ORIGINAL ARTICLES

Development and Validation of theDiabetes Fear of Injecting and Self-testing Questionnaire (D-FISQ): FirstFindingsF.J. Snoek*1,2, E.D. Mollema1, R.J. Heine1, L.M. Bouter1, H.M. van der Ploeg2

1Institute for Research in Extramural Medicine (EMGO Institute), VrijeUniversiteit, Amsterdam, The Netherlands2Department of Medical Psychology, Vrije Universiteit, Amsterdam,The Netherlands

To quantify the degree of fear of self-injecting insulin and self-testing of blood glucose inadult insulin-treated diabetic patients, the Diabetes Fear of Injecting and Self-testingQuestionnaire (D-FISQ) was developed. The D-FISQ is a 30-item self-report questionnaireconsisting of two subscales that measure Fear of Self-Injecting (FSI) and Fear of Self-Testing (FST).

To test validity and internal consistency, the D-FISQ was administered to a sample of266 insulin-treated patients (Type 1 and Type 2); four diagnosed injection phobic insulin-requiring diabetic patients also completed the D-FISQ. The minimal score was obtainedon the subscales by 62 % (FSI) and 57 % (FST) of the population. The D-FISQ demonstratedhigh internal consistency, with Cronbach’s as of 0.94 (D-FISQ), 0.94 (FSI), and 0.90 (FST).Spearman rho between fear of self-injecting and fear of self-testing was 0.59 (p , 0.001),justifying two separate subscales. Construct validity was confirmed by a correlation of0.44 with Spielbergers Trait Anxiety Inventory (Spearman rho, p , 0.001). FSI-scores fromthe injection phobic patients were all $95th percentile, while three scored $95 % onFST, indicating discriminative validity. Results confirm homogeneity and validity of the D-FISQ and suggest usefulness of this instrument in both clinical practice and research. 1997 by John Wiley & Sons, Ltd.

Diabet. Med. 14: 871–876 (1997)

No of Figures: 1. No of Tables: 3. No of Refs: 17

KEY WORDS Injection phobia Questionnaire Adults Validation Insulin therapy Self-monitoring of blood glucose

Received 16 October 1996; revised 7 April 1997; accepted 8 April 1997

compare the prevalence of fear of injections in diabeticIntroductionpatients to the general population, where the prevalenceis estimated to be 1 to 2 %.7,8 It should be noted,Self-injecting insulin and self-testing of blood glucose

are essential daily self-care activities for the management however, that these prevalence studies focus on(incidental) injections given by others, which is essentiallyof insulin-treated diabetes mellitus. It is generally recog-

nized that extreme fear of self-injecting and self-testing different from the daily self-injections performed bydiabetic patients. In a survey performed among 240occur, both in children and adults, often requiring

specialized psychological help.1,2 In spite of the fact that adult insulin-requiring diabetic patients attending ouroutpatient clinic, using the Barriers in Diabetes Question-these (extreme) fears are likely to compromise glycaemic

control3,4 and may result in long-term psychological naire (BDQ), 4 % of the patients reported to be sufferingto some degree from fear of self-injecting and/or self-morbidity, surprisingly little research has been conducted

in this area, for instance to determine the prevalence of testing.9 Interestingly, only in half of these patients bothfears coincided. These results suggest that fear offear of self-injecting/self-testing in people with diabetes.

Considering the significantly higher incidence of anxiety injecting/self-testing is not uncommon, and is reportedby patients in various degrees, that may not always bedisorders found in people with diabetes compared to

the general population,5,6 it would be interesting to recognizable as a ‘phobia’.To estimate the prevalence of fear of self-injecting and

self-monitoring in people with insulin-treated diabetes* Correspondence to: Dr F.J. Snoek, Department of Medical Psychology, mellitus, a valid and reliable fear measure is needed.Vrije Universiteit Hospital, P.O. Box 7057, 1007 MB Amsterdam,

However, questionnaires developed to assess needle andThe Netherlands.Sponsors: Diabetes Fund Netherlands blood phobia10,11 do not take into consideration the

871CCC 0742–3071/97/100871–06$17.50 1997 by John Wiley & Sons, Ltd. DIABETIC MEDICINE, 1997; 14: 871–876

ORIGINAL ARTICLESspecific circumstances of insulin-dependent patients (e.g. to a second, small sample of insulin-treated patients (n

= 4) referred to the Medical Psychology Department ofdependency, self-injecting, daily confrontation) and aretherefore less suited. our hospital for treatment of extreme fear of self-injecting.

