. Injectable - non-insulin 27 (8.3)
The cognitive debriefing and pilot testing was conducted with 9 Use of OHAs 243 (75.0)
Arabic-speaking adults with T2DM. All the items were considered Lifestyle changes 66 (20.4)

intelligible, and no additional modifications were required. The final OHAs – oral hypoglycaemic agents. The total does not add up to 327 in some
version of the Arabic instrument is available as Supplementary material. cells due to non-responses

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H. Alzubaidi et al. Primary Care Diabetes 16 (2022) 703–708

Table 2
EFA and CFA of the Arabic version of DSAS-2.
Items of the DSAS-2 3-factor solution One-factor
solution

Treated Blame and Self-stigma Diabetes

differently judgement stigma (total
score)

EFA CFA EFA CFA EFA CFA EFA CFA

1. Some people think I cannot fulfill my responsibilities (e.g., work, family) because I have type 2 diabetes 0.58 0.76 0.70 0.74
2. Some people treat me like I’m “sick” or “ill” because I have type 2 diabetes 0.77 0.87 0.76 0.80
3. Some people see me as a lesser person because I have type 2 diabetes 0.83 0.88 0.73 0.79
4. Some people exclude me from social occasions that involve food/drink they think I shouldn’t have 0.80 0.82 0.69 0.74
5. I have been discriminated against in the workplace because of my type 2 diabetes 0.77 0.84 0.72 0.77
6. I have been rejected by others (e.g., friends, colleagues, romantic partners) because of my type 2 diabetes 0.77 0.88 0.75 0.79
7. I have been told that I brought my type 2 diabetes on myself 0.76 0.75 0.62 0.63
8. There is blame and shame surrounding type 2 diabetes 0.46 0.74 0.74 0.77
9. Because I have type 2 diabetes, some people judge me for my food choices 0.57 0.74 0.67 0.70
10. Health professionals think that people with type 2 diabetes don’t know how to take care of themselves 0.80 0.74 0.59 0.60
11. Because of my type 2 diabetes, health professionals have made negative judgments about me 0.77 0.83 0.71 0.72
12. There is a negative stigma about type 2 diabetes being a “lifestyle disease” 0.71 0.78 0.68 0.70
13. Because I have type 2 diabetes, some people assume I must be overweight, or have been in the past 0.59 0.74 0.65 0.66
14. I feel embarrassed in social situations because of my type 2 diabetes 0.66 0.78 0.71 0.74
15. I’m ashamed of having type 2 diabetes 0.76 0.81 0.67 0.69
16. I blame myself for having type 2 diabetes 0.72 0.81 0.69 0.70
17. Because I have type 2 diabetes, I feel like I am not good enough 0.66 0.73 0.63 0.64
18. Having type 2 diabetes makes me feel like a failure 0.76 0.80 0.66 0.68
19. I feel guilty for having type 2 diabetes 0.76 0.83 0.67 0.77
Eigenvalue 8.96 1.78 1.61 N/A
% of variance explained 47.16 8.37 8.45
Cumulative % of variance explained 69.73
Cronbach α 0.91 0.88 0.88 0.94

DSAS-2, Type-2 Diabetes Stigma Assessment Scale; EFA, Exploratory Factor Analysis; CFA, Confirmatory Factor Analysis

