Fear of hypoglycaemia among insulin-treated Hong Kong Chinese patients: implications for diabetes patient education

Identifying the deficiencies of currently available CGM to improve uptake and benefit

BACKGROUND AND AIMS

The use of diabetes technologies is increasing worldwide, with health systems facilitating improved access to devices. Continuous glucose monitoring is a complex intervention that provides information on glucose concentration, rate and direction of change, historical data and alerts and alarms for extremes of glucose. These data do not themselves change glycaemia and require translation to a meaningful action for impact. It is, therefore, crucial that such systems advance to better meet the needs of individuals using them.

METHODS

Narrative review of the use of, engagement with, limitations and unmet needs of continuous glucose monitoring systems.

RESULTS

CGM devices have made a significant contribution to the self-management of diabetes; however, challenges with access and user experience persist, with multiple limitations to uptake and benefit. These limitations include physical size and implementation, with associated stigma, alarm fatigue, sleep disturbance and the challenge of addressing large volumes of real-time data. Greater personalisation throughout the continuous glucose monitoring journey, with a focus on usability, may improve the benefits derived from the device and reduce the burden of self-management. Healthcare professionals may have unconscious biases that affect the provision of continuous glucose monitors due to deprivation, education, age, ethnicity and other characteristics.

CONCLUSIONS

Continuous glucose monitoring exerts a dose-dependent response; the more it is used, the more effective it is. For optimal use, continuous glucose monitors must not just reduce the burden of management in one dimension but facilitate net improvement in all domains of self-management for all users.

Hypoglycaemia fear, treatment adherence, and the quality of life in patients with type 2 diabetes and its determinants

AIM

This work aims to evaluate the relationship between the fear of hypoglycaemia, treatment adherence, and the quality of life in patients with type 2 diabetes mellitus (T2DM) and its determinants.

METHODS

This descriptive and cross-sectional study sample recruited 1060 T2DM outpatients in a health centre between January and July 2022. The Hypoglycemia Fear Survey (HFS), Type 2 DM Treatment Patient Compliance Scale, and the 5-Level EuroQol 5-Dimension (EQ-5D-5L) were used for data collection.

RESULTS

There was a positive correlation between age, duration of T2DM, and the scores obtained from the HFS and its subscales (p < 0.001). There was a positive, moderate correlation between the total HFS score and the TCS (p < 0.001). There was a negative correlation between the scores obtained from the HFS and the EQ-5D-5L (p < 0.001). The multiple regression analysis showed that the quality of life scores of the patients were significantly predicted by hypoglycaemia fear, duration of T2DM diagnosis, and age. (F = 91.691, p < 0.001). Hypoglycaemia fear, duration of T2DM diagnosis, and age explained 38.1% of the quality of life of patients.

CONCLUSION

We determined that the increase in hypoglycaemia fear resulted in a decrease in treatment adherence. Besides, hypoglycaemia fear increased with increasing age and duration of T2DM diagnosis.

Cost-Effectiveness of a Real-Time Continuous Glucose Monitoring System Versus Self-Monitoring of Blood Glucose in People with Type 2 Diabetes on Insulin Therapy in the UK

INTRODUCTION

Real-time continuous glucose monitoring (rt-CGM) involves the measurement and display of glucose concentrations, potentially improving glucose control among insulin-treated patients with type 2 diabetes (T2D). The present analysis aimed to conduct a cost-effectiveness analysis of rt-CGM versus self-monitoring of blood glucose (SMBG) based on a USA retrospective cohort study in insulin-treated people with T2D adapted to the UK.

METHODS

Long-term costs and clinical outcomes were estimated using the CORE Diabetes Model, with clinical input data sourced from a retrospective cohort study. Patients were assumed to have a baseline glycated hemoglobin (HbA1c) of 8.3%. Patients using rt-CGM were assumed to have a 0.56% reduction in HbA1c based on the mean difference between groups after 12 months of follow-up. Reduced fingerstick testing when using rt-CGM was associated with a quality of life (QoL) benefit. The analysis was performed over a lifetime time horizon from a National Health Service (NHS) perspective, including only direct costs from published data. Future costs and clinical outcomes were discounted at 3.5% per annum. Extensive sensitivity analyses were performed.