The objective of this study was to develop and validatea short self-report questionnaire that permits detection Statistical Analysisand quantification of the degree in which adults withinsulin-requiring diabetes (Type 1 and Type 2) suffer Data analyses were performed using SPSS-PC+. Values

are expressed as means and standard deviation forfrom fear of self-injecting of insulin and/or fear of self-testing of blood glucose. Such an instrument would be normally distributed data, or as median with range and

interquartile range for skewed data. Spearman rankuseful for both research and clinical purposes. This articlereports on our first findings regarding the psychometric correlation coefficients were calculated to determine

associations between the various variables. Mann-Whit-properties of the Diabetes Fear of Injecting and Self-testing Questionnaire (D-FISQ). ney tests were performed to examine differences in

questionnaire scores between men/women and Type1/Type 2 patients. Corrected item-total correlations werePatients and Methodsobtained, and Cronbach’s a was determined for internalconsistency. A p-value ,0.05 was considered to beDevelopmentstatistically significant. The distinction between Type 1and Type 2 diabetes was made on the basis of aIn constructing this questionnaire, items were solicited

from the literature12,13 and from clinical experience. It combination of age at diabetes onset, age at the start ofinsulin therapy, and duration of insulin therapy.was considered important to include items that pertain

not only to the emotional aspects, but also to thecognitive, behavioural, and physiological level of fear. ResultsItem formulation and item scoring were made accordingto psychometric conventions; the items are presented as Description of the Populationstatements, scored on a 4-point Likert-scale, from 0([almost] never) to 3 ([almost] always). Subscale scores Response rate was 61 %. Of all received questionnaires,

38 had to be excluded because patients did not fulfilare calculated by summation. The D-FISQ refers to thepast month. criteria, or on account of missing data.

Patient characteristics of the total group of respondersAs fear of self-injecting and fear of self-testing areassumed to be linked but not identical, they are presented (n = 266), and for Type 1 (n = 90) and Type 2 patients

(n = 163) separately, are presented in Table 1. As couldin two separate subscales: Fear of Self-Injecting (FSI) andFear of Self-Testing (FST). Both subscales contain the be expected, mean age of Type 2 patients is higher and

duration of diabetes shorter, compared to Type 1 patients.same 15 items, with a different caption for each scale(see Appendix). Also the percentage of patients on 3 to 4 injections per

day is lower in Type 2 patients compared to Type 1.Patients, Measures, and Procedure

Score DistributionA sample of 501 insulin-treated diabetic patients wasrecruited from members of the Dutch Diabetic Association The D-FISQ scores showed a highly skewed distribution

on both subscales (Figure 1). One-hundred and sixty-six(Type 1 and Type 2), and from a ‘shared care programme’for Type 2 patients.14 Inclusion criteria were: older than patients (62 %) had the lowest possible score on Fear of

Self-Injecting. Thirteen patients scored at or above the16 years, and being on insulin therapy for at least 6months, as we were interested in fear of self-injecting/self- 95th percentile on FSI, coinciding with a score of 12 or

higher. On Fear of Self-Testing, 151 patients (57 %)testing that endures beyond the initial habituation period.The D-FISQ was mailed to the subjects, together scored minimally. Again, the 95th percentile cut-off point

was 12, 14 patients scoring above this point. In total 18with the Dutch version of the Worry Scale of theHypoglycaemia Fear Survey,15,16 which is a diabetes- patients scored at or above the 95th percentile on FSI

and/or FST; of these 18 patients seven (39 %) scoredspecific fear questionnaire, and the Trait subscale of theSpielberger State-Trait Anxiety Inventory (STAI), a much high on both subscales.

