Diabetes Attitude Scale (DAS-3)

Abstract

The Diabetes Attitude Scale (DAS-3) is a widely recognized, psychometrically sound instrument developed to measure beliefs and attitudes concerning the management, seriousness, and psychosocial impact of Diabetes Mellitus (DM). The third version (DAS-3), published in 1998, represents a refinement of earlier iterations designed specifically for assessing the perspectives of both patients living with diabetes and the healthcare professionals who treat them. The scale is critical for identifying potential barriers to effective patient-provider communication and adherence to treatment plans, focusing on five key domains of diabetes care.

Keywords

Diabetes Attitude Scale, DAS-3, Type 2 Diabetes, NIDDM, attitudes, psychosocial impact, patient autonomy, tight control, healthcare professionals, scale development.

Authors

Robert M. Anderson, Martha M. Funnell, James T. Fitzgerald, Leslie D. Grupen, 1998. (Building upon foundational work by Anderson, Donnelly, Gressard, and Dedrick from 1989 and 1990).

Purpose

The primary purpose of the DAS-3 is to systematically assess an individual’s deeply held beliefs regarding essential aspects of diabetes management and prognosis. By quantifying these attitudes, the instrument facilitates the identification of discrepancies between patient and provider beliefs, which are crucial for improving patient education, adherence, and overall care outcomes. It specifically investigates attitudes toward the necessity of tight Blood Glucose Control, the seriousness of Type 2 Diabetes, and the appropriate level of patient involvement in therapeutic decisions.

The scale serves as a valuable tool in clinical research and practice, allowing educators and clinicians to tailor educational interventions. Understanding attitudes about topics like the seriousness of the disease or the value of intensive therapy is foundational to resolving conflicts and encouraging self-management behaviors necessary for long-term health in individuals with diabetes.

Construct

The DAS-3 is a multi-dimensional scale measuring five distinct psychological constructs related to diabetes care, derived through factor analysis. These constructs capture beliefs about the medical severity of the disease, the emotional burden it imposes, and the relational dynamics within the healthcare setting. The measured constructs are:

• Need for Special Training: Measures the perceived necessity for healthcare professionals (HCPs) to possess specialized communication and teaching skills beyond standard medical knowledge.
• Seriousness of NIDDM (Non-Insulin Dependent Diabetes Mellitus): Assesses the belief that Type 2 Diabetes is a serious condition, comparable to Type 1 Diabetes, and requires proactive management.
• Value of Tight Control: Measures the belief that intensive management aimed at near-normal blood sugar levels is beneficial and achievable, despite potential risks like hypoglycemia or the perceived difficulty of the regimen.
• Psychosocial Impact of DM: Assesses recognition of the significant emotional, social, and psychological burden that diabetes places on the patient’s life.
• Patient Autonomy: Measures the belief that the patient should be the central decision-maker and most important member of the diabetes care team, having the final say in setting goals and care plans.

Validity

The validity of the DAS-3 is supported by extensive developmental research, particularly the 1998 study published in Diabetes Care. The scale demonstrates strong construct validity, confirmed by the consistent extraction of five theoretically meaningful factors across diverse samples of patients and healthcare professionals. This factor structure aligns well with current clinical models emphasizing self-management and collaborative care.

Furthermore, the DAS-3 has shown criterion validity, with attitude scores correlating significantly with relevant behavioral and clinical outcomes, such as self-reported adherence to treatment regimens. The scale’s ability to differentiate between the attitudes of patients and various categories of healthcare providers (e.g., physicians versus diabetes educators) also supports its discriminative validity.

Reliability

The DAS-3 exhibits high internal consistency, which is a key measure of reliability. Across the five subscales, Cronbach’s alpha coefficients typically range from acceptable to very good (often above 0.70 and approaching 0.90 in some factors), indicating that the items within each factor reliably measure the same underlying construct. These reliability statistics are consistently reported across different studies and populations, confirming the scale’s stability.

Factor Analysis

The DAS-3 is structured around five empirically derived factors identified through rigorous factor analysis. The original 33 items were subjected to principal components analysis, confirming the clear distinction between the five subscales. This structure moved beyond earlier versions (DAS and DAS-2) to better separate concepts that were previously conflated, such as the seriousness of Type 2 Diabetes from the value of tight control.

The five factors, along with their constituent item numbers, are: 1) Need for Special Training (Items 1, 6, 10, 17, 20); 2) Seriousness of NIDDM (Items 2, 7, 11, 15, 21, 25, 31); 3) Value of Tight Control (Items 3, 8, 12, 16, 23, 26, 28); 4) Psychosocial Impact of DM (Items 4, 13, 18, 22, 29, 33); and 5) Patient Autonomy (Items 5, 9, 14, 19, 24, 27, 30, 32).

Instrument

Test Type: Self-report questionnaire / Attitude Survey

Format: 33 items utilizing a 5-point Likert scale (5=Strongly Agree, 1=Strongly Disagree). Items 2, 3, 7, 11, 13, 15, 16, 23, 26, and 28 are reverse-scored.

Language Available: Primarily English (translated versions may exist based on subsequent research use).