RESULTS

Projections showed that rt-CGM was associated with increased quality-adjusted life expectancy of 0.731 quality-adjusted life years (QALYs) and increased mean total lifetime costs of Great British pounds (GBP) 2694, and an incremental cost-effectiveness ratio of GBP 3684 per QALY compared with SMBG. Key drivers of outcomes included HbA1c reduction and reduced fingerstick testing QoL benefit.

CONCLUSIONS

Over patient lifetimes, rt-CGM was associated with improved clinical outcomes and is highly likely to be cost effective versus SMBG in people with T2D on insulin therapy in the UK.

Compliance with treatment and fear of hypoglycaemia in patients with type 2 diabetes

AIMS

The aim of this study was to determine the compliance with treatment and fear of hypoglycaemia in patients with type 2 diabetes.

BACKGROUND

One of the important problems of patients is the fear of hypoglycaemia and compliance with treatment, which impairs general health and quality of life. It is believed that nurses contribute to the improvement of compliance with treatment in patients with type 2 diabetes, a decrease in hypoglycaemia rates.

DESIGN

This study was conducted as a descriptive study. The STROBE checklist was used.

METHODS

The study was carried out with 376 patients with type 2 diabetes between January and June 2019. The Patient Information Form, Type 2 Diabetes Mellitus Treatment Patient Compliance Scale and Hypoglycemia Fear Survey applied and SAS 9.4 package program was used for statistical analysis. Data were evaluated using descriptive statistics, t test, chi-square and variation analysis.

RESULTS

It was determined that 58.2% of the participants were female, mean age was 62.19 ± 9.60, 57.7% were primary school graduates, 50.3% were using oral antidiabetic, and 34.5% were using oral antidiabetic and insulin. Patients' compliance with treatment was moderate (60.9%). According to the mean score of the Hypoglycemia Fear Survey, the patients had a low level of fear of hypoglycaemia ( X ¯  = 1.20). There was a statistically significant difference between compliance and fear of hypoglycaemia and education, economic status, self-monitoring of blood glucose, physical activity and education about diabetes (p < .05). Patients with type 2 diabetes had decreased compliance with treatment with increased fear of hypoglycaemia (p < .05).

CONCLUSION

The participants' compliance with the treatment was moderate, and the fear of hypoglycaemia mean score was low. Nursing interventions should be planned to increase compliance with treatment and reduce the fear of hypoglycaemia in patients with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Assessing the fear of hypoglycaemia and the level of compliance with treatment by healthcare professionals, especially nurses, in patients with type 2 diabetes and providing education on this subject can be helpful in reducing the fear of hypoglycaemia, increasing treatment compliance and providing optimal glycaemic control.

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates

BACKGROUND

Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses.

METHODS

We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained.

RESULTS

There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features.

CONCLUSIONS

The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis

Background

Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care.

Methods

Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley’s checklist for survey designs. A thematic synthesis was then conducted of the collected studies.

Results

Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians.

Conclusions

This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0753-2) contains supplementary material, which is available to authorized users.

Patient Understanding of Hypoglycemia in Tertiary Referral Centers

BACKGROUND

Hypoglycemia is an important complication in the treatment of patients with diabetes. We surveyed the insight by patients with diabetes into hypoglycemia, their hypoglycemia avoidance behavior, and their level of worry regarding hypoglycemia.

METHODS

A survey of patients with diabetes, who had visited seven tertiary referral centers in Daegu or Gyeongsangbuk-do, Korea, between June 2014 and June 2015, was conducted. The survey contained questions about personal history, symptoms, educational experience, self-management, and attitudes about hypoglycemia.

RESULTS

Of 758 participants, 471 (62.1%) had experienced hypoglycemia, and 250 (32.9%) had experienced hypoglycemia at least once in the month immediately preceding the study. Two hundred and forty-two (31.8%) of the participants had received hypoglycemia education at least once, but only 148 (19.4%) knew the exact definition of hypoglycemia. Hypoglycemic symptoms identified by the participants were dizziness (55.0%), sweating (53.8%), and tremor (40.8%). They mostly chose candy (62.1%), chocolate (37.7%), or juice (36.8%) as food for recovering hypoglycemia. Participants who had experienced hypoglycemia had longer duration of diabetes and a higher proportion of insulin usage. The mean scores for hypoglycemia avoidance behavior and worry about hypoglycemia were 21.2±10.71 and 23.38±13.19, respectively. These scores tended to be higher for participants with higher than 8% of glycosylated hemoglobin, insulin use, and experience of emergency room visits.

