Addictive Behaviors 31 (2006) 309–319

Psychometric characteristics of a Spanish version

of the DAST-10 and the RAGS

Luis E. Bedregal a,T,1, Linda Carter Sobell b, Mark B. Sobell b, Edward Simco b

aYale University School of Medicine, Hispanic Clinic, One Long Wharf Drive, New Haven, CT 06511, United StatesbNova Southeastern University, United States

Abstract

Although Hispanics/Latinos constitute the largest ethnic minority group in the United States, there are few

culturally and linguistically valid Spanish language clinical assessment instruments. This shortage is even more

critical in the addictions field. This article presents the psychometric characteristics of two drug abuse screening

instruments; the Drug Abuse Screening Test (DAST-10), and the Reduce Annoyed Guilty Start (RAGS) test that

were translated into Spanish. Participants included 60 drug abusers, 35 alcohol abusers, and 127 individuals with

no alcohol and/or drug problem. Results indicated that the Spanish versions of the two drug abuse screening

instruments were reliable and unidimensional and differentiated drug abusers from non-substance abusers and from

alcohol abusers.

D 2005 Elsevier Ltd. All rights reserved.

Keywords: Cross-cultural research; Hispanics; Drug abuse; Psychometric properties

The ethnic landscape in the United States (U.S.) will experience dramatic changes in the next few

decades. The Hispanic population currently represents 13.4% of this country’s population increasing

from 22.4 million people in 1990 to 38.8 million people in 2002 (U.S. Bureau of the Census, 2002a).

Hispanics are currently the largest minority group in the U.S. and these numbers are expected to increase

in the future. Hispanics, as a group, comprise individuals from different races and heritages. What

0306-4603/$ -

doi:10.1016/j.a

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E-mail add1 Copies of t

www.nova.edu

see front matter D 2005 Elsevier Ltd. All rights reserved.

ddbeh.2005.05.012

ing author.

ress: luis.bedregal@yale.edu (L.E. Bedregal).

he Spanish versions of the DAST-10 and RAGS are available from the author and are available to download at

/gsc/.

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319310

Hispanics have in common is their geographic location of origin (i.e., North America, Central America,

South America, Caribbean), their shared history of conquest by Spain, and their Spanish language. In the

U.S. (U.S. Bureau of the Census, 2002b), the Hispanic population is primarily comprised of Mexican–

Americans, who represents the largest group (66.9%), followed by Hispanics from Central and South

America (14.3%), Puerto Ricans (8.6%), Cubans (3.7%), and other Hispanics (6.5%).

The problems of evaluating minorities using assessment instruments developed for and normed with

English speakers have received considerable attention (Brislin, 1990; Brislin, Loner, & Thorndike, 1973;

Cuellar & Paniagua, 2000; Geinsinger, 1992; Rogler, Malgady, & Rodriguez, 1989). For example, when

Demsky, Mittenberg, Quintar, Katell, and Golden (1998) compared the results of a Spanish translation of

the Wechsler Memory Scale–Revised to American norms, a bias close to one standard deviation below

the U.S. norms occurred for both the verbal and nonverbal tests. Although some questionnaires and

scales have been translated into Spanish, a common practice is to interpret the results according to U.S.

norms derived largely from Caucasian samples (Sobell et al., 2001). Such an approach is inappropriate

as it presumes no differences in language translations across cultures. Clinicians, therefore, should only

use assessment instruments that are culturally valid (American Psychological Association, 1993, 2002;

Sleek, 1999).