Scores on the D-FISQ, HFS-Worry Scale, and STAI-used and validated generic fear measure.12,17 In addition,a short self-developed questionnaire was added to acquire Trait are represented in Table 2 for the total population,

and for Type 1 and Type 2 groups separately. Comparisonbackground information and data regarding frequency ofself-testing, experienced painfulness of self-injecting/self- of Type 1 and Type 2 patients revealed significantly

higher scores for Type 1 patients on Fear of Self-Testingtesting, and the extent to which patients performed insulininjections and blood glucose monitoring themselves. (Mann-Whitney, Z = −2.76, p , 0.01), but not on Fear

of Self-Injecting. Type 1 patients also scored significantlyInformation on metabolic control was not obtained.For validation purposes, the D-FISQ was administered higher on the Worry Scale of the Hypoglycaemia Fear

872 F.J. SNOEK ET AL.

Diabet. Med. 14: 871–876 (1997) 1997 by John Wiley & Sons, Ltd.

ORIGINAL ARTICLESTable 1. Characteristics of the total study population and of Type 1 and Type2 subgroups

Variable Total Type 1a Type 2a

population (n = 90) (n = 163)(n = 266)

Sex (% male) 50.0 55.6 48.5Age (yr) 54.3 37.7 62.9mean ± SD ±17.2 ±15.0 ±10.2Diabetes 14.2 18.2 11.7duration (yr) ±11.3 ±14.1 ±8.3mean ± SD0–5 yr (%) 16.9 13.4 20.35–10 yr (%) 22.9 17.8 27.6.10 yr (%) 57.1 68.9 52.1

Self-injections1–2 inj. per day (%) 63.2 37.8 77.33–4 inj. per day (%) 32.7 57.8 18.4

Self-testing0–5 times per wk (%) 60.9 44.4 71.85–10 times per wk (%) 10.9 12.2 9.810–20 times per wk (%) 11.3 18.9 5.5.20 times per wk (%) 10.9 20.0 6.1

aThirteen patients did not report crucial data to determine type of diabetes.

Table 2. Questionnaire scores of the total study population and of Type 1 and Type2 subgroups

Questionnaires Median Median Median(min-max) (IQR) (IQR) (IQR)

D-FISQ (0–90) 0 (0–3) 1 (0–5) 0 (0–3)FSI (0–45) 0 (0–1) 0 (0–1) 0 (0–1)FST (0–45) 0 (0–2) 0 (0–3) 0 (0–1)aHFS-Worry (0–42) 10 (4–18) 11 (6–20) 8 (3–16)bSTAI-Trait (20–80) 35 (28–44) 34 (28–43) 36 (27–44)

aMann-Whitney test, Z = −2.76, p , 0.01; bMann-Whitney test, Z = −2.41, p, 0.05. IQR,interquartile range (25th–75th centile); HFS-Worry, Hypoglycemia Fear Survey-Worry scale;STAI-trait - State-Trait Anxiety Inventory - Trait scale.

Survey (Mann-Whitney, Z = −2.41, p , 0.05). Significant (FST), respectively. Item-total correlations (within therespective scales) ranged from 0.50 to 0.85 (FSI) andnegative associations were found between age and

FSI/FST-scores (Spearman rho, p , 0.001): younger 0.36 to 0.77 (FST).people scored higher on both fear of self-injecting andself-testing. In line with this, the rank correlation between ValidityFSI and duration of diabetes proved significant (p , 0.01):the longer people had suffered from diabetes, the lower To test for construct validity of the D-FISQ, non-

parametric Spearman rank correlations were calculatedthey scored on fear of self-injecting. This associationwas not found for fear of self-testing. No significant between the D-FISQ, STAI-Trait, and HFS-Worry Scale.

As can be seen from Table 3, all correlations proved todifferences in scores were found between men andwomen. be statistically significant and in the expected direction.

D-FISQ-scores correlated moderately strong (0.44) withTrait Anxiety scores and Fear of Hypoglycaemia (0.31).Internal ConsistencyFear of Self-Injecting correlated 0.59 with Fear ofSelf-Testing.Internal consistency of the subscales and the total

questionnaire was determined by calculating Cronbach’s D-FISQ scores of four diabetic patients known to beextremely fearful of self-injecting insulin were analysed,alpha (a) coefficient. For the D-FISQ, Cronbach’s a

proved to be 0.94, indicating high homogeneity. For the to test for discriminative validity. These four patientswere two women of respectively 36 (Type 2) and 51two subscales Cronbach’s a were 0.94 (FSI) and 0.90