CONCLUSION

Many patients had experienced hypoglycemia and worried about it. We recommend identifying patients that are anxious about hypoglycemia and educating them about what to do when they develop hypoglycemic symptoms, especially those who have a high risk of hypoglycemia.

Quality of life and its predictors among Hong Kong Chinese patients with diabetes

AIM

To adapt, cross-culturally, an established quality of life (QoL) scale for Hong Kong Chinese patients with diabetes; to measure their QoL and to identify the predictors of QoL in this population.

BACKGROUND

Healthcare providers are called on to assess and enhance the QoL of patients with diabetes. However, there is a lack of empirical QoL data pertaining to such individuals in China.

METHODS

The diabetes-specific QoL scale (DQoL) developed by Jacobson and the Diabetes Control and Complications Trial research group was cross-culturally adapted for use in a sample of 206 Hong Kong Chinese patients recruited from a diabetes specialist outpatient clinic. Demographic and clinical data were also collected.

RESULTS

The cross-cultural adaptation process produced a Hong Kong Chinese version of the DQoL scale with 37 items (HKC-DQoL-37) that demonstrated good internal consistency (alpha = 0.87) and acceptable test-retest validity (ICC 0.70, 95% CI 0.36-0.87). Discriminant validity was confirmed by comparing QoL scores between patients with and without insulin treatment. The QoL status of this sample (Mean = 2.2, SD = 0.5) is similar to that of Chinese immigrants and Caucasians in North America. Multiple regression analyses identified four predictors of poor QoL: (i) younger age, (ii) with diabetes complications, (iii) with admission due to hypoglycaemia, (iv) on insulin treatment.

CONCLUSIONS

Findings provide preliminary evidence on the validity and reliability of the HKC-DQoL-37. The four predictors of poor DQoL in Hong Kong Chinese patients are consistent with those identified in the West.

RELEVANCE TO CLINICAL PRACTICE

Understanding these predictors of poor QoL could help nurses and others to design and deliver appropriate interventions to these patients.

Fear of hypoglycaemia in adults with Type 1 diabetes: results from Diabetes MILES - The Netherlands

AIMS

To examine sociodemographic, clinical and psychological factors associated with fear of hypoglycaemia in adults with Type 1 diabetes.

METHODS

Data were obtained from Diabetes MILES - The Netherlands, an online self-report national survey. This cross-sectional analysis focused on participants with Type 1 diabetes who completed the 18-item Hypoglycaemia Fear Survey - Second Version Worry subscale (HFS-II-W; possible total score range 0-72, higher scores indicating higher fear) (n = 288). To explore correlates of fear of hypoglycaemia, a hierarchical linear regression analysis was performed in participants with full data on sociodemographic, clinical and psychological factors (n = 232; younger and more highly educated than those excluded).

RESULTS

HFS-II-W mean score was 11.1 ± 11.1. Gender, age, education and having a partner (model 1) were not associated with fear of hypoglycaemia. In model 2, history of severe hypoglycaemia (irrespective of number of events) was associated with (greater) fear of hypoglycaemia, whereas diabetes duration, pump therapy and HbA1c were not. Type D personality was positively correlated (model 3), as were symptoms of depression, but not anxiety (model 4). Adding loneliness (model 5) did not improve the model. The fully adjusted analysis showed that fear of hypoglycaemia was associated with depressive symptoms (β = 0.38, P < 0.001) and history of hypoglycaemia (1-2 events: β = 0.30, P < 0.001; ≥ 3 events: β = 0.19, P = 0.002). Total explained variance was 23%.

CONCLUSIONS

Depressive symptoms and history of hypoglycaemia are associated with fear of hypoglycaemia in adults with Type 1 diabetes. These factors may help to identify people with excessive fear, who may particularly benefit from interventions to reduce hypoglycaemia risk and worries.