Substance abuse is a serious problem among minorities (Castro, 1994; Castro et al., 1992; Castro,

Sharp, Barrington, Walton, & Rawson, 1991; Castro & Tafoya-Barraza, 1997; Maddox & Desmond,

1992; Moore, 1990). In this regard, while psychometrically sound and culturally relevant substance use

assessment instruments in Spanish are scarce (Allen & Wilson, 2003; Sobell, Toneatto, & Sobell, 1994),

there are two exceptions, and both only assess alcohol use. The first, the Alcohol Use Disorder and

Associated Disabilities Interview Schedule (AUDADIS), was developed by Grant & Hasin (1992) and

later translated into Spanish and validated (Canino et al., 1999). The second, the Alcohol Use Disorders

Identification Test (AUDIT; Reinert & Allen, 2002; Saunders, Aasland, Babor, De La Fuente, & Grant,

1993; Volk, Steinbauer, Cantor, & Holzer, 1997), was validated in Mexico as part of a multinational

World Health Organization (WHO) effort (De la Fuente & Kershenobich, 1992). To achieve cultural

equivalence, the AUDADIS and AUDIT were translated following a rigorous procedure (e.g., semantic,

content, technical, criterion, and conceptual correspondence). The AUDIT is useful for identifying

people whose drinking problems are mild to moderate to severe (Conigrave, Saunders, & Reznik, 1995;

Reinert & Allen, 2002), and it is available in several languages besides Spanish. The WHO’s Spanish

language version of the AUDIT (De la Fuente & Kershenobich, 1992) was used in the present study.

While both the AUDADIS and the AUDIT have been normed with Spanish-speaking populations,

both instruments are alcohol-specific with no drug use items. One of the most frequently used drug

assessment instruments is the Drug Abuse Screening Test (DAST; Skinner, 1982). The DAST modeled

after the Michigan Alcohol Screening Test (MAST) created by Selzer (1971) classifies individuals on a

continuum from low to high drug problem severity, and has good internal consistency and can

differentiate drug abusers from alcohol abusers. Factor analysis demonstrated that the DAST was a

unidimensional scale. Skinner (1982) also developed a 20- and 10-item version of the DAST, both of

which had high internal consistency, correlated highly with the original 28-item DAST, and discriminated

drug abusers from alcohol abusers (Gavin, Ross, & Skinner, 1989; Skinner & Goldberg, 1986).

The CAGE (Cut-down Annoyed Guilty Eye-opener), a 4-item alcohol abuse screening measure, is a

well-known assessment instrument that has been used in the alcohol field for two decades (Ewing,

1984). The CAGE was Adapted to Include Drugs (CAGE-AID; Brown & Rounds, 1995). Although the

CAGE-AID was intended to assess alcohol and drug use, as can be seen, the questions are not worded to

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319 311

be specific for drug use (italics indicate modifications from the original CAGE questionnaire): (a) Have

you felt you ought to cut down on your drinking or drug use? (b) Have people annoyed you by

criticizing your drinking or drug use? (c) Have you felt bad or guilty about your drinking or drug use?

and (d) Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get

rid of a hangover (eye-opener).

The Reduce Annoyed Guilty Start (RAGS) test was developed by Sobell and Sobell (Levin et al.,

1999) as a drug specific counterpart to the CAGE. The RAGS, like the CAGE and CAGE-AID, contains

four questions, is self-administered, but specifically asks about lifetime drug use: (a) Have you ever felt

you should Reduce or stop your drug use? (b) Have people ever Annoyed you by criticizing your use of

drugs? (c) Have you ever felt Guilty about using drugs? and (d) Have you ever needed drugs to Start

your daily activities. The psychometric validation of the RAGS occurred with three groups of English-

speaking participants: (a) drug abusers (n=218), (b) alcohol abusers (n=109), and (c) college students

with no alcohol and/or drug problem (n=71). In that study, the RAGS was found to have good internal

consistency (coefficient alpha=0.78) and excellent test–retest reliability (r=0.64). In addition, a

discriminant function analysis demonstrated that the RAGS was highly sensitive and specific to drug

abusers compared to college students with no alcohol and/or drug problem and alcohol abusers. The

present study was designed to evaluate the reliability and validity of Spanish translations of the DAST-

10 and the RAGS with Spanish-speaking Hispanics.

