الفهرس 
Introduction and Aim of the present studyOnly 14 pages are availabe for public view
 |  | from | 125 |  |  |
| | | from | 125 | | |
Abstract
Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in pediatric population. Adolescence is a developmental stage during which youth are developing independence from parents, while they are experiencing rapid biological and hormonal changes. Therefore, having T1DM during adolescence may add to the psychological challenges experienced during this period.
Hypoglycemia is the most common, life-threatening acute complication of diabetes management and presents a major barrier to achieving optimal glycemic control. Hypoglycemia has a range of adverse consequences including autonomic and neuroglycopenic symptoms. Severe prolonged hypoglycemia, if not timely and appropriately treated, could result in coma, seizures, and even death.
Hypoglycemic episodes are distressing as they are difficult to predict. The frequency of hypoglycemia may increase as the adolescents become more physically active and spend more time away from parents with unpredicted pattern of eating and physical activity. With less cognitive ability and emotional maturity than adults, children and adolescents are at risk of developing a fear of hypoglycemia (FOH). This fear may lead them to accept high blood glucose levels with maladaptive compensatory behaviors to avoid hypoglycemia, and subsequently poor glycemic control.
The aim of the present study was to study the effectiveness of an educational intervention program on the FOH among adolescents with T1DM attending diabetes outpatient students’ health insurance clinics in Alexandria. In addition, FOH, its determinants and its impact on self-management practices and glycemic control were assessed.
To fulfill this aim, a cross-sectional design was used to assess FOH, its determinants and its impact on self-management practices and glycemic control among adolescents with T1DM attending diabetes outpatient students’ clinics affiliated to the Health Insurance Organization in Alexandria. A pretest posttest quasi-experimental design was used to evaluate the impact of an educational intervention program on FOH among adolescents with T1DM.
Adolescents of both sexes aged between 12 and 18 years and diagnosed with T1DM for at least 6 months were included in the study sample. Adolescents with any concomitant chronic illness, visual or hearing impairment were excluded. Diabetic adolescents with the highest score for the Hypoglycemia Fear Survey-child version (CHFS) were included in the quasi-experimental design. They were divided into two groups (i.e., control and intervention).
The minimal required sample size for the cross-sectional design was 400 adolescents using a prevalence rate of 50% for FOH among adolescents with T1DM, a margin of error 5% and α error of 0.05. For the pretest posttest quasi-experimental design, the minimal required sample size was 75 adolescents for each group (control and intervention), considering an effect size of 0.5 for the educational intervention to reduce FOH, power of 80%, α error of 0.05 and 10% dropout rate. However, the overall dropout rate after the 2-months follow-up was 9.3% (14/150).
For the execution of this work, the adolescents with T1DM were subjected to:
Data collection tools and techniques:
The present study were divided into four phases:
I) Pre-intervention phase:
1. A pre-designed structured interviewing questionnaire was used to collect the following data from the sampled adolescents:
a) Socio-demographic data: age, sex, school grade, family size, parent education, occupation, and income.
b) Personal characteristics: hobbies, smoking and physical activity.
c) Medical history and self-management practice of diabetes.
d) Adolescents’ knowledge regarding T1DM.
e) School functioning: scholastic achievement, school absenteeism and interference with school activities due to diabetes.
2. The Arabic version of the Hypoglycemia Fear Survey - child version (HFS-C) was used to measure adolescents worries and behaviors related to their hypoglycemia.
3. Diabetes Self- Management Questionnaire (DSMQ) was used to test adherence of the adolescents to the prescribed management regimen.
4. Review of medical records was conducted to obtain the glycosylated hemoglobin level in the last 6 months.
II) Intervention phase:
The intervention group (n=75) received 4 educational sessions, while the control group (n=75) did not receive any intervention. The educational program aimed at reducing FOH, increasing knowledge and improving self-management practices.
III) Post-intervention phase:
The effect of the educational intervention program was evaluated by comparing pre and post assessments among intervention and control groups using two assessments: immediately and two months after termination of the program.
V) After completion of the study intervention program:
Non-intervention participants were scheduled for educational sessions after completion of the study intervention program.