873DIABETES INJECTION PHOBIA QUESTIONNAIRE

1997 by John Wiley & Sons, Ltd. Diabet. Med. 14: 871–876 (1997)

ORIGINAL ARTICLES

Figure 1. Cummulative population percentages on FSI- and FST scores (n=266). The arrow indicates the 95th cut-off score (12).FSI: 11% missing data; FST: 12% missing data

Table 3. Spearman rank correlations between HFS, STAI and not always perform the insulin injections themselves.D-FISQ (subscales) Four patients out of the 14 high-scorers on FST reported

that they did not (always) perform the blood glucoseD-FISQ FSI FST HFS- STAI-

tests themselves.Worry Trait

DiscussionD-FISQ – 0.82 0.90 0.31 0.44FSI – 0.59 0.27 0.46

Findings from this study lend support to the validity ofFST – 0.31 0.35HFS-Worry – 0.49 this newly developed questionnaire, designed to assess

the degree of fear of self-injecting and self-testing inAll correlations p , 0.001. adults with insulin-treated diabetes. Whether or not all

relevant aspects of fearing self-injecting and self-testingare sampled by the D-FISQ is not an easy question to(Type 2) years old, and two men of respectively 33

(Type 1) and 55 (Type 2) years old. The total and answer. In constructing the scale, we tried to find theright balance between usefulness and validity.subscale scores of these four patients were all well above

the 95th percentile on the FSI-scale (range 22–30), and Cronbach’s a for the D-FISQ and its subscales (FSIand FST) are 0.90 or higher, indicating high internalthree were above the cut-off score on the FST-scale

(range 10–31). consistency. It could be suggested that the scales maysuffer from redundancy, which would be in favour ofFor the total population, no significant associations

were found between FSI-scores and (self-reported) number reducing the number of items, and perhaps adding oneor two new ones that tap into different aspects of anxietyof injections per day, nor between FST-scores and the

number of (reported) performed blood-glucose tests per that might be of relevance in this field (e.g. fainting).Further research is needed to confirm content validity ofweek. Self-reported painfulness of self-injecting correlated

0.30 with FSI (Spearman rho, p , 0.001), painfulness of both subscales, as well as the test–retest reliability(stability) of the D-FISQ.self-testing correlated 0.42 with FST (Spearman rho,

p , 0.001). Of the 13 patients who scored at or above The distribution of scores proved to be more or lessconsistent with our expectations, with the majority ofthe 95th percentile on FSI, two reported that they did

874 F.J. SNOEK ET AL.

Diabet. Med. 14: 871–876 (1997) 1997 by John Wiley & Sons, Ltd.

ORIGINAL ARTICLESthe population scoring minimally. The data strongly Acknowledgementssuggest that fear of self-injecting and fear of self-testingare not simple ‘yes/no’ phenomena, but are experienced This study was financially supported by the Diabetes

Fund Netherlands.by patients in various degrees. Further research is neededwith regard to the consequences and determinants ofdifferent levels of reported fear, in emotional, cognitive,physiological, and behavioural terms.

ReferencesIt was demonstrated here that four clinically diagnosed‘injection phobic’ patients scored high ($95th percentile)

1. Kolko DJ, Milan MA. Misconception correction throughon the D-FISQ. However, to confirm discriminative reading in the treatment of a self-injection phobia. Jvalidity of the D-FISQ a behavioural test is required, Behav Ther Exp Psychiatry 1980; 11: 273–276.

2. Rainwater N, Sweet AA, Elliott L, Bowers M, McNeil J,including an exposure procedure and observers’ ratingsStump N. Systematic desensitization in the treatment ofof the patients avoidance responses. Such a procedureneedle phobias for children with diabetes. Child andwill be conducted in the near future as part of this Family Behav Ther 1988; 10: 19–31.

ongoing study. 3. Metsch J, Tilill H, Koebberling J, Sartory G. On therelations among psychological distress, diabetes-relatedInterestingly, most of the high-scoring patients reportedhealth behaviour and level of glycosylated hemoglobinthat they did perform injections and blood glucose testsin type I diabetes. Int J Behav Med 1995; 2: 104–117.themselves. This does not necessarily mean that the high 4. Berlin I, Bisserbe JC, Eiber R, Balssa N, Sachon C, Bosquet

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duration of diabetes, but such a relation was not found 6. Mayou R, Peveler R, Davies B, Mann J, Fairburn C.Psychiatric morbidity in young adults with insulin-depen-for self-testing. This may be related to the (perceived)dent diabetes mellitus. Psychol Med 1991; 1: 639–645.inevitability of insulin injections, in contrast to self-

7. Agras S, Sylvester D, Oliveau D. The epidemiology ofmonitoring, which may be regarded as being avoidable common fears and phobia. Comp Psychiatry 1969; 10:to a certain extent. Again, further research is needed to 151–156.

