Psychometric validation of the Hypoglycemia Fear Survey-II (HFS-II) in Singapore

Abstract

ObjectiveWe conducted a cross-sectional study to adapt and validate the Hypoglycemia Fear Survey-II (HFS-II) for use in Singapore among persons with type 1 and 2 diabetes mellitus.Research design and methodsA total of 144 patients with type 1 or 2 diabetes on insulin therapy for at least a year completed the HFS-II between September and December 2013 in the Diabetes Center at Singapore General Hospital. We examined the validity (content, concurrent and discriminant validity, and construct validity) and reliability (internal consistency and test–retest reliability) of the instrument. Content validity was established using cognitive interviews. Construct validity was assessed using confirmatory factor analysis (CFA) followed by exploratory factor analysis (EFA) after the hypothesized two-factor structure was not confirmed by CFA. Measures of anxiety (Generalized Anxiety Disorder-7 (GAD-7)) and depression (Patient Health Questionnaire-9 (PHQ-9)) were used to establish concurrent validity; history of severe hypoglycemia and status of glycemic control were used to establish discriminant validity. Internal consistency was measured by Cronbach’s α; test–retest reliability was measured by intracluster correlation coefficient (ICC).ResultsScores of the adapted HFS-II had moderate positive correlations with measures of anxiety and depression scores (ranxiety=0.41, p<0.01; rdepression=0.37, p<0.01). Patients with a recent history of severe hypoglycemia had higher HFS-II scores than those without (mean difference=9, p<0.01). Patients with poor glycemic control had higher HFS-II scores than those with good control (p<0.05). The original two-factor structure was not confirmed in our sample. EFA results suggested a three-factor solution with the original Behavior subscale splitting into two dimensions. The adapted HFS-II displayed good internal consistency (Cronbach’s α=0.93) and test–retest reliability (ICC=0.75).ConclusionsThe adapted HFS-II has good content, concurrent and discriminant validity, and reliability, but its constructvalidity was not proven with the Behavior subscale turning out to be non-unidimensional.

The suitability of patient-reported outcome measures used to assess the impact of hypoglycaemia on quality of life in people with diabetes: a systematic review using COSMIN methods

“…Most studies [ 32 , 33 , 35 , 38 , 39 , 41 , 42 ] had an ‘adequate’ COSMIN quality rating. Four studies had a ‘very good’ COSMIN quality rating [ 31 , 36 , 37 , 40 ].…”

Fear of hypoglycaemia among patients with type 2 diabetes mellitus: a cross-sectional study

“…The original HFS questionnaire was developed in 1987 by Prof. Cox of the University of California, with the purpose of assessing the fear of hypoglycaemia and the related behaviours of patients with diabetes. Afterward, the author revised the scale and developed the commonly used HFS-II 22 , 23 , 25 . HFS-II has 33 items and two subscales: worry subscale (HFS-W) and behaviour subscale (HFS-B), covering fear of the consequences of hypoglycaemia for the former part and the measures taken to prevent hypoglycaemic episodes in the latter part.…”

“…HFS-II has 33 items and two subscales: worry subscale (HFS-W) and behaviour subscale (HFS-B), covering fear of the consequences of hypoglycaemia for the former part and the measures taken to prevent hypoglycaemic episodes in the latter part. The items in HFS-W part measure worry about hypoglycaemia and its negative effects (18 items), and the items in HFS-B part measure the behaviours to avoid hypoglycaemia and its negative consequences (15 items) 25 . The participants were asked to indicate their fear of hypoglycaemia in each of the 33 items on 5-point Likert-type HFS from 0 (never) to 4 (always).…”

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

“…In this population, HA is most often conceptualized as fear of hypoglycemia (FoH) comprised of specific worries associated with insulin reaction and the different behaviours to avoid hypoglycemia (see definition above) and measured with the Hypoglycemia Fear Survey [128]. Like other manifestations of HA, it is associated with lower QOL, distress, anxiety, and depressive symptoms [7,128,196,[265][266][267][268][269][270][271]. Hypoglycemia is a common adverse event for people living with diabetes and can have very severe consequences if untreated, leading to coma and death.…”