varied from 0.593 (item 10) to 0.756 (item 2). 3.7. Convergent validity

The correlation coefficients between the DSAS-2 total and subscale

3.5. Structural validity - confirmatory factor analysis
scores and diabetes distress and self-esteem are presented in Table 5.
Higher diabetes stigma was significantly negatively correlated with
All factor loadings for the CFA models were good (three-factor
general self-esteem (r = − 408, p < 0.01 for the total scale) and positively
model: range 0.73–0.88; single-factor model: range 0.60–0.80)
correlated with diabetes-specific distress (r = 0.378, p < 0.01), although
(Table 2). In the CFA with the three-factor model, the χ2 value indicated
the correlation was insufficient to confirm convergent validity.
a good fit (χ2 = 772.7), while the other fit indices revealed poor fit
(CFI=0.844, GFI=0.770, RMR=0.236, RMSEA=0.111) (Table 3). Sec­
ond, the three-factor model was tested with correlated residuals allowed 4. Discussion
on these pairs. The χ2 value (541.7) and the CFI (0.901) met the
required standard criteria, while the other indices showed poor fit This study reports the cultural adaptation, translation and psycho­
(GFI=0.843, RMR=0.224, RMSEA=0.090). Finally, a single-factor metric properties of the DSAS-2 for Arabic-speaking adults with T2DM,
model was assessed, and although the fit indices improved, they following standardized guidelines for the translation and validation
remained below adequate (χ2 = 1431.2, CFI=0.679, GFI=0.843, process. Our results showed that the Arabic version of the 19-item DSAS-
RMR=0.098, RMSEA=0.160). 2 is a valid and reliable tool for assessing perceived and experienced
stigma among Arabic adults with T2DM.
The Arabic version of the DSAS-2 revealed a clear structure,
3.6. Internal consistency reliability consistent with the original English scale, [13] with all items organized
in the same three factors (Treated differently, Blame and judgment, and
Internal consistency for the total scale was satisfactory (Cronbach’s Self-stigma), and explaining 65 % of the total variance. All factor
α = 0.94). The three subscales also showed good internal consistency loadings were above 0.4, revealing good correlation coefficients be­
(Factor 1: α = 0.91; Factor 2: α = 0.88; and Factor 3: α = 0.88) (Table 2). tween observed variables and latent common factors. Additionally, the
one-factor solution was robust, with good factor loadings, and explain­
Table 3 ing 47 % of the variance. Moreover, the high Cronbach’s alpha of the
Model fit summaries of the confirmatory factor analysis. translated tool indicates a high internal consistency of the total scale
Model χ2 CFI GFI RMR RMSEA (0.94) and each of three factors (all above 0.88). These values are similar
to those observed in the original English version of the DSAS-2 in
Model 1 772.7 * 0.844 0.770 0.236 0.111
Model 2 541.7 * 0.901 0.843 0.224 0.090 Australia.[13] The poor fit indices for the three-factor model with no
Model 3 1431.2 * 0.679 0.843 0.098 0.160 cross-loadings in the CFA were similar to the ones in the Danish vali­
dation [30]. The one-factor model showed slightly improved fit indices,
CFI, comparative fit index; GFI, goodness of fit index; RMR, root mean square
residual; RMSEA, root mean square error of approximation; *p < 0.001 revealing inconclusive results about the existence of three dimensions
Model 1 - Three-factor model with no cross-loadings or correlated residuals related to a latent theoretical variable. This is often observed when
allowed. assessing complex psychological phenomena, such as perceived and
Model 2 - Three-factor model with correlated residuals allowed. experienced social stigma. Notwithstanding, all factor loadings for the
Model 3 - Single-factor model. final CFA models were above 0.4, suggesting that the items have good

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H. Alzubaidi et al. Primary Care Diabetes 16 (2022) 703–708

Table 4
Response distribution and means of the DSAS-2 items per subscale.
Items of the DSAS-2 Strongly Disagree Neutral Agree Strongly Mean (SD)
disagree agree

n ( %) n ( %) n ( %) n ( %) n ( %)

