Introduction

Diabetes affects 537 million of the global population aged 20 to 79 years as of 2021, and is expected to increase to 783 million by 2045 [1]. Therefore, the economic and social burden required to manage diabetes is expected to increase [2]. Diabetes requires self-care, including a proper diet, exercising, and medical treatment [3]. It is very important for patients to practice self-care especially when visits to hospitals, clinics, or public health centers may be limited due to certain restraining factors, as during the coronavirus disease 2019 (COVID-19) pandemic. However, several psychosocial factors act as obstacles to self-care in patients with diabetes, such as disease-related stress and self-stigma [4]. Acceptance and commitment therapy (ACT) has recently received attention as an intervention method to reduce negative emotions, such as disease-related stress in patients with diabetes and to increase their self-care practices [5,6].

ACT is a cognitive-behavioral therapy, and an acceptance-centered approach that allows one to accept facts rather than judge them [7]. ACT emphasizes that recognizing thoughts, sensations, or emotions about an event and stopping those thoughts can reduce the restrictions on behavior [3]. This technique is called psychological flexibility [3]. Psychological flexibility is the active acceptance of current personal experiences through a flexible cognitive process [8]. It means accepting even if an individual experiences negative and harmful consequences and adopting a positive attitude [9,10].

For patients to be diagnosed with diabetes and subsequently self-care successfully, they must go through a process of re-recognition of having a healthy self to a self with disease [11]. Acceptance is the most important factor in this re-awareness process [11]. Acceptance and action is an active acceptance of experiences, such as thoughts, emotions, and sensations, with a non-judgmental attitude of self-perception [12]. A qualitative study on the experiences of patients with diabetes found that when these patients accept that they have diabetes, they readjust their lives, manage their illness and lead a better life [13]. In other words, patients need to accept diabetes non-judgmentally and take action to manage it. This willingness to accept thoughts and feelings while acting in a way that is consistent with one's values and goals is called acceptance and action [12]. When individuals with diabetes do not accept diabetes, they develop negative perceptions of themselves, which in turn results in self-stigma [4]. Self-stigma reduces self-efficacy and self-esteem, and acts as an obstacle to self-care, reducing the quality of life of patients with diabetes [14]. In this process, acceptance and action were found to improve the quality of life by acting as a mediating factor in the relationship between self-stigma and quality of life [15]. As such, the acceptance action of diabetes patients is very important; therefore, a tool is needed to adequately measure, manage, and improve acceptance.

In Korea, the Acceptance and Action Questionnaire (AAQ) and the Acceptance and Action Questionnaire-Stigma (AAQ-S) are used as acceptance and action tools. The AAQ measures aspects related to acceptance and action in assessing psychological flexibility; Moon translated the tool developed by Hayes et al. to measure general acceptance and action and its validity and reliability have been verified [12,16]. Levin et al. developed the AAQ-S to measure the psychological flexibility of stigmatizing thinking. This tool was translated by Lee et al. to verify the validity and reliability of patients with diabetes [17,18]. The validity and reliability of these two tools have been confirmed in Korean samples. However, because the AAQ measures acceptance and action in the general population, a limitation is that it does not reflect the characteristics of acceptance and action of diabetes patients in particular. In addition, the AAQ-S has been used for diabetes patients; however, a limitation is that it is difficult to measure the diabetes acceptance and action of diabetes patients because the tool measures these variables in response to stigma.

The Diabetes Acceptance and Action Scale (DAAS), developed by Greco and Hart [19], measures the degree of acceptance and action when faced with diabetes-related problems in adolescents with type 1 diabetes. Gillanders and Barker [3] evaluated the validity and reliability of the Diabetes Acceptance and Action Scale-Revised (DAAS-R), a shortened scale consisting of nine items based on 42 items of the DAAS. At the time, both type 1 and type 2 diabetes patients were included, and validity was confirmed in a sample comprising adults as well as teenagers; thus, the acceptance and action of diabetes patients across different age groups can be measured with the tool [3]. To use this tool, which consists of a single factor and nine items, it is necessary to evaluate whether it is appropriate to measure the acceptance and action of Korean people with type 2 diabetes. Therefore, in this study, we tried to evaluate the construct and concurrent validity and reliability of the tool by translating it into Korean and applying it to Korean people with type 2 diabetes.