Annual Psychological Screening in Youth and Young Adults with Type 1 Diabetes

Aim

Youth and young adults with type 1 diabetes are at a great risk for developing depression and diabetes specific distress, therefore, systematic psychological screening is recommended. Routine psychological screening was implemented in Slovene diabetes clinic for children, adolescents and young adults in 2012. One-year results are presented.

Methods

Adolescents and young adults (N = 159, aged 11 – 25 years), attending the obligatory yearly educational outpatient visit at University Children’s Hospital, Ljubljana, Slovenia, were examined using questionnaires measuring depression (depression scale from Slovene version of Trauma Symptom Checklist for Children) and diabetes distress (Diabetes Distress Screening Scale). Six additional items were included to assess the fear of hypoglycemia and family support. Socio-demographic and diabetes-related data were collected. Questionnaires were analyzed by a psychologist, and the patients that scored above cut-off point were invited to an individual psychological assessment.

Results

Of the sample, 1.3 % reached the threshold for elevated depressive symptoms, and 32.7 % reported significant diabetes distress. The need for psychological support from a specialist was expressed by 5.0 %. There were statistically significant associations between all psychological variables; moreover, better glycemic control was associated with lower diabetes distress and better family support. Nine patients (5.7 %) started with psychological treatment according to the referrals after screening.

Conclusions

The results after one year of psychological screening in Slovene type 1 diabetes population displayed small rates of depression and a large proportion of diabetes distress. Only a small percentage of patients attended the offered individual psychological assessment.

Fears and concerns of Iranian diabetic women: A phenomenological study

This study explored the fears and concerns of 19 Iranian diabetic women using a phenomenological approach. Semistructured individual interviews were conducted; each interview was transcribed verbatim and analyzed simultaneously using Van Manen's method. Data analysis resulted in the emergence of two main themes: (1) "a vague and uncertain future" with sub-themes of "fears of dependency," "loneliness," "disease complications," and "children's future"; and (2) "changing lifestyles" with sub-themes of "dietary restrictions" and "insulin injection." Psychological concerns are common in Iranian diabetic women. These concerns can contribute to poor disease self-management. Thus, it is hoped that identifying these concerns can lead to better management of these issues and a better outcome in diabetic patients.

Exploring the relationship between cognitive illness representations and poor emotional health and their combined association with diabetes self-care. A systematic review with meta-analysis

OBJECTIVE

Depression and anxiety are common in diabetes and are associated with lower diabetes self-care adherence. How this occurs is unclear. Our systematic review explored the relationship between cognitive illness representations and poor emotional health and their combined association with diabetes self-care.

METHODS

Medline, Psycinfo, EMBASE, and CINAHL were searched from inception to June 2013. Data on associations between cognitive illness representations, poor emotional health, and diabetes self-care were extracted. Random effects meta-analysis was used to test the relationship between cognitive illness representations and poor emotional health. Their combined effect on diabetes self-care was narratively evaluated.

RESULTS

Nine cross-sectional studies were included. Increased timeline cyclical, consequences, and seriousness beliefs were associated with poorer emotional health symptoms. Lower perceived personal control was associated with increased depression and anxiety, but not mixed anxiety and depressive symptoms. Remaining cognitive illness representation domains had mixed statistically significant and non-significant relationships across emotional states or were measured only once. Effect sizes ranged from small to large (r=±0.20 to 0.51). Two studies explored the combined effects of cognitions and emotions on diabetes self-care. Both showed that cognitive illness representations have an independent effect on diabetes self-care, but only one study found that depression has an independent effect also.

CONCLUSIONS

Associations between cognitive illness representations and poor emotional health were in the expected direction - negative diabetes perceptions were associated with poorer emotional health. Few studies examined the relative effects of cognitions and emotions on diabetes self-care. Longitudinal studies are needed to clarify directional pathways.

Fear of hypoglycaemia in patients with type 1 diabetes: do patients and diabetologists feel the same way?

AIM

This study described and compared the perception of hypoglycaemia in both patients with type 1 diabetes and diabetologists.