Treated differently 12.75

(5.18)
1. Some people think I cannot fulfill my responsibilities (e.g., work, family) because I 70 (21.4) 129 50 63 (19.3) 15 (4.6) 2.46 (1.16)
have type 2 diabetes (39.4) (15.3)
2. Some people treat me like I’m “sick” or “ill” because I have type 2 diabetes 77 (23.5) 149 39 50 (15.3) 12 (3.7) 2.30 (1.10)
(45.6) (11.9)
3. Some people see me as a lesser person because I have type 2 diabetes 85 (26.0) 165 27 (8.3) 35 (10.7) 15 (4.6) 2.17 (1.08)
(50.5)
4. Some people exclude me from social occasions that involve food/drink they think I 109 (33.3) 154 30 (9.2) 27 (8.3) 7 (2.1) 1.99 (0.98)
shouldn’t have (47.1)
5. I have been discriminated against in the workplace because of my type 2 diabetes 112 (34.3) 155 31 (9.5) 18 (5.5) 11 (3.4) 1.96 (0.98)
(47.4)
6. I have been rejected by others (e.g., friends, colleagues, romantic partners) because of 128 (39.1) 153 20 (6.1) 16 (4.9) 10 (3.1) 1.86 (0.95)
my type 2 diabetes (46.8)
Blame and judgment 18.42
(6.29)
7. I have been told that I brought my type 2 diabetes on myself 52 (15.9) 105 34 111 25 (7.6) 2.85 (1.26)
(32.1) (10.4) (33.9)
8. There is blame and shame surrounding type 2 diabetes 77 (23.5) 145 47 44 (13.5) 14 (4.3) 2.31 (1.10)
(44.3) (14.4)
9. Because I have type 2 diabetes, some people judge me for my food choices 59 (18.0) 128 55 66 (20.2) 19 (5.8) 2.57 (1.17)
(39.1) (16.8)
10. Health professionals think that people with type 2 diabetes don’t know how to take 55 (16.8) 102 67 79 (24.2) 24 (7.3) 2.74 (1.21)
care of themselves (31.2) (20.5)
11. Because of my type 2 diabetes, health professionals have made negative judgments 61 (18.7) 129 81 36 (11.0) 20 (6.1) 2.46 (1.10)
about me (39.4) (24.8)
12. There is a negative stigma about type 2 diabetes being a “lifestyle disease” 50 (15.3) 94 (28.7) 86 74 (22.6) 23 (7.0) 2.77 (1.17)
(26.3)
13. Because I have type 2 diabetes, some people assume I must be overweight, or have 56 (17.1) 114 50 80 (24.5) 27 (8.3) 2.72 (1.24)
been in the past (34.9) (15.3)
Self-stigma 12.38
(4.67)
14. I feel embarrassed in social situations because of my type 2 diabetes 94 (28.7) 155 38 30 (9.2) 10 (3.1) 2.10 (1.02)
(47.4) (11.6)
15. I’m ashamed of having type 2 diabetes 111 (33.9) 157 35 16 (4.9) 8 (2.4) 1.94 (0.93)
(48.0) (10.7)
16. I blame myself for having type 2 diabetes 93 (28.4) 145 51 33 (10.1) 5 (1.5) 2.12 (0.99)
(44.3) (15.6)
17. Because I have type 2 diabetes, I feel like I am not good enough 76 (23.2) 133 63 50 (15.3) 5 (1.5) 2.31 (1.04)
(40.7) (19.3)
18. Having type 2 diabetes makes me feel like a failure 126 (38.5) 157 24 (7.3) 16 (4.9) 4 (1.2) 1.82 (0.86)
(48.0)
19. I feel guilty for having type 2 diabetes 107 (32.7) 139 33 42 (12.8) 6 (1.8) 2.09 (1.05)
(42.5) (10.1)

