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VOLUME 11 NUMBER 4 • NOVEMBER 2014
165
SA JOURNAL OF DIABETES & VASCULAR DISEASE
LEARNING FROM PRACTICE
testing (Table 3), unrelated to anxiety to the finger prick, were
reported in 22.5% and included: (Table 3) ‘don’t like it’, ‘forgetting’,
‘time pressure’, ‘pain’, ‘no need as readings stable’,‘broken
meter’, ‘laziness’, ‘fearful of glucose result’, ‘only test when unwell’,
‘not necessary to test’, ‘boring to test’, ‘self conscious of testing in
public’, and ‘scared of infection’.
Discussion
This is one of the first studies specifically to assess anxiety to the
finger-prick method of blood glucose testing. The results show
that a third of diabetes out-patients report at least some anxiety to
the finger-prick method of glucose testing in addition to increased
levels of general anxiety. There is limited evidence about this
important aspect of patient self-management. Other studies have
shown indirect evidence of levels of anxiety. In a Dutch study, fear
of monitoring glucose was characterised by emotional distress and
avoidance behaviour in a group of insulin-treated individuals.
7
A
small group (less than 10%) who scored highly in the Diabetes
Fear of Injecting and Self-testing questionnaire were invited to
participate in a behavioural avoidance test and nearly a quarter
refused to perform an additional self blood glucose test.
7
This study is consistent with previous studies on injection-related
phobia, which is also more common in women than men.
8
Differences were also found in general anxiety levels between
gender and age groups. Older adults reported less general anxiety,
with a possible explanation that they may have developed effective
coping strategies over time or have fewer stressors (for example,
workplace related) in their retirement. In addition, women reported
higher levels of general anxiety, as has been highlighted in previous
research.
9
It has been argued that, despite the HADS having
a sensitivity of 80–100% for identifying high anxiety levels, it is
not diagnostic of general anxiety. It has been suggested that the
proportion of cases, for example, on the HADS having a DSM-
1V-R diagnosis of general anxiety is poor.
10
One of the purposes of
the present study was to identify possible cases of general anxiety
rather than diagnose generalised anxiety disorder, and the results
concur with previous reports.
The strong association found for FPA with general anxiety
corroborates previous findings with subcutaneous injection,
2
and supports the notion that high levels of injection anxiety are
associated with high levels of general anxiety and suggests that
methods to decrease general anxiety may have a positive effect on
reducing injection anxiety and needle phobia.
Despite the high proportion of FPA, the study found a large
proportion of participants claiming to monitor their blood glucose.
Of those reporting a reduced frequency of testing, a considerable
proportion reported pain as the reason and this is consistent with
previous research with avoidance of insulin injections.
11
A USA-
based study found that 6% (of 1 895 participants), reported fear of
needles as a reason for reduced testing, and of the participants not
monitoring their blood glucose, 14% reported a fear of needles.
12
In the present study (Table 3), 32% of the total group avoided
glucose testing due to either dislike (with no reason stated) or
injection pain, while 26% forgot or cited ‘laziness’. One in eight
subjects considered ‘ time pressure’ as the reason for avoidance,
while 5% were scared of the result or infection and a further
5% had technical issues or no testing strips. This highlights two
distinct potential management strategies: a practical/educational
strategy and psychological intervention strategies, such as cognitive
behavioural therapy. In our view psychological intervention
would be best to manage the reasons reported including specific
‘anxiety’/‘dislike’/‘scared responses’ while ‘forgetfulness’, ‘time
pressures’, ‘broken meters’ could potentially be remedied by
education and appropriate practice support targeting these issues.
Possible limitations of the study were that the assessment of
FPA was undertaken using a self-reported method derived from
injection-anxiety assessment and self-reported rather than observed
behavioural characteristics. Some psychological symptoms are similar
to physical responses to a low glucose level and may be confounders
when assessing feelings to undertaking the finger prick. The type
of device used may also be a determinant of the response. Despite
using questions from established psychological assessments, further
work is required to refine and validate the scoring system of injection
anxiety with regard to all groups within diabetes.
The present study, by assessing FPA and general anxiety, places
in context the recent findings that psychological reasons for not
monitoring blood glucose are not always addressed in diabetes
clinics.
11
Conclusions
The high levels of FPA and general anxiety observed in the current
study highlight that professionals should be sensitive to the
Table 2.
Prevalence of avoidance of testing and ethnicity (
n
= 313)
Ethnicity
No avoidance
Avoidance
(fear)
Avoidance
(other)
Total
Caucasian
63.9% (149)
9.4% (22)
26.6% (62)
(233)
Asian/Asian
British
73.5% (25)
17.6% (6)
8.8% (3)
(34)
Mixed
66.6% (10)
26.6% (4)
6.6% (1)
(15)
Black/black
British
52.3% (11)
28.5% (6)
19.0% (4)
(21)
Other ethnic
group
40.0% (4)
50.0% (5)
10.0% (1)
(10)
Not specified
0.01% (2)
Table 3.
Reasons for avoidance of self glucose testing with the finger-
prick method
Finger-prick anxiety specifically to
the finger-prick method
13.7% prevalence in total group
(
n
= 315)
Reasons other than finger-prick
anxiety
Number in subgroup (
n
= 71) who
had reasons other than anxiety
to finger-prick method
Don’t like (or no reason)
17 (23.9%)
Forgetting
15 (21.1%)
Time pressures
9 (12.6%)
Injection pain/soreness
6 (8.4%)
Readings stable
6 (8.4%)
Broken meter or no strips
4 (5.6%)
Laziness
4 (5.6%)
Scared of result
3 (4.2%)
Test only when unwell
2 (2.8%)
Not necessary to test
2 (2.8%)
Boring
1 (1.4%)
Scared of infection
1 (1.4%)
Self-conscious in public testing
1 (1.4%)