8. Fredrikson M, Annas P, Fischer H, Wik G. Gender anddraw more definite conclusions.age differences in the prevalence of specific fear andOut of 18 patients with high D-FISQ scores, sevenphobias. Behav Res Ther 1996; 34: 33–39.had elevated scores on both subscales. This is an 9. Mollema ED, Snoek FJ, Heine RJ. Assessment of perceived

indication that fear of injecting and fear of self-testing barriers in self-care of insulin-requiring diabetic patients.do not necessarily coincide, as we had found earlier.9 Pat Educ Couns 1996; 29: 277–281.

10. Klorman R, Weerts TC, Hastings JE, Melamed BG,It will be part of future research to explore the differencesLang PJ. Psychometric description of some specific fearand similarities between patients who score high onquestionnaires. Behav Ther 1974; 5: 401–409.

either subscale or both. Further investigations will also 11. Arrindell WA. Dimensional structure and psychopathologyfocus on the aetiology and actual content of both fears. correlates of the Fear Survey Schedule (FSS-III) in a phobic

population: a factorial definition of agoraphobia. BehavFrom our study we can conclude that FSI/FST-scores areRes Ther 1980; 18: 229–242.partly explained by trait anxiety. It will be interesting to

12. Spielberger CD. Manual for the State-Trait Anxiety Inven-further explore specific individual fears, which may be tory, STAI (Form Y). Palo Alto, California: Consultingheterogeneous. Some may typically fear pain, for others Psychologists Press, 1983.

13. Emmelkamp DMG, Bouman TK, Scholing A. Angst,the fear of self-injecting may be provoked by just seeingfobieen en dwang: diagnostiek en behandeling (Anxiety,or feeling the needle, the thought of a bubble or thePhobias and Compulsion: Assessment and Treatment).risk of hypoglycaemia. Self-testing fear may be provoked Deventer: Van Loghum Slaterus, 1989.

by seeing blood and/or the needle, and may be an 14. Sonnaville de JJJ, Colly LP, Wijkel D, Heine RJ. Sharedanticipatory fear for ‘bad’ test results. care in general practice improves glycemic control

and cardio-vascular risk profile in NIDDM (Abstract).We conclude that fear of self-injecting and self-testingDiabetologia 1995; 38 (suppl 1): A182.is a largely neglected area of clinical research in diabetes

15. Irvine A, Cox D, Gonder-Frederick L. The fear ofthat deserves to be addressed. For this purpose, the D- hypoglycemia survey. In: C. Bradley, ed. Handbook ofFISQ may prove to be a useful tool. It is a promising Psychology and Diabetes. Switzerland: Harwood Aca-

demic Publishers, 1994; 133–155.and easy to (self-) administer instrument, with satisfactory16. Snoek FJ, Pouwer F, Mollema ED, Heine RJ. The Dutchpsychometric properties. Further research will be conduc-

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ORIGINAL ARTICLESAppendix: Items of the FSI/FST-Scalesa

When I have to inject myselfWhen I have to test my blood glucose1. I feel afraid2. I start to sweat3. I become restless4. I try to avoid it5. I feel tense6. I get a stomach ache7. I panic8. I worry about it9. My heart starts pounding10. I feel nervous11. I start trembling12. I feel anxious13. I have trouble breathing14. I try to postpone it15. I get angry

aThe two subscales are presented with the respectiveheading. The items are scored by the patient on a 4-point scale from 0 ’[almost] never’ to 3 ‘[almost]always’ referring to the past month.

876 F.J. SNOEK ET AL.

Diabet. Med. 14: 871–876 (1997) 1997 by John Wiley & Sons, Ltd.