1. Method

1.1. Participants

All participants were recruited from South Florida. The inclusion criteria were (a) z18 years of age;

(b) signed an inform consent; (c) fluent Spanish-speaking Hispanic; and (d) completed all items on the

RAGS and DAST-10. Participants were assigned to one of three groups: (a) Non-Substance Abusers

(NSA, n=127), who reported no prior alcohol and/or drug problem and who were recruited from places

with high concentration of Hispanics (i.e., Hispanic churches, markets, and festivals); (b) Alcohol

Abusers (AA, n=35), who reported a primary alcohol problem and who were recruited from substance

abuse treatment programs; and (c) Drug Abusers (DA, n=60), who reported a drug problem and who

were recruited from substance abuse treatment programs. None of the participants received monetary

compensation. The study was approved by the Institutional Review Board of Nova Southeastern

University (FL).

1.2. Measures and translation

When translating materials into another language, it is imperative to conduct translations and

retrotranslations. The backtranslation technique use to translate questionnaires from their original

language versions has been demonstrated to be a valid research methodology for attaining linguistic

accuracy (i.e., semantic equivalence) of the new language version (Brislin et al., 1973; Cuellar &

Paniagua, 2000; Garcia & Zea, 1997; Hendricson et al., 1989). Even when a careful process of

translation and retrotranslation is conducted, it can be challenging to capture the exact meaning of some

words due to subtle differences between different Spanish-speaking countries (Sobell et al., 2001).

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319312

As in other cross-cultural studies (Babor et al., 1994; Room, Janca, Bennett, Schmidt, & Sartorious,

1996), the English language versions of the DAST-10 and the RAGS underwent a process of translation

into Spanish and retrotranslation (i.e., backtranslation) into English. First, a bilingual, primary Spanish

speaker translated the original English instruments into Spanish. Then the measures were backtranslated

into English by another bilingual person, equally proficient in Spanish and English. After this, a primary

English speaker compared the retrotranslated English versions with the original English versions. The

two English versions of each instrument were judged to be identical. Consequently, the Spanish versions

were estimated to have attained equivalence to their original English counterparts. Appendices A and B

depict the Spanish language DAST-10 and RAGS tests.

1.3. Language version equivalence evaluation

The original English and the translated Spanish versions of the DAST-10 and RAGS were pilot tested

with seven bilingual participants. The English and Spanish versions of these two instruments were

administered back to back; the order of the two language versions was randomly determined (four

participants received the English version first and three received the Spanish version first). All seven

participants gave identical answers to the two different language versions of the RAGS and the DAST-

10. These findings suggest that the two language versions of each instrument parallel each other.

1.4. Procedure

At the first interview, all participants completed Spanish versions of a demographic and substance

abuse history questionnaire, the AUDIT, the DAST-10, and the RAGS. To control for order effects, the

DAST-10 and the RAGS were administered in a counterbalanced order. Seventy-eight participants from

the three groups were available for a second interview that was scheduled 2 to 3 weeks after the first

interview. At the second interview, the DAST-10 and RAGS were readministered. The mean (SD) test–

retest interval for the 78 participants was 14.8 (2.2) days.

2. Results

The psychometric properties of the Spanish versions of the DAST-10 and the RAGS were analyzed in

the following ways: (a) internal consistency reliability was assessed using Cronbach’s alpha and test–

retest correlation; (b) internal structure was examined using principal component analysis (PCA); (c)

convergent validity was evaluated by correlating the two measures; (d) predictive validity and cut-off

scores were estimated with Receiver Operating Characteristic (ROC) curves; (e) discriminant validity

was evaluated using one-way analyses-of-variance (ANOVA); and (f) criterion reliability was

established by inspecting participants’ group membership and their mean scores on the RAGS and

DAST-10. To control for type I error, the alpha level was set at 0.01.

Country of origin of Spanish-speaking participants was 20.3% Cubans, 16.2% Peruvians, 14.4%

Colombians, 12.2% U.S.-born Latinos, 7.7% Hondurans, 5.9% Puerto Ricans, and 5% Nicaraguans.