METHODS

This was an observational cross-sectional study undertaken in France in 2011. Data for what hypoglycaemia represents and practices related to it were collected using a questionnaire completed by patients with type 1 diabetes (all>12 years of age) and their diabetologists. Agreement between patients and physicians was evaluated by the intraclass correlation coefficient (ICC) and Gwet's coefficient (GC).

RESULTS

A total of 485 patients were enrolled by 118 diabetologists. Half the patients thought that hypoglycaemia was always symptomatic. According to both patients and diabetologists, hypoglycaemia impaired quality of life, caused anxiety and was disturbing, especially at night. Clinical symptoms of hypoglycaemia (sweating, shakiness, anxiety) were linked to patient's age and diabetes duration. Regarding hypoglycaemia frequency, agreement was good for severe hypoglycaemia (GC: 0.61 and 0.72 for diurnal and nocturnal hypoglycaemia, respectively) and poor for mild hypoglycaemia (ICC: 0.44 and 0.40, respectively). Diabetologists correctly evaluated the impact of hypoglycaemia on quality of life, but overestimated the hypoglycaemia-induced burden and anxiety. Counteractive behaviours were frequent: 23% of patients decreased their insulin dose, 20% increased their sugar intake and 12% ate extra snacks. Diabetologists were generally aware of these measures, but not of how often patients used them.

CONCLUSION

Diabetologists and patients do not share enough information about hypoglycaemia. Fear of hypoglycaemia and counteractive behaviours should be looked for by diabetologists. Systematic advice and specially adapted education should also be provided to increase patients' awareness of hypoglycaemia.

Hypoglycemia is associated with increased worry and lower quality of life among patients with type 2 diabetes treated with oral antihyperglycemic agents in the Asia-Pacific region

AIMS

We examined the relationship of hypoglycemic symptoms with health-related quality of life and worry about hypoglycemia among type 2 diabetic patients using oral antihyperglycemic agents (AHA) in the Asia-Pacific region.

METHODS

A total of 2257 type 2 diabetic patients with at least 6 months of oral AHA were enrolled in China, Korea, Malaysia, Thailand, and Taiwan. Quality of life was measured with the EuroQol Visual Analog Scale (EQ-VAS) and EuroQol-5 Dimensions questionnaire (EQ-5D), and worry about hypoglycemia with the worry subscale of the Hypoglycemic Fear Survey-II (HFS).

RESULTS

The mean (SD) age was 58.7 (10.2) years and HbA(1c) was 7.5% (1.5). The proportion of patients with an HbA(1c) <6.5% and <7% was 24.9% and 41.8%, respectively. Hypoglycemic symptoms in the prior 6 months were reported by 35.8% of patients. Mean scores on the EQ-VAS and the EQ-5D were significantly lower for patients who had hypoglycemic symptoms compared to those who did not (73.6 vs. 76.9, p<0.001; 0.88 vs. 0.90, p<0.0001, respectively), whereas mean score on the HFS was significantly higher (12.5 vs. 6.3, p<0.001). In multivariate models, hypoglycemic symptoms were independently associated with scores on the EQ-5D, EQ-VAS, and HFS (all p ≤ 0.01-0.001). Symptom severity was positively associated with fear of hypoglycemia (all p ≤ 0.001).

CONCLUSION

Hypoglycemic symptoms were associated with reduced quality of life and increased patient worry in patients with type 2 diabetes treated with AHA.

The impact of hypoglycaemia on quality of life and related patient-reported outcomes in Type 2 diabetes: a narrative review

As a common side effect of insulin treatment for diabetes, hypoglycaemia is a constant threat and can have far-reaching and potentially devastating consequences, including immediate physical injury as well as more pervasive cognitive, behavioural and emotional effects. Moreover, as a significant limiting factor in achieving optimal glycaemic control, exposure to hypoglycaemia can influence diabetes self-management. Although hypoglycaemia is known to occur in Type 2 diabetes, its morbidity and impact on the individual are not well recognized. The aim of the current review is to examine published evidence to achieve a synthesis of the scope and significance of the potential detriment caused by hypoglycaemia to individuals with Type 2 diabetes. The implications of these observations for treatment and research have also been considered. A narrative review was performed of empirical papers published in English since 1966, reporting the effect of hypoglycaemia on quality of life and related outcomes (including generic and diabetes-specific quality of life, emotional well-being and health utilities) in Type 2 diabetes. Research demonstrates the potential impact of hypoglycaemia on the lives of people with Type 2 diabetes, from an association with depressive symptoms and heightened anxiety, to impairment of the ability to drive, work and function in ways that are important for quality of life. Few studies consider hypoglycaemia as an explanatory variable in combination with quality of life or related primary endpoints. As a consequence, there is a pressing need for high-quality research into the overall impact of hypoglycaemia on the lives of people with Type 2 diabetes.