Methods

1. Design and Participants

This was a descriptive, cross-sectional study. The survey was conducted from September 1, 2021 to September 30, 2021, through a survey institution (PMI Co., Ltd.) for patients diagnosed with diabetes who understood the purpose of the study and voluntarily agreed to participate in it. The inclusion criteria for the study participants were as follows: 1) adults diagnosed with type 2 diabetes by a doctor, 2) people who are able to practice self-care to manage the condition, and 3) people who are able to fill out the questionnaire. The exclusion criteria were as follows: 1) people who have not been diagnosed with diabetes by a doctor, 2) people who face difficulties in self-care, and 3) people experiencing difficulty in filling out the questionnaire. A self-report questionnaire consisting of general characteristics, DAAS-R, acceptance and action, quality of life, diabetes self-stigma, and experiential avoidance was prepared as an online questionnaire and distributed to 4,800 panelists at the survey institution (PMI). The sample size required to perform confirmatory factor analysis (CFA) was at least 150 participants for verifying the tool’s construct validity [20]; considering the response rate of the survey and accounting for missing responses, the survey was conducted with 250 patients with diabetes. The questionnaire was administered to those who answered that they had diabetes to both questions about current health problems and diseases diagnosed by a doctor, among 15 chronic diseases. For participants who did not select diabetes for either of the two questions, the questionnaire was designed to end automatically. Thereafter, the accepted participants were asked to answer four questions about diabetes-related characteristics, and after answering these, the rest of the questionnaire was compiled. After 250 responses were collected sequentially based on those that were completed first, the survey ended. The final analysis included 231 participants, excluding data from 19 with insufficient responses.

This study was conducted, with data analysis using the abovementioned raw data, after obtaining approval from the Institution Review Board of Joongbu University (IRB No: JIRB-2022050301-01-220509).

2. Measures

The questionnaire used in this study consisted of 10 items on general characteristics, 9 on DAAS-R, 16 on acceptance and action, 26 on quality of life, 16 on the diabetes self-stigma scale, and 24 on the experiential avoidance questions.

1) Diabetes Acceptance and Action

Diabetes acceptance and action is the outcome of the translation-reverse translation process of the DAAS-R developed by Gillanders and Barker [3] with the permission of the original developer, and then translated into the Korean version, followed by facial validation. It was used after the correction was completed. This tool is a measure to estimate the degree of acceptance and adaptation when faced with diabetes-related problems. It consists of nine items evaluated on a 5-point Likert scale that ranges from 1 point for “not at all” to 5 points for “always.” The higher the total score, the higher was the acceptance action. The reliability of the tool at the time of development was, Cronbach's α=.90.

2) Acceptance and action

The Korean version of the Acceptance and Action Questionnaire, which was originally developed by Hayes et al. [12] and adapted to Korean by Moon [16], was used. It measures the degree to which one is willing to accept a thought or emotion, acting in a way that is consistent with one's values and goals. The scale consists of 16 items rated on a 7-point Likert scale ranging from 1= “not at all” to 7= “always.” A higher total score indicated a higher degree of acceptance. Cronbach's α was .82 in Moon [16] and .90 in this study.

3) Quality of life

Based on the World Health Organization Quality of Life assessment instrument-100 (WHOQOL-100), the Korean version of the World Health Organization quality of life simple scale developed by Min et al. [21] was used. This tool consists of 26 questions in four domains: physical health (7 questions), psychological domain (6 questions), social domain (3 questions), living environment domain (8 questions), and overall quality of life (2 questions), which are constituted on a 5-point Likert scale, with higher scores indicating a higher quality of life. Negative questions (Numbers 3, 4, and 26) were reverse-coded. The Cronbach's ɑ was .89 in Min et al. [21], and the reliability of the tool in this study had a Cronbach's α=.93.

4) Diabetes self-stigma

The Diabetes Self-Stigma Scale developed by Seo and Song [22] to measure self-stigma. The tool consists of 16 items in four sub-domains: comparative inability, social withdrawal, self-devaluation, and apprehensive feeling. All items are measured on a 5-point Likert scale (1= “not at all,” 2= “not,” 3= “average,” 4= “yes,” 5= “very much”). The Cronbach's α was .89 in the original study [22] and .95 in this study.

5) Experiential avoidance

For experiential avoidance, the Korean version of the Multidimensional Experiential Avoidance Scale (MEAQ) developed by Gamez et al. [23] was translated into Korean by Lee and You [23], and its validity was tested (K-MEAQ-24). This tool consists of six factors: avoidance behavior, pain aversion, procrastination behavior, distraction/inhibition, repression/denial, and pain tolerance. It is measured on a 6-point Likert scale (1 point: totally disagree, 6 points: completely agree), with a higher score indicating higher experience avoidance. In the study by Lee and Yoo [24], Cronbach’s α=.93, and the reliability of the tool in this study was Cronbach’s α=.88.