Participants’ mean (SD) age was 39.6 (12.8) years. In addition, 46.2% reported being married and 72.3%

had completed high school. The mean (SD) number of years participants reported living in the U.S. was

15.8 (11.3). Two-thirds (66.2%) were male and 12.8% were unemployed. The mean (SD) number of

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319 313

years of education in the U.S. was 4.1 (6.2). Participants reported starting using alcohol and drugs at a

mean age of 17.0 (4.8) and 19.8 (8.7) years, respectively. The primary drug of abuse for the drug abusers

was cocaine (67%), followed by marijuana (20%), heroin (10%), and ecstasy (3%).

In comparing the three groups on the abovementioned variables, a modified Bonferroni adjustment

procedure was used to control for inflation of the level of significance (Stevens, 1990, p. 63). Instead of

using the conventional level of significance of 0.05, a conservative alpha level of 0.01 was adopted. Four

sets of pairwise v2 comparisons were performed between group membership (Non-Substance Abusers,

Drug Abusers, and Alcohol Abusers) on dichotomous variables (e.g., high school education, marriage

status, gender, employment), and one-way analysis-of-variance (ANOVA) was conducted on interval

variables (e.g., age, length of time living in the U.S.). Each post-hoc pairwise comparison between

groups on variables assessed was subjected to a 0.01 level of significance in order to control for inflation

of overall error rate. Significantly more Non-Substance Abusers (NSA) reported having completed high

school (82.7%) compared to both, Drug Abusers (DA, 64.4%), v2 (1, n=186)=7.6, pb0.01, and

Alcohol Abusers (AA, 47.1%), v2 (1, n=161)=18.2, pb0.01. A significantly higher percentage of NSA

were married (60.6%) compared to the DA (28.3%), v2 (1, n=187)=17.0, pb0.01, and the AA (23.5%),

v2 (1, n=161)=14.8, pb0.01, and significantly more NSA participants (48.8%) were female compared

to DA participants (15%), v2 (1, n=187)=19.8, pb0.01, and the AA (11.4%), v2 (1, n=162)=15.9,

pb0.01. Unemployment rates were significantly higher in the DA group (27.6%) than in the NSA group

(5.5%),v2 (1, n=185)=17.8, pb0.01. Similar to other studies with Spanish-speaking drug abusers

(Castro et al., 1992; Castro & Tafoya-Barraza, 1997), the majority of Hispanic drug abusers in the

present study were male and unemployed. There were no statistically significant (pN0.01) differences

among groups on variables age and length of time living in the U.S.

2.1. Psychometric characteristics of the RAGS and DAST-10

A Pearson product–moment correlation between the RAGS and DAST-10 scores was very high

(r=0.87, pb0.01). Test–retest reliabilities for both the RAGS and DAST-10 scores (n=78) were also

very high (r=0.89 and0.90, pb0.01, respectively). Internal consistency reliabilities for the DAST-10

and RAGS (N=222) as examined by Cronbach’s alpha were excellent (coefficient alpha=0.94 and 0.90,

Table 1

Item—Component Loadings for the DAST-10T

Measure and variables Component loading

DAST-10

Variable 1 0.76

Variable 2 0.82

Variable 3 0.54

Variable 4 0.80

Variable 5 0.89

Variable 6 0.85

Variable 7 0.89

Variable 8 0.88

Variable 9 0.81

Variable 10 0.75

T N =222.

Table 2

Item—Component loadings for the RAGST

Measure and variables Component loading

RAGS

Variable 1 0.87

Variable 2 0.87

Variable 3 0.93

Variable 4 0.83

T N =222.

Table 3

DAST-10 cut-off point analysisT

Cut-off point SE SP PPP NPP HR Kappa

1 0.97 0.74 0.57 0.98 0.80 0.58

2 0.97 0.90 0.78 0.99 0.92 0.81

3 0.93 0.94 0.85 0.97 0.94 0.85

4 0.90 0.97 0.90 0.96 0.95 0.86

5 0.83 0.96 0.89 0.94 0.93 0.81

6 0.75 0.96 0.88 0.91 0.91 0.75

7 0.58 0.98 0.90 0.86 0.87 0.63

8 0.48 0.98 0.91 0.84 0.85 0.55

9 0.32 0.99 0.95 0.80 0.81 0.39

SE—sensitivity; SP—specificity; PPP—positive predictive power; NPP—negative predictive power; HR—hit rate; Kappa—

Cohen’s Kappa.