Assessing fear of hypoglycemia in children with Type 1 diabetes and their parents

This article summarizes the literature on fear of hypoglycemia in pediatric Type 1 diabetes and the assessment of this fear in both children with Type 1 diabetes and their parents. The most common instrument for assessing fear of hypoglycemia in this population is the children's and parent's versions of the Hypoglycemia Fear Survey (HFS), although studies using other assessment measures are also reviewed. Studies using this survey have identified variables contributing to fear of hypoglycemia in children with Type 1 diabetes and their parents, such as history of frequent or traumatic hypoglycemia, as well as trait anxiety. In addition to this summary of the literature, new data are presented supporting the reliability of hypoglycemic fear assessment in younger children and comparing fear of hypoglycemia in children in different age groups (6-18 years old) and their parents. Also reviewed are studies investigating the relationship between fear of hypoglycemia and diabetes control, which have yielded inconsistent results. Given the potential importance of fear of hypoglycemia in pediatric diabetes, there has been limited research in this area.

Religion, faith and the empowerment process: stories of Iranian people with diabetes

Empowerment concerning people with diabetes is well researched. However, few researchers specifically focus on the barriers to and facilitators of empowerment in Iranian people with diabetes. Understanding the factors could help health professionals facilitate self-empowerment more effectively. This study aims to determine the barriers to and facilitators of empowerment in Iranian people with diabetes. A qualitative exploratory study was conducted using in-depth interviews to collect the data from 11 women and men in 2007. Themes were identified using constant comparative analysis method. Common barriers to empowerment were similar to other chronic diseases: prolonged stress, negative view about diabetes, ineffective health-care systems, poverty and illiteracy. Diabetes education, fear of diabetes' complications, self-efficacy and hope for a better future emerged as being crucial to empowerment. Facilitators specific to Iranians were: the power of religion and faith, the concept of the doctor as holy man, accepting diabetes as God's will, caring for the body because it was God's gift and support from families especially daughters. Empowerment was strongly influenced by cultural and religious beliefs in Iran and the power of faith emerged as an important facilitator of diabetes empowerment. The findings will help health professionals understand how Iranian people with diabetes view life and the factors that facilitate empowerment.

The impact of non-severe hypoglycemic events on work productivity and diabetes management

OBJECTIVES

Hypoglycemia is a common complication of treatment with certain diabetes drugs. Non-severe hypoglycemic events (NSHEs) occur more frequently than severe events and account for the majority of total events. The objective of this multi-country study was to identify how NSHEs in a working population affect productivity, costs, and self-management behaviors.

METHODS

A 20-minute survey assessing the impact of NSHEs was administered via the Internet to individuals (≥ 18 years of age) with self-reported diabetes in the United States, United Kingdom, Germany, and France. The analysis sample consisted of all respondents who reported an NSHE in the past month. Topics included: reasons for, duration of, and impact of NSHE(s) on productivity and diabetes self-management.

RESULTS

A total of 1404 respondents were included in this analysis. Lost productivity was estimated to range from $15.26 to $93.47 (USD) per NSHE, representing 8.3 to 15.9 hours of lost work time per month. Among individuals reporting an NSHE at work (n = 972), 18.3% missed work for an average of 9.9 hours (SD 8.4). Among respondents experiencing an NSHE outside working hours (including nocturnal), 22.7% arrived late for work or missed a full day. Productivity loss was highest for NSHEs occurring during sleep, with an average of 14.7 (SD 11.6) working hours lost. In the week following the NSHE, respondents required an average of 5.6 extra blood glucose test strips. Among respondents using insulin, 25% decreased their insulin dose following the NSHE.

