Audrey A. Irvine

Fear of Hypoglycemia: Quantification, Validation, and Utilization

Hypoglycemia can lead to various aversive symptomatic, affective, cognitive, physiological, and social consequences, which in turn can lead to the development of possible phobic avoidance behaviors associated with hypoglycemia. On the other hand, some patients may inappropriately deny or disregard warning signs of hypoglycemia. This study presents preliminary reliability and validity data on a psychometric instrument designed to quantify this fear: the hypoglycemic fear survey. The instrument was found to have internal consistency and test-retest stability, to covary with elevated glycosylated hemoglobin, and to be sensitive to a behavioral treatment program designed to increase awareness of hypoglycemia.

Fear of hypoglycemia: relationship to physical and psychological symptoms in patients with insulin-dependent diabetes mellitus.

Among diabetic patients, experience with hypoglycemia ranges from the unpleasant to the life threatening. The aversiveness of these episodes often results in fear. To examine the impact of hypoglycemia on fear, 69 patients with insulin-dependent diabetes mellitus completed the Behavior and Worry subscales of the Hypoglycemia Fear Survey along with measures of psychological symptoms, perceived stress, risk of future hypoglycemic episodes, and glycosylated hemoglobin. Behavior and Worry scores were positively related to psychological symptoms, perceived stress, and previous experiences with hypoglycemia. Fear was unrelated to glycosylated hemoglobin but was significantly higher for patients who had greater variability and lower mean daily blood glucose.

Validation of Scale Measuring Environmental Barriers to Diabetes-Regimen Adherence

This study reports on the validation of a diabetesspecific measure of environmental barriers to regimen adherence. The reliability and validity of the environmental barriers to adherence scale (EBAS) were determined for a sample of 214 insulin-dependent and non-insulin-dependent diabetic patients. The scale was shown to be a valid measure of barriers to adherence as assessed by its relationship to the barriers to adherence questionnaire and the barriers to adherence portion of the diabetes-care profile. The medication, testing, exercise, and diet subscales of the EBAS were correlated with four corresponding and three noncorresponding measures of self-care behavior from the diabetes selfcare behaviors scale. Each subscale correlated well with its corresponding self-care behavior and less well with noncorresponding self-care behavior. The internal consistency of the scale and the test-retest reliability were found to be good. The results suggest that the EBAS scale is a valid, reliable measure of barriers to diabetes-regimen adherence.

Predicting utilization of home health resources. Important data from routinely collected information.

This study examined the feasibility of using routinely collected information on patients enrolled in home health care to predict their subsequent use of services. Data were gathered from 1,984 episodes of care randomly sampled from home health care agencies of the Virginia Health Department. Age, sex, Medicare and Medicaid enrollment, referral source, medical diagnosis, and prognosis were used to predict the total number of visits, the duration of enrollment, and the intensity of service. Since the data were originally gathered to study the effects of the implementation of diagnosis-related groups (DRGs) on home health services, half of the patients were enrolled before and half after the implementation of DRGs. Using multiple linear regression analysis, significant amounts of variance in each measure of home health care utilization were explained by the predictor variables (R2= 0.04 to 0.10). For example, after controlling for other predictor variables, age 75 years or older predicted longer durations of enrollment and lower intensities of service as compared with other age groups(P < 0.05),and four of 14 diagnosis categories predicted at least one measure of utilization (P < 0.05). Medicaid enrollment predicted longer durations of enrollment and lower intensities of service in home health care (P < 0.05) in the post–DRG but not the pre–DRG period. These results demonstrate the value of routinely collected information in predicting the use of home health services. To develop more accurate estimates of needs for home health services for particular groups of patients, additional information on chronic functional impairments, informal caregiving, and the chronicity of needs may be useful.

