Background and aims:
Insufficient diabetes acceptance has been associated with reduced self-care and glycaemic control. However, satisfactory tools to measure diabetes acceptance are lacking. Therefore, the Denial versus Integration of Diabetes Scale (DIDS) was developed. This report presents its development and preliminary evaluation.

Materials and methods:
56 items were generated and revised based on patient feedback and expert reviews (27 directed towards acceptance/ integration, e. g. ‘I accept diabetes as a part of my life’, 29 towards denial/non-acceptance/avoidance, e. g. ‘I often push diabetes to the back of my mind’). A four-point Likert scale (3 - ‘applies to me very much’ to 0 - ‘does not apply to me’) was used for responses. Negatively keyed items were reverse-scored; hence, higher scores indicate higher acceptance. The items were tested in a pilot study with 222 patients (age 49±16 y.; 49% female; BMI 30±7; 64% type 1 DM; duration 17±11 y.; HbA1c 8.5± 1.7%) to exclude unsatisfactory items and define the scale. A subsequent validation study is recruiting; at the time of this report, 66 patients (age 48 ±13 y.; 46% female; BMI 28±5; 62% type 1 DM; duration 14±10 y.; HbA1c 8.0±1.0%) had been included, providing data on diabetes nonacceptance (AADQ), self-care (DSMQ), treatment satisfaction (DTSQ), diabetes distress (PAID), depression (PHQ-9) and HbA1c (central lab). Analyses comprised item and scale properties, exploratory factor analyses (EFA), correlations and t-Test.

Results:
Item selection: Initially, 5 items were excluded for psychometric problems. Through EFA, 8 items were excluded for loadings on noninterpretable factors, finally yielding an interpretable four-factor structure. Based on this, 11 items were excluded for poor statistical or semantic fit and 4 for redundancy, leading to the final 28-item scale. Scales/reliability: EFA of the selected items yielded four factors (71% explained variance), interpreted as ‘acceptance/integration’ (7 items, Cronbach’s α=0.93), ‘treatment motivation’ (7 items, α=0.93), ‘denial/defence’ (7 items, α= 0.91) and ‘emotional suffering’ (7 items, α=0.92). The derived subscales were highly correlated, providing summing to a reliable total score (α= 0.97). Reliability was again tested on the validation sample, yielding the following α coefficients (scales in above order): 0.91, 0.91, 0.90, 0.87 and 0.96. Validity: A correlation of -0.76 (P<0.01) was found with the AADQ, a measure of diabetes non-acceptance. The correlation with HbA1c was -0.45 (P<0.01). Patients with higher DIDS scores (suggesting higher acceptance; n=34) compared to those with lower ones (n=32; median split) reported better self-care, particularly regarding diet (6.4± 1.9 vs. 4.0±2.0, P<0.01), glycaemic self-management (8.7±1.9 vs. 7.1± 2.3, P<0.01) and physician visiting (9.2±1.3 vs. 7.9±3.3, P<0.01), and showed better glycaemic control (HbA1c: 7.6±1.1 vs. 8.3±1.1%, P<0.05). They also reported higher treatment satisfaction (30±4 vs. 24 ±6), less diabetes distress (21±15 vs. 37±16) and less depressive symptoms (6±4 vs. 9±6); all P<0.01.

Conclusion: The DIDS appears reliable and valid in assessing problems related to illness acceptance in both major types of diabetes. It may help explain inadequate self-care and suboptimal glycaemic control. Further data to expand these initial findings are being collected.