Attitudes and perceptions towards hypoglycaemia in patients with diabetes mellitus: A multinational cross-sectional study

Autoři: Abdallah Y. Naser aff001;  Ian C. K. Wong aff001;  Cate Whittlesea aff001;  Hassan Alwafi aff001;  Amjad Abuirmeileh aff002;  Zahra Khalil Alsairafi aff004;  Fawaz Mohammad Turkistani aff005;  Nedaa Saud Bokhari aff005;  Maedeh Y. Beykloo aff001;  Dalal Al-Taweel aff004;  Mai B. Almane aff006;  Li Wei aff001
Působiště autorů: Research Department of Practice and Policy, UCL School of Pharmacy, London, the UK aff001;  Isra University, Faculty of Pharmacy, Amman, Jordan aff002;  Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong aff003;  Department of Pharmacy Practice, Kuwait University, Kuwait, Kuwait aff004;  Alnoor hospital, Ministry of Health, Mecca, Saudi Arabia aff005;  Sabah Al-Ahmad Cardiology Center Pharmacy, Al Amiri Hospital, Kuwait, Kuwait aff006
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222275



Preventing hypoglycaemia is an essential component of diabetes self-management that is affected by patients’ attitudes and perceptions. This study aimed to explore the hypoglycaemia problem-solving ability of patients who have diabetes mellitus and factors that determine their attitudes and perceptions towards their previous events.


A cross-sectional study was conducted between October 2017 and May 2018 in three Arab countries (Jordan, Saudi Arabia and Kuwait) in patients with diabetes mellitus, who were prescribed antidiabetic therapy and had experienced hypoglycaemic events in the past six months. The Hypoglycaemia Problem-Solving Scale was used in this study. This scale contains two subscales, problem orientation (six questions) and problem-solving skills (eighteen questions), using a five-point Likert scale (range 0–4). Multiple linear regression analysis was used to identify predictors of hypoglycaemia problem-solving abilities.


A total of 895 patients participated in this study from the three countries (300 in Jordan, 302 in Saudi Arabia, and 293 in Kuwait). The average age of the patients was 53.5 years (standard deviation = 13.7) and 52.4% (n = 469) were males. Patients had moderate overall problem-solving ability with a median score of 63.00 (interquartile range = 13.00). Patients’ problem-solving skills score (68.1%) was better than their problem-orientation skills score (58.3%). The highest sub-scale scores were for detection control, setting problem-solving goals, and evaluating strategies, 75.0%. The lowest sub-scale score was for problem-solving perception and immediate management, 50.0%. Older age, being educated, being married, having T2DM, prescribed insulin therapy, and not having been admitted to hospital for hypoglycaemia were important predictors of patients’ problem-solving ability (p < 0.05).


Healthcare professionals are advised to provide more education to patients on how to self-manage hypoglycaemic events. Specifically, they should focus on the overall problem-solving perception of hypoglycaemia and its immediate management.

Klíčová slova:

Arabic people – Diabetes mellitus – Educational attainment – Health education and awareness – Insulin – Language – Patients – Questionnaires


1. National Institute for Health and Care Excellence. Adverse reactions to drugs. 2016 December, 2016 January 11, 2017]; Available from:

2. Umpierrez G, Korytkowski M. Diabetic emergencies—ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol, 2016. 12(4): p. 222–232. doi: 10.1038/nrendo.2016.15 26893262

3. Yun JS, Ko SH. Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus. Diabetes, Obesity and Metabolism, 2016. 40(6): p. 423–432.

4. Morales J, Schneider D. Hypoglycemia. Am J Med, 2014. 127((10 Suppl)): p. S17–24. doi: 10.1016/j.amjmed.2014.07.004 25282009

5. Wu FL, Juang JH, Lin CH. Development and validation of the hypoglycaemia problem-solving scale for people with diabetes mellitus. Journal of International Medical Research, 2016. 44(3): p. 592–604. doi: 10.1177/0300060516636752 27059292

6. Mulcahy K, Maryniuk M, Peeples M, Peyrot M, Tomky D, Weaver T, et al. Diabetes Self-Management Education Core Outcomes Measures. The Diabetes Educator, 2003. 29(5): p. 768–803. doi: 10.1177/014572170302900509 14603868

7. D'Zurilla T, Nezu A. Problem-solving therapy: A positive approach to clinical intervention. 3rd ed. 2007, New York: Springer Publishing Company.