3. Procedure

The double translation method suggested by Waltz et al. [25] was used to translate the DAAS-R into Korean. One nursing professor and a professional who holds a PhD in nursing, who were bilingual speakers of Korean and English, translated the DAAS-R into Korean, and revised and supplemented the translated version while comparing the results. Another doctor who had English as his mother tongue and who was also fluent in Korean, translated the Korean version back into English. After the reverse translation, a person with a nursing major fluent in English and Korean performed a comparative analysis and verified whether there were any items with differences in meaning from the original tool. To check the content validity of the translated tool, two nursing professors and three diabetes experts verified the validity of the questionnaire. They also checked whether the contents of the questionnaire were applicable to Korean culture. The content validity index (CVI) evaluates the degree to which the tool is appropriate to measure diabetes acceptance and action on a 4-point Likert scale ranging from 4 (strongly agree) to 1 (strongly disagree).” All items were confirmed to be valid with a CVI of 0.8 or higher [26]. In addition, it was judged that the contents of the questionnaire could be applied to Korean culture.

Before the validity test, the translated questionnaire was administered to 10 patients with diabetes, and the time taken to complete the questionnaire and the responses of the participants were observed. Additionally, the participants were asked to present their opinions when the meaning was unclear or when they did not understand vocabulary or sentences while filling out the questionnaire. The time to respond to the questionnaire ranged from three to five min. The final translation of the tool was completed without any modifications, as there were no complaints about difficulty in responding.

Thereafter, the construct and concurrent validity of the DAAS-K was verified. The DAAS-R was reduced to a nine-item instrument with a single factor by repeatedly performing exploratory factor analysis (EFA) on the 42 items of the DAAS (original version of the instrument) according to strict standards [3]. The DAAS-R was later confirmed to have construct validity as a single scale through CFA [3]. In this study, CFA was performed to test the single attribute identified at the time of tool development [27]. To evaluate the concurrent validity, a Pearson correlation analysis was performed by simultaneously applying the acceptance and action, quality of life, diabetes self-stigma, and experiential avoidance, which previous studies found to be related to diabetes acceptance and action. The reliability of the tool was verified by calculating Cronbach's α, which represents internal consistency.

4. Statistical Analysis

The data were analyzed using SPSS/WIN version 24.0 and Amos version 22.0. The general characteristics of the participants were analyzed using descriptive statistics, and CFA was performed to verify the model suitability structures of the existing items to verify construct validity. Goodness of fit index (GFI), root mean square residual (RMR), and root mean square error of approximation (RMSEA) were used as model fit indices. The comparative fit index (CFI), Tucker–Lewis index (TLI), and incremental fit index (IFI) were identified as incremental fit indices. Concurrent validity was verified using Pearson’s correlation analysis, and reliability was calculated using Cronbach's α.

Results

1. Participants’ Characteristics

The general characteristics of the participants are listed in Table 1. Of the participants, 49.8% (n=115) were male and 50.2% (116) were female. The mean age was 56.06 (±12.12) years, and 69.7% (n=161) had spouses. Those who had a job accounted for 61.9% (n=143), and those who graduated from university accounted for the majority (61.5%, n=142). The number of participants receiving treatment at the clinic was 54.1% (n=125), and 71.4% (n=165) were taking oral drugs only, and 12.1% (n=28) were on insulin therapy. Only 31.6% (n=73) of the participants answered that they had experience in education related to diabetes.

2. Item Analysis

For item analysis, the mean and standard deviation of each item and each factor were measured, and normality was evaluated by checking skewness and kurtosis. As a result, the average score of the questions was 3.13–3.63, the standard deviation was 0.95–1.07, and the average score and standard deviation of the total score were 3.36±0.90. Skewness and kurtosis were evaluated as criteria [28] that normality was satisfied when the value was less than ±1.97 at the 5% significance level. The correlation coefficient value between the revised item-total score to evaluate the correlation between individual items and the total score can be interpreted as showing a low correlation when the value is less than .30 [29], and the result of this study is .63 to .87. Therefore, it met these criteria (Table 2).

3. Confirmatory Factor Analysis

The construct validity of the DAAS-K was verified using CFA. The standardization coefficients of the items corresponding to each factor were all above .50, confirming the validity of the items. Accordingly, the suitability of the DAAS-K, consisting of two factors and nine items, was confirmed. The absolute fit index of χ²=61.06 (p<.001), the degree of freedom (df)=27, and Normed χ² (χ² /df)=2.26. RMR=.08, and RMSEA=.07. Referring to Roh [30], Normed χ² should be less than 3, and RMR and RMSEA should range from .05 to .08 or are less in value. All incremental fit indices above .90 are accepted as a good fit [30]. The results of this study showed that GFI, CFI, TLI, and IFI had a good fit at .90 or higher (Tables 3).