CONCLUSIONS

NSHEs are associated with substantial economic consequences for employers and patients. Greater attention to treatments that reduce NSHEs could have a major, positive impact on lost work productivity and overall diabetes management.

A critical review of the literature on fear of hypoglycemia in diabetes: Implications for diabetes management and patient education

OBJECTIVE

In many individuals with diabetes, the unpleasant symptoms and negative consequences associated with hypoglycemia may result in significant anxiety or even a fear of hypoglycemia (FoH). This fear may have significant clinical implications for diabetes management. The aim of this review is to integrate existing research on FoH (its measurement, predictors, correlates, impact and treatment) and discuss its implications for diabetes management and patient education.

METHODS

A literature search was conducted using Medline and Embase. The search was limited to journal articles published in English from 1985 to 2007 inclusive. Three hundred and one abstracts were reviewed and 273 were rejected on the basis of non-relevance. In addition to the 28 papers included, six additional papers were identified by further searches and were added to this review.

RESULTS

FoH appears to be a widespread phenomenon. It is measured primarily through the use of a specific scale, the Hypoglycemic Fear Survey (HFS). There are a number of factors that relate to whether an individual is likely to develop FoH including whether there is a history of hypoglycemia in an individual, length of time since first insulin treatment, and a higher level of variability in blood glucose level. FoH has been linked to both state and trait anxiety although the relationship is complex.

CONCLUSIONS

There is evidence that FoH may have a significant negative impact on diabetes management, metabolic control and subsequent health outcomes. There is evidence that blood glucose (BG) awareness training and CBT can reduce levels of fear and improve disease management. More research is needed on how FoH arises and the individual variables which predict its development. In addition, well designed research is required to better understand the behavioral and medical impact of FoH, and interventions to reduce it.

PRACTICE IMPLICATIONS

There is some evidence to suggest that interventions including BG awareness training and cognitive behavioral therapy can reduce levels of fear and improve disease management. While many aspects of FoH require further well-designed research, it is evident that this phenomenon can have a major impact on diabetes management and needs to be specifically addressed in patient education programs.

Impact of hypoglycaemia on quality of life and productivity in type 1 and type 2 diabetes

AIM

To characterise the impact of increasing severity and frequency of hypoglycaemia on utility, quality of life, primary care resource use and productivity (time away from normal activities) in people with both Type 1 and Type 2 diabetes.

METHODS

A postal survey was sent to 3200 people with diabetes. Self-reported episodes of mild, moderate, severe and nocturnal hypoglycaemia were quantified from a list of signs and symptoms. A number of instruments were used to explore the effect of frequency and severity of hypoglycaemia on quality of life and productivity.

RESULTS

There were 861 respondents for whom diabetes type was identifiable. Of these respondents, 629 (73%) experienced some form of hypoglycaemia, 516 (60%) non-exclusively experienced mild or moderate hypoglycaemia, 57 (7%) experienced severe hypoglycaemia and 191 (22%) experienced nocturnal hypoglycaemia. Quality of life and health-related utility decreased as the frequency and severity of hypoglycaemia increased. The use of primary care resources and lost productivity increased as the severity and frequency of hypoglycaemia increased. These associations were independent in multivariate analysis.

CONCLUSIONS

These findings suggest hypoglycaemia impacts heavily on the well-being, productivity and quality of life of people with diabetes, and that every effort should be made to minimise hypoglycaemia while aiming for good glycaemic control.

Reliability and validity of the Chinese version of the Worry Scale

This article presents the findings on the development and validation of a Chinese version of the Worry Scale (WS), a measure of worry about hypoglycemia. A previously developed 16-item WS was back-translated and applied to 117 Chinese diabetic patients living in Hong Kong. An iterative process of factor and item analyses identified a unidimensional 10-item Chinese WS (WS-10), which accounted for 57.15% of the total variance. Cronbach's alpha was 0.91. Strong correlation was demonstrated between the WS-10 and WS with 16 items (r = 0.97, p = 0.000). Comparing the level of worry about hypoglycemia between Type 1 and Type 2 diabetic patients established a contrast-group validity of the WS-10 (p = 0.002). Criterion validity was established by correlating the WS-10 with the respondents' glycosylated hemoglobin (r = -0.29, p = 0.002). Test-retest reliability using intraclass correlation (ICC) was established, ICC(1, 1) = 0.68. As the clinical administration of this scale takes less than 5 min, the Chinese WS-10 offers a useful instrument to identify patients with high levels of worry about hypoglycemia for clinical and education interventions. It also provides public health nurses with a reliable and valid prepost measure of intervention effectiveness. The Chinese WS-10 will facilitate further research about the effects of worry concerning hypoglycemia on self-care behaviors with the Chinese populations.

