The Cultural Lens: Who Was the DDS-17 Designed For?

One Size Doesn’t Fit All: Cultural Variability in Emotional Expression

Living with diabetes isn’t just about managing blood sugar—it’s also about managing the emotional weight that comes with it. This emotional strain, known as diabetes distress (DD), is the often-overlooked psychological side of diabetes. It’s the stress, frustration, and burnout that can build up from the daily demands of managing a chronic condition.

To better understand and measure this emotional burden, researchers developed the Diabetes Distress Scale (DDS-17) back in 2005. It’s a 17-question tool that looks at four key areas of distress:

• Emotional Burden: Feeling overwhelmed by diabetes

• Regimen-Related Distress: Struggles with sticking to treatment plans

• Physician-Related Distress: Frustrations with healthcare providers

• Interpersonal Distress: Feeling unsupported by family or friends

While the DDS-17 has become a widely used tool in diabetes care, it’s important to note that it was originally validated in a U.S. population that may not reflect the cultural and emotional experiences of people living with diabetes in other parts of the world. This raises an important question: Is the DDS-17 truly universal, or do we need culturally adapted tools to better capture diabetes distress in diverse communities?

Bangladesh: Linguistic Adaptation with Strong Psychometric Backbone

In Bangladesh, researchers translated and validated the DDS-17 into Bengali (BDDS-17) to address the lack of culturally relevant tools. Administered to over 1,100 patients, the BDDS-17 showed:

• High internal consistency (Cronbach’s α = 0.838)

• Strong test-retest reliability (ICC = 0.941)

• Clear factor structure matching the original DDS domains

However, one item—“Feeling that I don’t have a doctor I can see regularly”—cross-loaded between domains, hinting at cultural nuances in physician-patient relationships. In Bangladesh, overcrowded clinics and limited consultation time may foster distrust, affecting how patients interpret distress.

Takeaway: DDS works well with linguistic adaptation, but cultural context can shift item interpretation.

Philippines: Cultural and Linguistic Validation in a Multilingual Setting

In the Philippines, researchers translated and validated the DDS-17 into Filipino to better assess diabetes distress among local patients. Conducted at a tertiary government hospital in Quezon City, the study involved 170 adult patients with Type 1 and Type 2 diabetes. The Filipino DDS demonstrated:

• Strong internal consistency across all domains (Cronbach’s α = 0.81–0.85)

• Factor analysis confirmed the original four-domain structure (EB, RD, PD, ID)

• Physician-related distress was significantly higher among patients with Type 1 diabetes

Although no statistically significant correlation was found between DDS scores and HbA1c levels, weak positive associations were observed in emotional burden, regimen distress, and physician distress among patients with Type 2 diabetes.

Takeaway: The Filipino DDS is a reliable and culturally appropriate tool for assessing diabetes distress, especially in a linguistically diverse population where English proficiency may vary.

India: Hindi Translation Validated for Primary Care Use

In India, researchers translated and validated the DDS-17 into Hindi (DDS-17 H) to make diabetes distress screening accessible to Hindi-speaking populations. The study involved 200 adult patients with Type 2 diabetes from a tertiary care hospital’s field practice area. The DDS-17 H demonstrated:

• Exceptional internal reliability (Cronbach’s α = 0.958)

• High content validity (Content Validity Index = 0.99; Content Validity Ratio = 1)

• Factor analysis supported the original four-domain structure

• Strong convergent validity with the Depression Anxiety Stress Scale (DASS-21), correlation coefficient = 0.78, p < 0.000

The tool identified 18.5% of participants with moderate diabetes distress and 16.5% with high distress.

Takeaway: DDS-17 H is a robust and culturally relevant tool for early detection of diabetes distress in Hindi-speaking patients, especially in primary care and community health settings.

Taiwan: Building a New Scale from the Ground Up

Taiwanese researchers went a step further. Finding that existing Chinese translations of DDS were linguistically awkward and culturally misaligned, they developed the Taiwan Diabetes Distress Scale (TDDS). Key innovations included:

• Emphasis on “face” and social perception—critical in Chinese culture

• Domains like “Life and interpersonal stress” and “Communication concerns”

• A visual 0–10 scale for emotional intensity

The TDDS showed strong reliability (Cronbach’s α = 0.863–0.924) and significant correlation with both HbA1c and mental health scores.

Takeaway: Cultural values like social harmony and emotional restraint necessitate entirely new tools for accurate distress assessment.

So, Is DDS Universally Applicable?

Yes—and no.

• The DDS-17 is psychometrically sound and adaptable across cultures.

•  But without linguistic and cultural tailoring, its sensitivity and relevance can falter.

• Local adaptations like BDDS-17, revised DDS2, and TDDS demonstrate that emotional distress is shaped by cultural norms, healthcare systems, and social expectations.

Final Thoughts

As diabetes continues to rise globally, so does the need for culturally intelligent care. Emotional distress isn’t one-size-fits-all, and neither should be the tools we use to measure it. The DDS is a powerful starting point—but the journey to universal applicability requires listening to local voices, respecting cultural nuances, and embracing adaptation.