Self care behaviors in a rural population with diabetes

Abstract Sixty-nine diabetic patients from three rural Appalachian communities were assessed on levels of diabetes knowledge, self-reported adherence and metabolic control. Adherence to diabetic self-care was inadequate for the maintenance of adequate metabolic control and the prevention of long term complications. Fewer than 20% of the patients stayed on their diet everyday. Only half of the sample tested their glucose levels, and those testing averaged only twice a week. Footcare was sporadic, and exercise was too infrequent for beneficial results. Only the medication regimen was closely followed. Diabetes knowledge averaged seven correct responses out of 24 total. Regression models were developed predicting self-care. A four-group discriminant analysis demonstrated that patients on oral medication, diet-only, and insulin regimens could be significantly discriminated using attitudes toward living diabetes and relative weight.

Methodological Issues in Examination of Fear of Hypoglycemia

Initial research on fear of hypoglycemia (FH) has focused on quantifying FH and predicting its impact on glycemic control (1-6; unpublished observations). Explanatory models have suggested that experience with hypoglycemia should increase fear (worry) and the behavior to avoid future hypoglycemia, thus jeopardizing metabolic control (1; unpublished observations). Currently, FH is related to the number and intensity of hypoglycemic episodes (2; unpublished observations), risk of having hypoglycemia (4), psychological symptoms (5; unpublished observations), and self-care activities to avoid hypoglycemia (3,6). Despite these promising results, no consistent linear relationship has been found between FH and glycemic control. A combination of factors may account for this. Research on FH has exclusively used cross-sectional designs. This can create several problems, the most serious of which concerns the use of HbA,. HbA, has been used predominantly as an outcome measure (dependent variable); however, it can also be conceptualized as a risk factor (independent variable) for hypoglycemia (unpublished observations). Unfortunately, the inability to separate factors predicting hypoglycemia from those functioning as dependent variables renders HbA, all but uninterpretable. HbA, also obscures the role of blood glucose (BG) as a risk factor by failing to reflect variability. This has resulted in individuals with stable BG levels (low risk of hypoglycemia) being grouped with individuals with labile BG (high risk) at the same level of HbA,. The current use of cross-sectional designs and HbA, also assumes that FH is stable over several months. Whereas some research has associated FH with relatively enduring states, e.g., perceived stress and psychological symptomatology (unpublished observations), other research suggests that FH may be influenced by recent experience with hypoglycemia (2). If FH is statelike, then different research methodologies may be warranted. Self-reports, for example, should be limited to the recent past. Because of the infrequency of severe hypoglycemia, this would yield few data unless samples were large. A better strategy for examining FH would be to use prospective designs that follow subjects across time and multiple hypoglycemic episodes. Measurement of conditions likely to precipitate FH has also been problematic, relying in most cases on retrospective reports of hypoglycemia. Along with the usual problems of memory failure and self-presentational biases, retrospective reports limit the examination of hypoglycemic events to global characteristics, e.g., number of episodes or degree of distress. Prospective examination of hypoglycemia would allow the expansion of the models to include detailed information on qualities and consequences of hypoglycemic episodes. Early models of FH assumed a linear relationship between fear and later glycemic control. Fear was believed to be adaptive when low and maladaptive when high. Recent research suggests that FH is highest when risk of hypoglycemia is high (unpublished observations). High fear when risk of hypoglycemia is high may be adaptive, motivating appropriate behavior to avoid hypoglycemia. Low fear (denial) in the face of high risk suggests a maladaptive response and a decreased likelihood of appropriate action to avoid hypoglycemia. These examples argue that the appropriateness of fear should be defined, in part, by actual hypoglycemic risk. We decrease the likelihood of identifying an FH-BG relationship by ignoring risk. To summarize, further exploration of FH should include the use of prospective research designs and an expanded model of FH that includes risk of hypoglycemia, qualities and consequences of episodes, specific measures of self-care, and differential (e.g., adaptive/ maladaptive) responses to hypoglycemic experiences. By addressing these issues, we may gain a more accurate description of the psychological impact of hypoglycemia on self-care and glycemic control.