8. Fitzpatrick S, Schumann K, Hill-Briggs F. Problem solving interventions for diabetes self-management and control: A systematic review of the literature. Diabetes Research and Clinical Practice, 2013. 100(2): p. 145–161. doi: 10.1016/j.diabres.2012.12.016 23312614

9. Wang J. Self-monitoring of blood glucose is associated with problem-solving skills in hyperglycemia and hypoglycemia. Diabetes Educator, 2012. 38(2): p. 207–218. doi: 10.1177/0145721712440331 22454405

10. Babu M, Gowdappa H, Kalpana T, Vidyalaxmi K, Nikhil B, Chakravarthy T. Knowledge, Attitude and Practices of Diabetic Patients—A Cross Sectional Study in a Tertiary Care Hospital in Mysore. The Journal of the Association of Physicians of India, 2015. 63(8).

11. Morales J, Schneider D. Hypoglycemia. The American Journal of Medicine, 2014. 127(10 Suppl): p. S17–24. doi: 10.1016/j.amjmed.2014.07.004 25282009

12. International Diabetes Federation, IDF Diabetes Atlas. 2017. p. 1–147.

13. Wu FL, Wu EC, Chang YC, Hu WY, Juang JH, Yeh MC. Factors Affecting the Ability of People With Diabetes to Avoid Hypoglycemia. Journal of Nursing Research 2017.

14. Mathers N, Fox N, Hunn A. Surveys and Questionnaires. 2007, The NIHR RDS for the East Midlands / Yorkshire & the Humber.

15. Smith F. Research Methods in Pharmacy Practice. 2002, London: Pharmaceutical Press.

16. World Health Organization. Process of translation and adaptation of instruments. 2017 April 24, 2017]; Available from:

17. Hernandez CA. The Development and Pilot Testing of The Diabetes Activities Questionnaire (TDAQ): An Instrument to Measure Adherence to the Diabetes Regimen. Applied Nursing Research, 1997. 10(4): p. 202–211. 9419917

18. Bussey-Jones J, Genao I. Impact of culture on health care. Journal of the National Medical Association, 2003. 95(8): p. 732–735. 12934872

19. Hahn KA, Truman BI. Education Improves Public Health and Promotes Health Equity. International Journal of Health Services, 2015. 45(4): p. 657–78. doi: 10.1177/0020731415585986 25995305

20. Aminto J. How Does Access Affect Health Care Outcomes? A Study of 60 Countries’ Health Care Systems. Breithaupt Paper Competition, 2012: p. 1–34.

21. Nezu AM. Problem solving and behavior therapy revisited. Behavior Therapy, 2004. 35(1): p. 1–33.

22. Rijken M, Bekkema N, Boeckxstaens P, Schellevis F, Maeseneer J, Groenewegen P. Chronic Disease Management Programmes: an adequate response to patients' needs? Health Expectations, 2014. 17(5): p. 608–21. doi: 10.1111/j.1369-7625.2012.00786.x 22712877

23. Ladouceur R, Blais F, Freeston M, Dugas M. Problem Solving and Problem Orientation in Generalized Anxiety Disorder. Journal of Anxiety Disorders, 1998. 12(2): p. 139–152. 9560176

24. Maatsch JL, Munger BS, Podgorny G. Reliability and validity of the Board examination in emergency medicine. 1982, Emergency Medicine Annual: Appleton, Century, Croft, Norwalk.

25. Norman GR. Problem‐solving skills, solving problems and problem‐based learning. Medical Education, 1988. 22: p. 279–286. doi: 10.1111/j.1365-2923.1988.tb00754.x 3050382

26. D’Zurilla TJ, Goldfried MR. Problem solving and behavior modification. Journal of Abnormal Psychology, 1971. 78(1): p. 107–126. doi: 10.1037/h0031360 4938262

27. Plotka A, Prokop E, Migaj J, Straburzyńska-Migaj E, Grajek S. Patients' knowledge of heart failure and their perception of the disease. Patient Preference and Adherence, 2017. 11: p. 1459–1467. doi: 10.2147/PPA.S126133 28883713

