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)



We aimed to (a) culturally and linguistically adapt the Type 1 Diabetes Stigma Assessment Scale (DSAS-1) from English (for Australia) into Danish and (b) examine psychometric properties of the measure among Danish adults with type 1 diabetes.


We performed a forward–backward translation, face validity interviews with experts and cognitive debriefing of the Danish version (DSAS-1 DK) with ten adults from the target group. The DSAS-1 DK was then completed by 1594 adults with type 1 diabetes. Electronic clinical records provided age, diabetes duration, diabetes-related complications, and glycemic control [glycated hemoglobin (HbA1c)]. We examined internal consistency, construct validity and structural validity of the DSAS-1 DK using exploratory and confirmatory factor analysis in a cross-validation design.


The translated measure was found acceptable by the experts and target group, with only minor adaptations required for the Danish context. The DSAS-1 DK structure was best represented by a three-factor model representing the subscales ‘Treated Differently,’ ‘Blame and Judgement,’ and ‘Identity Concern’ (α = 0.88–0.89). The results also provided some support for calculation of a total score (19-item scale; α = 0.75). The subscales and total scale demonstrated satisfactory convergent and discriminant validity. Good structural validity was demonstrated for the three-factor model for four out of five indices [normed χ 2 = 4.257, goodness-of-fit index (GFI) = 0.923, root mean square error of approximation (RMSEA) = 0.065, standardized root mean square residual (SRMSR) = 0.0567, comparative fit index (CFI) = 0.93].


The DSAS-1 DK has a confirmed three-factor structure, consistent with the original Australian English version. The measure is now validated and available to advance research into the stigma perceived and experienced by adults with type 1 diabetes in a Danish context.

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We thank all the study participants for volunteering their time and insights. We acknowledge Dr. Kylie Mosely, who contributed to the development of the original DSAS-1 (English version, for Australia) and to the concept elaboration document enabling linguistic adaptation. We acknowledge Dr. Birgit Gemal (a native Danish-speaking psychologist fluent in English), who provided independent advice to the DSAS-1 developers during the translation process. We acknowledge Dr. Sonia Zafar who undertook the backward translation of the DSAS-1 DK. The DSAS-1 DK as well as the original DSAS-1 are available free of charge to academic researchers, clinicians and students for use in non-commercially funded research. Potential users are advised to email to enquire about or access the latest version of the questionnaire (including instructions for administering the measure) and scoring guidance.


This work was supported by an unrestricted grant from Innovation Fund Denmark (Grant no. 4135-00019B). JS and JLB are supported by core funding provided to the Australian Centre for Behavioural Research in Diabetes from Diabetes Victoria and Deakin University.

Author information




The cultural and linguistic validation protocol was prepared by UMH with feedback from all authors. UMH, KO and IW translated the DSAS-1 from English to Danish and designed the survey, which included the DSAS-1 DK. JLB, ADV and JS developed the original DSAS-1 in English (for Australia), provided a concept elaboration document to inform the translation, and provided feedback on the translation reconciliations prior to finalizing the new language version. UMH conducted data analyses, which were reviewed by ADV, KO and JLB. UMH prepared the first draft of the manuscript, and all authors provided feedback and revisions on the first and subsequent drafts. All authors approved the final submitted manuscript. JLB, as senior author, takes overall responsibility for the content of the article.

Corresponding author

Correspondence to Ulla Møller Hansen.

Ethics declarations

Ethical approval

The study was registered with the Danish Data Protection Agency ( SDC-2015-033 DiA/I-Suite nr. 03813). According to the Committees on Health Research Ethics in the Capital Region of Denmark, the study does not require ethical approval, as it does not implicate the use of human biological materials ( forespørgsel H-15015747/2015).

Informed consent

In the invitation to take part in the survey, participants were informed about the purpose of the study and informed that by proceeding to the survey and completing it they provided consent. They were also informed that no personally identifiable data would be disclosed.

Conflict of interest

ADV, JS and JLB are employed at the Australian Centre for Behavioural Research in Diabetes, which owns the copyright of the DSAS-1 in all its language versions. UMH, IW, and KO have no conflict of interest to declare.

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Hansen, U.M., Willaing, I., Ventura, A.D. et al. 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, 403–412 (2018).

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