Sense of coherence amongst Hong Kong Chinese adults with insulin-treated type 2 diabetes

Sense of coherence (SOC) is proposed as a salutogenic approach explaining good health and positive adjustment. This paper reports a study that replicated two previous Swedish studies in 72 Hong Kong Chinese adults with diabetes. This study extended the Swedish studies by using multiple linear regression and partial correlations to examine the relationship between SOC, fear of hypoglycaemia and metabolic control to identify whether other variables including age, hypoglycaemic experience and adherence to self-care practice, confounded the Swedish findings. Results agree with that of the Swedish studies that SOC contributes to lower fear of hypoglycaemia. Implications for nursing practice are discussed.

Development of a reliable and valid Chinese version of the diabetes empowerment scale

OBJECTIVE

To translate the Diabetes Empowerment Scale (DES) into Chinese and establish its psychometric properties among Hong Kong Chinese people.

RESEARCH DESIGN AND METHODS

A two-stage study design, incorporating qualitative and quantitative components, determined the cultural equivalency and content validity of the translated scale and established the psychometric properties of the Chinese DES (C-DES) in 207 patients.

RESULTS

Psychometric analysis supported the reliability and validity of the 20-item Chinese DES (C-DES-20) and five subscales: overcoming barriers (alpha = 0.89), determining suitable methods (alpha = 0.79), achieving goals (alpha = 0.78), obtaining support (alpha = 0.78), and coping (alpha = 0.76). The test-retest reliability of the intraclass correlations was satisfactory when a subsample of 20 patients was tested after a 2-week interval. There was criterion validity between the global scale and metabolic control (HbA(1c)) of respondents with type 2 diabetes (P = 0.03).

CONCLUSIONS

The C-DES-20 is a reliable and valid outcome measure for patient education and psychosocial interventions among Hong Kong Chinese people with diabetes.

Fears and worries associated with hypoglycaemia and diabetes complications: perceptions and experience of Hong Kong Chinese clients

AIM

This paper reports the second phase of a study that explored the perceptions and experience of Hong Kong Chinese insulin-treated clients who demonstrated fear of hypoglycaemia and worry about diabetes complications.

BACKGROUND

The first phase of the study, a descriptive survey (n = 120), identified 15% of respondents as simultaneously sustaining fears and worries associated with hypoglycaemia and diabetes complications. Although a small percentage, given the increasing number of clients using insulin treatment, this finding suggests a pocket of clients suffering from undesirable emotional health. However, a search of the literature identified few studies exploring Chinese clients' perceptions and experience in this area.

DESIGN

The second phase of the study employed a purposive sampling method and semi-structured interviews to collect data from 13 participants experiencing these fears and worries. FINDINGS; Two researchers independently used content analysis to code and categorize data. Six categories identified were: the influence of perceptions of glycaemic control on emotion, hypo- and hyperglycaemia as a constant threat, keeping optimal glycaemic control or maintaining a working life, financial and psychological burden of blood glucose self-monitoring, being alone with the threat and finally distancing as the coping method. An overriding issue, a sense of losing control, emerged from the findings that described participants' perceptions and experience. This issue and two major health needs, developing self-efficacy and emotional support from nurses, were drawn from the findings for discussion. It is suggested that self-efficacy theory can be adopted as a conceptual framework to guide nursing practice for enhancing clients' capacity to exercise control over diabetes self-management.

CONCLUSIONS

Findings obtained from the second phase of the study illuminated those from the first phase. Implications for nursing practice were identified, including facilitating both technical and psychosocial self-efficacy, assessing clients' total life situation, strengthening competence in counselling skills and forming alliances with clients.