28. Henderson JN, Allen KV, Frier BM. Hypoglycaemia in insulin-treated Type 2 diabetes: frequency, symptoms and impaired awareness. Diabetic Medicine, 2003. 20: p. 1016–1021. doi: 10.1046/j.1464-5491.2003.01072.x 14632703

29. Alsairafi Z, Taylor K, Smith F, Alattar A. Patients’ management of type 2 diabetes in Middle Eastern countries: review of studies. Patient Preference and Adherence, 2016. 10: p. 1051–1062. doi: 10.2147/PPA.S104335 27354775

30. Elliott JA, Abdulhadi N, Al-Maniri A, Al-Shafaee M, Wahlstrom R. Diabetes self-management and education of people living with diabetes: a survey in primary health care in Muscat Oman. PLOS One, 2013. 8(2): p. e57400. doi: 10.1371/journal.pone.0057400 23451219

31. Tanjia N, Fannana T, Naved M, Sultana S. Assessing the Knowledge, Attitude, and Practice of Diabetes Mellitus among Diabetes Patients in Dhaka City, Bangladesh. Journal of Pharmaceutical, Chemical and Biological Sciences, 2016. 4(1): p. 64–75.

32. Dickinson J, O’Reilly M. The lived experience of adolescent females with type 1 diabetes. Diabetes Educator, 2004. 30(1): p. 99–107. doi: 10.1177/014572170403000117 14999898

33. Wu F, Juang J, Yeh M. The dilemma of diabetic patients living with hypoglycaemia. Journal of Clinical Nursing, 2011. 20(15–16): p. 2277–8225. doi: 10.1111/j.1365-2702.2011.03725.x 21627701

34. Mandrik O, Severens J, Doroshenko O, Pan'kiv V, Kravchun N, Vlasenko M, et al. Impact of hypoglycemia on daily life of type 2 diabetes patients in Ukraine. Journal of Multidisciplinary Healthcare, 2013. 6: p. 249–257. doi: 10.2147/JMDH.S39133 23874102

35. Gholipour K, Asghari-Jafarabadi M, Iezadi S, Jannati A, Keshavarz S. Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression. East Mediterr Health J, 2018. 24(8): p. 770–777. doi: 10.26719/emhj.18.012 30328607

36. Green EC, Murphy E. Health Belief Model. The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, & Society, 2014: p. 766–769.

37. Dehghani-T afti A, Mohmoodabad S, Morowatisharifabad M, Ardakani M, Rezaeipandari H, Lotfi M. Determinants of Self- Care in Diabetic Patients Based on Health Belief Model. Global Journal of Health Science, 2015. 7(5): p. 33–42. doi: 10.5539/gjhs.v7n5p33 26156902

38. Loveman E, Cave C, Green C, Royle P, Dunn N, Waugh N. The clinical and cost-effectiveness of patient education models for diabetes: a systematic review and economic evaluation. Health Technology Assessment, 2003. 7(22): p. 1–211.

39. National Institute for Health and Care Excellence. Diabetes in adults. Quality statement 3: Structured education programmes for adults with type 1 diabetes 2011 August 2016 July 05, 2018]; Available from:

40. World Health Organization, Global report on diabetes. 2016: Geneva. p. 1–88.

41. National Health Service. Hypoglycaemia (low blood sugar)—Causes. 2015 21/05/2015 [cited 2016 05/08/2016]; Available from:

42. Casparie AF, Elving LD. Severe hypoglycemia in diabetic patients: frequency,causes, prevention. Diabetes Care, 1985. 8(2): p. 141–145. doi: 10.2337/diacare.8.2.141 3888563

43. Zimmerman EB, Woolf SH, Haley A. Population Health: Behavioral and Social Science Insights. Understanding the Relationship Between Education and Health 2014 June 26, 2018]; Available from:

44. Kerns RD, Rosenberg R, Otis JD. Self-appraised problem solving and pain-relevant social support as predictors of the experience of chronic pain. Annals of Behavioral Medicine (Baltimore), 2002. 24(2): p. 100–105.

45. Yeung S, Lui M, Ross F, Murrells T. Family carers in stroke care: Examining the relationship between problem-solving, depression and general health. Journal of Clinical Nursing Research, 2007. 16(2): p. 344–352.