ROC Curve

Diagonal segments are produced by ties.

1 – Specificity

1.000.750.500.250.00

Sen

sitiv

ity

0.00

0.25

0.75

1.00

0.50

T N =222.

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319314

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319 315

respectively). These results support the reliability of the Spanish language versions of these two

instruments. Moreover, the internal consistency reliabilities of the DAST-10 and RAGS Spanish versions

were higher than those reported for their English counterparts (DAST-10 coefficient alpha=0.92,

Skinner, 1982; RAGS coefficient alpha=0.78, Levin et al., 1999).

To explore the internal structures of the Spanish test versions of the DAST-10 and RAGS, principal

component analyses (PCA) were performed. Criteria for retaining extracted components on the PCA

were (a) Eigenvalues of at least one, (b) percentage of variance accounted for by components retained,

and (c) Scree plot (Cattell, 1966). Tables 1 and 2 show component loadings for all items for the Spanish

versions of the DAST-10 and the RAGS. Data from the 222 participants who completed the DAST-10

and RAGS were included in the component analyses. The component loadings obtained on the DAST-10

and RAGS were in the dgoodT to dexcellentT range (Tabachnick & Fidell, 1996). A visual inspection of

the Scree plot on the DAST-10 and the RAGS clearly showed only one component before components

started to level off. Furthermore, only one component for the DAST-10 and one for the RAGS attained

Table 4

RAGS cut-off point analysisT

Cut-off point SE SP PPP NPP HR Kappa

1 0.97 0.88 0.75 0.99 0.91 0.78

2 0.97 0.96 0.89 0.99 0.96 0.90

3 0.82 0.98 0.94 0.94 0.94 0.83

SE—sensitivity; SP—specificity; PPP—positive predictive power; NPP—negative predictive power; HR—hit rate; Kappa—

Cohen’s Kappa.

ROC Curve

Diagonal segments are produced by ties.

1 – Specificity

1.000.750.500.250.00

Sen

sitiv

ity

0.00

0.25

0.75

1.00

0.50

T N =222.

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319316

the criterion of an Eigenvalue equal or greater than one for retaining components (6.48 and 3.05,

respectively). The variance accounted for by the single component was 64.83% for the DAST-10 and

76.12% for the RAGS. These results demonstrated that the instruments assessed a unidimensional

construct paralleling the internal structure found in their English counterparts.

Cut-off scores on the DAST-10 and RAGS for the drug abusers were examined using Receiver

Operating Characteristic (ROC) curves. The area under the curve (AUC) showed that for the RAGS, a

score of two or more and for the DAST-10, a score of four or more were the most critical values for

identifying a participant as a drug abuser (Tables 3 and 4 show results of ROC curves for the DAST-

10 and the RAGS).

To evaluate discriminant validity, one-way ANOVA was conducted using the total mean scores on

the DAST-10 and RAGS as the dependent variable and the participants’ substance use group (e.g.,

NSA, DA, and AA) as the independent variable. Assumptions of homogeneity of variance and normal

distribution of scores were tenable. The ANOVA for the DAST-10 was statistically significant,

F(2119)=311.66, pb0.01. Post-hoc analysis using Tukey’s procedure revealed that the mean (SD)

DAST-10 score for the DA group, 6.9 (2.5) was higher than scores in both, the NSA group, 0.2 (0.4),

pb0.01, and the AA group, 2.0 (2.7), pb0.01. Finally, DAST-10 mean score was significantly higher

in the AA group as compared to the NSA group (pb0.01).

The one-way ANOVA on the RAGS mean scores was significant, F(2219)=425.23, pb0.01. Post-

hoc comparisons using Tukey’s tests demonstrated that the RAGS mean score (SD) was significantly

higher for the DA group, 3.2 (0.9) as compared to the mean score for the NSA group, 0.1 (0.3),

pb0.01, and the mean score for the AA group, 0.5 (1.0), pb0.01. Lastly, RAGS mean score was

significantly higher for the AA group as compared to the NSA group, pb0.01.