DSAS-2, type-2 diabetes stigma assessment scale

Regarding the total mean stigma score, the mean in the Arab sample
Table 5
(43.55) was similar to the Danish sample, [30] both being slightly
Convergent validity of DSAS-2 total score and the three subscales.
negatively skewed compared to the Australian sample (mean=41.00)
Treated Blame and Self- Diabetes [13]. This may indicate that Arabic-speaking adults with T2DM may be
differently judgement stigma stigma
perceiving and/or experiencing more social stigma than Australian
(total score)
adults with T2DM. Some characteristics of the sample may help explain
Diabetes distress, 0.323 ** 0.317 ** 0.341 ** 0.378 ** these differences. While our sample derives from a clinical setting, the
PAID-5
Self-esteem, RSE -0.378 ** -0.280 ** -0.426 ** -0.409 **
Australian sample was selected from the general population. Although
not all the characteristics of the samples can be compared directly, the
DSAS-2, Type-2 Diabetes Stigma Assessment Scale; PAID-5, 5-item Problem Arab sample comprised more women than the Australian sample and
Areas in Diabetes scale; RSE, Rosenberg Self-Esteem
had fewer years of education. Moreover, the cultural and social context
Scale; *p = 0.05; **p < 0.01
may limit the openness to publicly disclose diabetes diagnosis, which
undermines its acceptance, increases stigma, and may decrease
correlations with the factors. engagement in appropriate self-care activities [20,22].
Convergent validity has been shown by the significant negative This study has some limitations. Due to the study’s cross-sectional
correlation between stigma and self-esteem, with patients with higher design, it was not possible to assess test-retest reliability or predictive
stigma presenting lower self-esteem, as previously reported [15]. validity. The response rate was not calculated because the data on
Although the correlation was poor, diabetes-specific distress was posi­ number of people approached and invited was not systematically
tively correlated with social stigma, as expected [14]. This low corre­ collected across all sites.
lation may be related to the use of PAID-5 (measuring diabetes distress). This study has two main strengths: first, it relied on a rigorous
The English version of the DSAS-2 showed high correlations with dia­ translation and cultural adaptation process, which ensured the validity
betes distress when assessed using PAID-20 (rs =0.67, p < 0.001) [13].