Population Group: Patients with Diabetes Mellitus (Type 1 and Type 2) and Healthcare Professionals (HCPs) involved in diabetes care.

Age Group: Adults (typically 18 years and older).

Population Details: Used across various clinical settings and educational levels, applicable to individuals managing diabetes and their clinical support teams.

Test Methodology: Summed scoring across five subscales. Higher scores generally indicate more positive attitudes toward collaborative care, seriousness of the condition, and intensive management.

Keywords

Psychometrics, attitude measurement, patient education, self-management, adherence, diabetes care team, Michigan, Likert scale.

Authors

Author ORCID Identifier: Not provided in source content.

Affiliation Email addresses: Not provided in source content.

Correspondence Address: Developed at the University of Michigan, Department of Medical Education (as of 1998 publication).

Permissions & Fee and Test Year

Permissions and Fees: The scale is generally available for non-commercial research use. Interested parties should consult the original developers at the University of Michigan for formal permission and distribution details. The instrument can be found at: http://diabetesresearch.med.umich.edu/Tools_SurveyInstruments.php#das

Test Year: The third version (DAS-3) was published and validated in 1998.

Reference’s

• Anderson, R.M., Donnelly, M.B., Gressard, C.P., Dedrick, R.F. (1989). The Development of a Diabetes Attitude Scale for Health Care Professionals. Diabetes Care, 12:120-127.
• Anderson, R.M., Donnelly, M.B., Dedrick, R.F. (1990). Measuring the Attitudes of Patients Towards Diabetes and Its Treatment. Patient Education and Counseling, 16, 231-245.
• Anderson, R.M.(1993). Assessing Patient Attitudes About Diabetes: Implications for Health Care Professionals. Diabetes Spectrum, 6(2), 150-151.
• Anderson, R.M., Fitzgerald, J.T., Gorenflo, D.W., Oh, M.S. (1993). A Comparison of the Diabetes-Related Attitudes of Health Care Professionals and Patients. Patient Education and Counseling 21:41- 50.
• Anderson, R.M., Fitzgerald, J.T., Oh, M.S. (1993). The Relationship of Diabetes-Related Attitudes and Patients’ Self-Reported Adherence. The Diabetes Educator 19:287-292.
• Anderson, R.M., Fitzgerald, J.T., Funnell, M.M., Grupen, L.D. (1998). The Third Version of The Diabetes Attitude Scale (DAS-3). Diabetes Care 21(9):1403-1407.

Items of the Diabetes Attitude Scale (DAS-3)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

In general, I believe that:

1. …health care professionals who treat people with diabetes should be trained to communicate well with their patients.
2. …people who do not need to take insulin to treat their diabetes have a pretty mild disease.
3. …there is not much use in trying to have good blood sugar control because the complications of diabetes will happen anyway.
4. …diabetes affects almost every part of a diabetic person’s life.
5. …the important decisions regarding daily diabetes care should be made by the person with diabetes.
6. …health care professionals should be taught how daily diabetes care affects patients’ lives.
7. …older people with Type 2 diabetes do not usually get complications.
8. …keeping the blood sugar close to normal can help to prevent the complications of diabetes.
9. …health care professionals should help patients make informed choices about their care plans.
10. …it is important for the nurses and dietitians who teach people with diabetes to learn counseling skills.
11. …people whose diabetes is treated by just a diet do not have to worry about getting many long-term complications.
12. …almost everyone with diabetes should do whatever it takes to keep their blood sugar close to normal.
13. …the emotional effects of diabetes are pretty small.
14. …people with diabetes should have the final say in setting their blood glucose goals.
15. …blood sugar testing is not needed for people with Type 2 diabetes.
16. …low blood sugar reactions make tight control too risky for most people.
17. …health care professionals should learn how to set goals with patients, not just tell them what to do.
18. …diabetes is hard because you never get a break from it.
19. …the person with diabetes is the most important member of the diabetes care team.
20. …to do a good job, diabetes educators should learn a lot about being teachers
21. …Type 2* diabetes is a very serious disease.
22. …ha‎ving diabetes changes a person’s outlook on life.
23. …people who have Type 2 diabetes will probably not get much payoff from tight control of their blood sugars.
24. …people with diabetes should learn a lot about the disease so that they can be in ch‎arge of their own diabetes care.
25. …Type 2 is as serious as Type 1 diabetes.
26. …tight control is too much work.
27. …what the patient does has more effect on the outcome of diabetes care than anything a health professional does.
28. …tight control of blood sugar makes sense only for people with Type 1 diabetes.
29. …it is frustrating for people with diabetes to take care of their disease.
30. …people with diabetes have a right to decide how hard they will work to control their blood sugar.
31. …people who take diabetes pills should be as concerned about their blood sugar as people who take insulin.
32. …people with diabetes have the right not to take good care of their diabetes.
33. …support from family and friends is important in dealing with diabetes.

Scoring Key: 5= Strongly Agree, 4= Somewhat Agree, 3= Neutral, 2= Somewhat Disagree, 1= Strongly Disagree. Reverse scores apply for items 2, 3, 7, 11, 13, 15, 16, 23, 26, and 28.