4. Concurrent Validity

The DAAS-K showed a positive correlation with acceptance and action (r=.48, p<.001) and quality of life (r=.43, p<.001), and was negatively correlated with diabetes self-stigma (r=-.73, p<.001) and experiential avoidance (r=-.51, p<.001) (Table 4).

5. Reliability

As a result of the reliability test, the Cronbach's α value of the nine questions of the DAAS-K was .95, indicating a high level of internal consistency (Table 2).

Discussion

In this study, the DAAS-R developed by Gillanders and Barker [3] was translated into Korean to evaluate the diabetes acceptance and action levels of Korean patients with diabetes objectively, and was applied to verify its validity and reliability. For reliability verification, Cronbach's α, which indicates internal consistency, was used. As a result, the reliability of the DAAS-K was .95, similar to the .90 obtained in the study of Gillanders and Barker [3], and was higher than .70, criterion suggested by DeVellis [31], for patients with diabetes. It has been demonstrated that there is stability in measuring diabetes receptive behavior. However, in this study, stability tests, such as assessing test-retest reliability, were not conducted; therefore, it is suggested that a test-retest assessment be conducted in further studies.

For construct validity, CFA was performed. As factor analysis was confirmed with one factor with nine questions, the standardization coefficients for each question were all higher than .50, confirming that all questions were valid for one factor. Since the factor structure of the tool and the model fit for the item was evaluated, the CMIN/df was 2.25, which was less than 3.0, and all fit indices met the criteria, indicating that the fit was excellent. This concurs as all the model fit indices met the criteria in the original tool [3]. Rajaeiramsheh et al. [32] verified the validity and reliability of the Persian versions of the DAAS and the acceptance and action diabetes questionnaire (AADQ). Accordingly, the DAAS-R selected nine items from the DAAS consisting of three sub-areas and verified its validity and reliability, and presented it as a single area for easier measurement. When compared with the AAQ developed by Hayes et al. [12] and the AAQ-S developed by Levin et al. [17], the degree of fusion with diabetes-related thoughts, and avoidance of diabetes-related thoughts or distorted values, amongst others, the DAAS-K has the advantage of being able to measure acceptance and action that reflects the characteristics of diabetes.

To test concurrent validity, a positive correlation was found between acceptance and action and quality of life, and a negative correlation was found between diabetes self-stigma and experiential avoidance. This is similar to the findings of Gillanders and Barker [3], in which higher DAAS was associated with lower diabetes distress and experiential avoidance, and higher standards of self-care and worthwhile lives. When patients with diabetes accept their thoughts and feelings while acting according to their values and goals for diabetes, experience avoidance is lowered because unpleasant feelings about the experience or avoidance of images or thoughts are reduced [32]. This naturally lowers the stigma on oneself because negative emotions related to diabetes are not generated [22], which is consistent with previous studies showing that it leads to an improvement in one’s quality of life [15]. Therefore, it can be said that the concurrent validity of the DAAS-K has been proven. Hence, the DAAS-K is considered a reliable tool to measure diabetes acceptance and action in diabetic patients.

However, this study has some limitations. First, since it was a self-reported measurement, it may have been influenced by subjective bias or a desire for exemplary answers. This can be improved through a later test-retest reliability verification. Second, since this study only included few Type 2 diabetes patients in Korea, it may be biased; therefore, a follow-up study with a larger sample should be conducted in the future. Third, since the patients with type 1 diabetes have a disease pathogenesis that differs from patients with type 2 diabetes, a separate validation is required in applying this tool for type 1. However, this study is meaningful in that it is possible to measure acceptance action objectively by reflecting the characteristics of patients with diabetes by translating DAAS into Korean and verifying its reliability and validity. The clinical application of ACT to improve self-care and quality of life of patients with diabetes using this tool is necessary.

Conclusions

Through this study, the validity and reliability of the 9-item DAAS-K consisting of one factor was verified. Through exploratory factor analysis, it was confirmed that it consisted of one factor, and it was confirmed that there was simultaneous validity due to its high correlation with related concepts. In addition, the reliability of the tool was ensured owing to the high internal consistency of the items. Through this study, it is expected that the DAAS-K can be used to measure the diabetes acceptance action of patients with type 2 diabetes.

Acknowledgments

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