3. Discussion

This study evaluated the psychometric properties of two drug use assessment instruments

translated into Spanish and administered to Spanish-speaking alcohol abusers, drug abusers, and

individuals without substance use problems. The Spanish versions of the DAST-10 and the RAGS,

like their English counterparts, were found to be psychometrically sound drug use screening

instruments. In addition, the high correlations between the DAST-10 and the RAGS suggested good

convergent validity. Both the DAST-10 and RAGS also showed good discriminant validity as

evidenced by their ability to significantly differentiate drug abusers from alcohol abusers and from

those with no substance abuse problems. Principal component analyses for the DAST-10 and the

RAGS yielded unidimensional components suggesting that the Spanish versions, like the English

versions, measure a single construct. A future replication of this study using Confirmatory Factor

Analyses will provide further evidence of the underlying structure of these two drug use screening

instruments.

Cut-off scores on the DAST-10 and RAGS for Hispanic/Latino drug abusers were explored using

ROC curves, and it was found that a score of two on the RAGS and a four on the DAST-10 identified

participants as drug abusers. The cut-off score of two for identifying drug abusers on the RAGS

Spanish version was similar to the cut-off score on the original English version of the RAGS (Levin et

al., 1999). Although Skinner (1982) did not specify a cut-off score on the English version DAST-10, a

cut-off score of four on the Spanish version was most likely to correctly classified drug abusers.

L.E. Bedregal et al. / Addictive Behaviors 31 (2006) 309–319 317

The present study had two major limitations. First, because of the high percentage of Peruvians and

Cubans, the sample did not parallel the composition of Hispanics in the U.S. (U.S. Bureau of the Census,

2002b). Second, independent validation of participants’ self-reports was not obtained, although

considerable research has shown that substance abusers’ self-reports are as accurate as other data sources

(Babor, Brown, & Del Boca, 1990; Gladsjo, Tucker, Hawkins, & Vuchinich, 1992; Maisto & Connors,

1992; Sobell et al., 1994). In summary, the Spanish versions of the DAST-10 and the RAGS, like their

English language counterparts, were found to be psychometrically sound drug abuse screening

instruments. This study is a first attempt at empirically validating and, therefore, making available in

Spanish two drug use screening instruments. Future research with additional Hispanic groups is

necessary to extend generalization of these two instruments to other Hispanic populations.

Appendix A. Spanish language DAST-10

Estas Preguntas Estan Referidas a los Ultimos Doce Meses:

1. SHa usado drogas que no eran requeridas por razones medicas?

2. SUd. abusa mas de una droga a la vez?

3. SEs Ud. capaz de parar de usar drogas siempre cuando se lo propone?

4. SHa tenido bperdidas de conocimientoQ o una bmemoria repentinaQ como resultado del uso de

drogas?

5. SAlguna vez se siente mal o culpable debido a su uso de drogas?

6. SAlguna vez su pareja (o familiares) se han quejado de su uso de drogas?

7. SHa desatendido a su familia debido a su uso de drogas?

8. SSe ha implicado en actividades ilegales con el fin de obtener drogas?

9. SAlguna vez ha experimentado sıntomas de abstinencia (sentirse enfermo) cuando dejo de usar

drogas?

10. SHa tenido problemas medicos como resultado de su uso de drogas (perdida de la memoria,

hepatitis, convulsiones, hemorragia, etc.)?

Appendix B. Spanish language RAGS

1. SAlguna vez ha sentido que deberıa disminuir o reducir su uso de drogas?

2. SSe ha sentido alguna vez molesto por las crıticas de la gente acerca de su uso de drogas? (Note que

las crıticas son acerca de su uso de las drogas y no acerca de no usarlas)

3. SAlguna vez se ha sentido culpable debido al uso de drogas?

4. SAlguna vez ha necesitado drogas para empezar sus actividades diarias?

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