707
H. Alzubaidi et al.
of the new version of the instrument created. Second, it was based on a
clinical sample of Arab adults with T2DM recruited from 21 healthcare
locations in several cities of the UAE, with heterogeneous sociodemo­
graphic characteristics. These features increase the representativeness of
the results to other adults with T2DM. Moreover, the sample size
exceeded the minimum number needed, which increases the power of
the results obtained in the EFA.
In conclusion, this study produced a rigorous cultural adaptation of
the DSAS-2 to assess perceived and experienced stigma among Arabic
populations with T2DM. It showed good psychometric properties, which
support its use as a three-factor or one-factor scale. Furthermore, the
availability of the DSAS-2 in Arabic allows for its use in the 25 countries
where Arabic is an official language, enabling researchers, diabetes or­
ganisations and health professionals to collect much-needed data on the
extent and impact of perceived and experienced diabetes stigma among
adults with T2DM living in these countries. The Arabic version of the
DSAS-2 can now be used in a clinical context or for research purposes,
contributing to a better understanding of people’s experience with
T2DM, a fundamental dimension that impacts their self-care, self-esteem
and quality of life.
Funding
This study has been supported by an operational grant from the
University of Sharjah (grant number 150316).
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.pcd.2022.08.004.
References
[1] International Diabetes Federation, Diabetes in MENA, 2019). 〈https://www.idf.
org/our-network/regions-members/middle-east-and-north-africa/diabetes-in
-mena.html〉 (accessed July 13, 2021).
[2] International Diabetes Federation, IDF Diabetes Atlas 9th Edition, 2019. 〈https
://diabetesatlas.org/en/resources/〉.
[3] N.E. Perrin, M.J. Davies, N. Robertson, F.J. Snoek, K. Khunti, The prevalence of
diabetes-specific emotional distress in people with Type 2 diabetes: a systematic
review and meta-analysis, Diabet. Med. 34 (2017) 1508–1520, https://doi.org/
10.1111/dme.13448.
[4] K.E. Kreider, Diabetes distress or major depressive disorder? a practical approach
to diagnosing and treating psychological comorbidities of diabetes, Diabetes Ther.
8 (2017) 1–7, https://doi.org/10.1007/s13300-017-0231-1.
[5] T.C. Skinner, L. Joensen, T. Parkin, Twenty-five years of diabetes distress research,
Diabet. Med. 37 (2020) 393–400, https://doi.org/10.1111/dme.14157.
[6] J.L. Browne, A. Ventura, K. Mosely, J. Speight, “I call it the blame and shame
disease”: a qualitative study about perceptions of social stigma surrounding type 2
diabetes, BMJ Open 3 (2013), https://doi.org/10.1136/bmjopen-2013-003384.
[7] A. Kato, Y. Fujimaki, S. Fujimori, A. Isogawa, Y. Onishi, R. Suzuki, T. Yamauchi,
K. Ueki, T. Kadowaki, H. Hashimoto, Association between self-stigma and self-care
behaviors in patients with type 2 diabetes: a cross-sectional study, BMJ Open
Diabetes Res. Care 4 (2016) 1–7, https://doi.org/10.1136/bmjdrc-2015-000156.
[8] J. Schabert, J.L. Browne, K. Mosely, J. Speight, Social stigma in diabetes: a
framework to understand a growing problem for an increasing epidemic, Patient -
Patient-Cent. Outcomes Res. Volume. 6 (2013) 1–10, https://doi.org/10.1007/
s40271-012-0001-0.
708
Primary Care Diabetes 16 (2022) 703–708
[9] J.K. Dickinson, S.J. Guzman, M.D. Maryniuk, C.A. O’Brian, J.K. Kadohiro, R.
A. Jackson, N. D’Hondt, B. Montgomery, K.L. Close, M.M. Funnell, The use of
language in diabetes care and education, Diabetes Care. 40 (2017) 1790–1799,
https://doi.org/10.2337/dci17-0041.
[10] Diabetes stigma and discrimination: finding the right words, Lancet Diabetes
Endocrinol. 6 (2018) 673, https://doi.org/10.1016/S2213-8587(18)30235-3.
[11] W.H. Van Brakel, Measuring health-related stigma–a literature review, Psychol.,
Health Med. 11 (2006) 307–334, https://doi.org/10.1080/13548500600595160.
[12] S.S. Rai, E.V. Syurina, R.M.H. Peters, A.I. Putri, M.B.M. Zweekhorst, Non-
communicable diseases-related stigma: a mixed-methods systematic review, Int. J.
Environ. Res. Public Health 17 (2020) 1–25.
[13] J.L. Browne, A.D. Ventura, K. Mosely, J. Speight, Measuring the stigma
surrounding type 2 diabetes: development and validation of the type 2 diabetes