The results of the present study revealed the following:
• A total of 400 diabetic adolescents were enrolled in the study, out of which 75 adolescents were included in each group, intervention (n=75) and control (n=75)
• The age of the sampled adolescents ranged from 12-18 years with a mean age of 14.89±2.2 years.
• Both males and females were nearly equally represented (50.5% and 49.5, respectively).
• The mean duration of diabetes mellites was 5.098±3.63 years and the mean age of diagnosis was 9.69±3.88 years.
• More than three-quarters of the sampled adolescents (77.6%) had a suboptimal glycemic control (HbA1c > 7%).
• The majority of the sampled adolescents (90.2%) had good level of knowledge, meanwhile only 9.5% had fair knowledge.
• The mean total score of Child - Hypoglycemia fear survey (CHFS) among the sampled adolescents was 1.935 ±0.765. The mean score of CHFS - behavior subscale was 1.999 ± 0.653, while the mean score of CHFS - worry subscale was 1.893 ± 1.015.
• Females had higher mean score of CHFS - total (2.04±0.77) and CHFS-worry subscale (2.03±1.01) compared to males (1.83±0.75 and 1.75±1.00, respectively) with statistically significant difference (p=0.007 and 0.005, respectively).
• Negative experiences with hypoglycemia such as higher frequency of hypoglycemic episodes, wasting time due to hypoglycemia, perceiving hypoglycemia as a big problem in addition to experiencing hypoglycemia while asleep, alone, in front of strangers or during school time were significantly associated with higher FOH (p<0.05).
• The mean total score of diabetes self-management questionnaire (DSMQ) was 6.38 ± 1.727. Among the subscales, medication adherence had the highest mean score of 8.16±2.19, meanwhile dietary control had the lowest one (5.208±2.502).
• A correlation between diabetes self-management practice and FOH was found. There was a significant very week positive correlation between the total score of DSMQ and the behavior subscale of CHFS (r=0.120, p=0.016).
• A week positive correlation was found between glucose monitoring subscale and both CHFS-total (r=0.104, p= 0.038) and the behavior subscale (r=0.201, p=0.000).
• A significant very week negative correlation between health-care use subscale and CHFS-total (r= -0.140, p=0.005) as well as the worry subscale (r=-0.150, p=0.003) was reported.
• Sampled adolescents with poor glycemic control showed higher score of CHFS-worry subscale when compared to the controlled ones with a statistically significant difference (p= 0.05).
• Regarding school functioning, problems concerning paying attention in class, forgetting things, keeping up with school activities and missing school because of not feeling well were significantly associated with higher FOH total scores and worry subscale.
• Regarding scholastic achievement, results of exams and absenteeism days were not affected by FOH.
• With reference to the educational intervention program, a significant improvement in the level of knowledge and reduction in FOH was observed among the intervention group when compared to the control group. Meanwhile, the educational intervention had no impact on diabetes self-management practice or glycemic control.
Based on the results of the present study, the following was recommended:
I. Recommendations concerning health professionals:
• A developmentally appropriate diabetes self-management education should be provided by a multidisciplinary team to diabetic children and adolescents at time of diagnosis and at a regular basis later.
• Diabetes self-management plan regarding nutrition, physical activity, insulin doses should be individualized to avoid hypoglycemia.
• Establishment of a clinical cutoff point to FOH survey could be a future area of interest for additional studies to identify and manage individuals with significant FOH.
• Psychological interventions may be incorporated in the management plan to improve diabetes self-management practices and compliance.
• Screening for psychosocial and mental health problems should be considered as a vital component of the ongoing care.
II. Recommendations concerning school:
• Educational sessions should be targeted to all school staff and students, particularly those in contact with diabetic students in their classes.
• Supplies needed for treatment of hypoglycemia (i.e., fast acting sugar) should be available and accessible by the school nurse.
• Permissions should be provided for diabetic students to eat snacks anywhere and to check their blood glucose level anytime, particularly during intense physical activity, to prevent or treat hypoglycemia.
III. Recommendations concerning family
• Health education programs should include parents and caregivers of diabetic children and adolescents, to fill the gap in the knowledge and alleviate their myths and misconceptions regarding diabetes.
• Parents should learn how they can support their children and teenagers psychologically, communicate effectively with them, encourage healthy lifestyle that subsequently improve their adherence to treatment and reduce frequency of hypoglycemia and the associated fear.