46. Davis T, Brown S, Jacobs I, Bulsara M, Bruce D, Davis W. Determinants of severe hypoglycemia complicating type 2 diabetes: The Fremantle diabetes study. The Journal of Clinical Endocrinology and Metabolism, 2010. 95(5): p. 2240–2247. doi: 10.1210/jc.2009-2828 20305006

47. Minelli L, Pigini C, Chiavarini M, Bartolucci F. Employment status and perceived health condition: longitudinal data from Italy. BMC Public Health, 2014. 14(946): p. 1–12.

48. Schmitz H. Why are the unemployed in worse health? The causal effect of unemployment on health. Labour Economics, 2011. 18: p. 71–78.

49. Giatti L, Barreto S, César C. Unemployment and self-rated health: neighborhood influence. Social Science and Medicine, 2010. 71(4): p. 815–823. doi: 10.1016/j.socscimed.2010.05.021 20580141

50. Böckerman P, Ilmakunnas P. Unemployment and self-assessed health: Evidence from panel data. Health Economics, 2009. 18(2): p. 161–179. doi: 10.1002/hec.1361 18536002

51. D’Zurilla T, Maydeu-Olivares A, Kant G. Age and gender differences in social problem-solving ability. Personality and Individual Differences, 1998. 25(2): p. 241–252.

52. Leese G, Wang J, Broomhall J, Kelly P, Marsden A, Morrison W, et al. Frequency of Severe Hypoglycemia Requiring Emergency Treatment in Type 1 and Type 2 Diabetes. Diabetes Care, 2003. 26: p. 1176–1180. doi: 10.2337/diacare.26.4.1176 12663593

53. Marrett E, Radican L, Davies M, Zhang Q. Assessment of severity and frequency of self-reported hypoglycemia on quality of life in patients with type 2 diabetes treated with oral antihyperglycemic agents: A survey study. Bio Med Central Research Notes, 2011. 4(251): p. 1–7.

54. Sheu W, Sheu H, Ji L, Nitiyanant W, Baik S, Yin D, et al. 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. Diabetes Research and Clinical Practice, 2012. 96(2): p. 141–148. doi: 10.1016/j.diabres.2011.12.027 22265956

55. Leiter L, Yale J, Chiasson J, Harris S, Kleinstiver P. Assessment of the impact of fear of hypoglycemic episodes on glycemic and hypoglycemia management. Canadian Journal of Diabetes, 2005. 29(3): p. 186–192.

56. Hill-Briggs F, Gemmell L. Problem solving in diabetes self-management and control: A systematic review of the literature. The Diabetes Educator, 2007. 33(6): p. 1032–1050. doi: 10.1177/0145721707308412 18057272

57. Trizano-Hermosilla I, Alvarado JM. Best Alternatives to Cronbach's Alpha Reliability in Realistic Conditions: Congeneric and Asymmetrical Measurements. Frontiers in Psychology, 2016. 7: p. 769. doi: 10.3389/fpsyg.2016.00769 27303333

58. Anderson BJ, Rubin RR. Helping patients understand, recognize, and avoid hypoglycemia. 2nd ed. Practical Psychology for Diabetes Clinicians. 2002, Alexandria, VA: American Diabetes Association.

59. Johnson S. Managing insulin-dependent diabetes mellitus in adolescence: A developmental perspective, in Advances in Pediatric Psychology. Adolescent Health Problems: Behavioral Perspectives. 1995, The Guilford Press: New York, NY, US. p. 265–288.

60. Elliott T, Shewchuk R, Miller D, Richards J. Profiles in problem solving: Psychological well-being and distress among persons with diabetes mellitus. Journal of Clinical Psychology in Medical Settings, 2001. 8(4): p. 283–291.

61. Hill-Briggs F, Lazo M, Peyrot M, Doswell A, Chang Y, Hill M, et al., Effect of problem-solving-based diabetes self-management training on diabetes control in a low-income patient sample. Journal of General Internal Medicine, 2011. 26(9): p. 972–978. doi: 10.1007/s11606-011-1689-6 21445680

62. Grant J. Social problem-solving partnerships with family caregivers. Rehabilitation Nursing, 1999. 24: p. 256–262.

Článek vyšel v časopise


2019 Číslo 10