stigma assessment scale (DSAS-2, Diabetes Care 39 (2016) 2141–2148, https://doi.
org/10.2337/dc16-0117.
[14] R.M. Puhl, M.S. Himmelstein, J.L. Hateley-Browne, J. Speight, Weight stigma and
diabetes stigma in U.S. adults with type 2 diabetes: Associations with diabetes self-
care behaviors and perceptions of health care, Diabetes Res. Clin. Pract. 168
(2020), 108387, https://doi.org/10.1016/j.diabres.2020.108387.
[15] E. Holmes-Truscott, A.D. Ventura, S. Thuraisingam, F. Pouwer, J. Speight,
Psychosocial moderators of the impact of diabetes stigma: Results from the second
diabetes miles – australia (miles-2) study, Diabetes Care 43 (2020) 2651–2659,
https://doi.org/10.2337/dc19-2447.
[16] E. Holmes-Truscott, J.L. Browne, A.D. Ventura, F. Pouwer, J. Speight, Diabetes
stigma is associated with negative treatment appraisals among adults with insulin-
treated Type 2 diabetes: results from the second Diabetes MILES – Australia
(MILES-2) survey, Diabet. Med. 35 (2018) 658–662.
[17] International Diabetes Federation, International Diabetes Federation Strategic
Implementation Plan 2016–17, Brussels, Belgium, 2016.
[18] J. Speight, J. Conn, T. Dunning, T.C. Skinner, Diabetes Australia position
statement. a new language for diabetes: improving communications with and
about people with diabetes, Diabetes Res. Clin. Pract. 97 (2012) 425–431, https://
doi.org/10.1016/j.diabres.2012.03.015.
[19] Diabetes New Zealand, Love don’t judge, 2020. 〈https://www.diabetes.org.nz/
diabetes-action-month-2020〉 (accessed September 30, 2021).
[20] H. Fritz, R. Dizazzo-Miller, E.A. Bertran, F.D. Pociask, S. Tarakji, J. Arnetz, C.
L. Lysack, L.A. Jaber, Diabetes self-management among Arab Americans: patient
and provider perspectives, BMC Int. Health Hum. Rights 16 (2016) 1–7, https://
doi.org/10.1186/s12914-016-0097-8.
[21] E.A. Bertran, N.R. Pinelli, S.J. Sills, L.A. Jaber, The Arab American experience with
diabetes: perceptions, myths and implications for culturally-specific interventions,
Prim. Care Diabetes 11 (2017) 13–19, https://doi.org/10.1016/j.pcd.2016.07.004.
[22] R. DiZazzo-Miller, F.D. Pociask, E.A. Bertran, H.A. Fritz, M. Abbas, S. Tarakji, C.
L. Lysack, L.A. Jaber, J. Arnetz, Diabetes is devastating, and insulin is a death
sentence: Provider perspectives of diabetes self-management in Arab-American
patients, Clin. Diabetes 35 (2017) 43–50, https://doi.org/10.2337/cd15-0030.
[23] W.H. Van Brakel, Measuring health-related stigma–a literature review, Psychol.,
Health Med. 11 (2006) 307–334, https://doi.org/10.1080/13548500600595160.
[24] V. Zamanzadeh, A. Ghahramanian, M. Rassouli, A. Abbaszadeh, H. Alavi-Majd, A.-
R. Nikanfar, Design and implementation content validity study: development of an
instrument for measuring patient-centered communication, J. Caring Sci. 4 (2015)
165–178, https://doi.org/10.15171/jcs.2015.017.
[25] V.D. Sousa, W. Rojjanasrirat, Translation, adaptation and validation of instruments
or scales for use in cross-cultural health care research: A clear and user-friendly
guideline, J. Eval. Clin. Pract. 17 (2011) 268–274, https://doi.org/10.1111/
j.1365-2753.2010.01434.x.
[26] B. Gordon Willis, Cognitive interviewing, A “How to” Guide (1999), https://doi.
org/10.1002/9781118037003.ch5.
[27] B.E. McGuire, T.G. Morrison, N. Hermanns, S. Skovlund, E. Eldrup, J. Gagliardino,
A. Kokoszka, D. Matthews, M. Pibernik-Okanović, J. Rodríguez-Saldaña, M. De
Wit, F.J. Snoek, Short-form measures of diabetes-related emotional distress: the
problem areas in diabetes scale (PAID)-5 and PAID-1, Diabetologia 53 (2010)
66–69, https://doi.org/10.1007/s00125-009-1559-5.
[28] B. Gray-Little, V.S.L. Williams, T.D. Hancock, An item response theory analysis of
the Rosenberg self-esteem scale, Personal. Soc. Psychol. Bull. 23 (1997) 443–451,
https://doi.org/10.1177/0146167297235001.
[29] H. Schermelleh-Engel, K. Moosbrugger, H., &amp Müller, Evaluating the fit of
structural equation models: tests of significance and descriptive goodness-of-fit
measures, Methods Psychol. Res. Online 8 (2003) 23–74.
[30] U.M. Hansen, I. Willaing, A.D. Ventura, K. Olesen, J. Speight, J.L. Browne, 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 (2018) 403–412, https://doi.org/
10.1007/s40271-017-0289-x.