A Mixed Methods Investigation of Attitudes and Self-Care in Individuals with Type-1 Diabetes Mellitus with Intact and Impaired Awareness of Hypoglycemia

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Project Summary Hypoglycemia is an inevitable consequence of insulin therapy. Individuals with type-1 diabetes mellitus (T1DM) rely on symptom perception as the primary physiologic defense against developing severe hypoglycemia. Up to 60% of individuals with T1DM experience blunting of the sympathoadrenal response to hypoglycemia that results in impaired awareness of hypoglycemia (IAH). Those with IAH have a significantly higher likelihood of experiencing severe, life-threatening hypoglycemia. Racial disparities exist between Black and White individuals regarding incidence of severe hypoglycemia and prevalence of IAH. Further, current approaches to remedying IAH rely on advanced technologies, a form of intervention that Black individuals are significantly less likely to adopt. To reduce risk for severe hypoglycemic events and disparities, novel approaches to understanding IAH are warranted. Hypoglycemia awareness may be restored with significant hypoglycemia avoidance, yet we believe that many individuals are unable to achieve sufficient avoidance to restore awareness due to self-care behaviors that cause frequent iatrogenic hyperinsulinemia, and resultant hypoglycemia. Individuals with IAH have been shown to hold unique attitudes and beliefs that may encourage these behaviors. This fellowship application will determine differentiating attitudes and self-care of individuals with IAH, describe the common attitude and self-care profiles of individuals with IAH, and more deeply explain findings qualitatively to launch a line of inquiry for a career investigating these relationships. The specific aims of the study are to (1) compare the attitudes and self-care behaviors in adults with T1DM with and without IAH, (2) identify clusters of attitudes and self-care behavior patterns that correspond best with IAH classification, and (3) explore the relationship between attitudes and self-care in a racially diverse group of adults with T1DM complicated and uncomplicated by IAH to better explain patterns observed in cluster analysis. Data will be collected from a sample of patients at the Penn Rodebaugh Diabetes Center, the largest diabetes center in the University of Pennsylvania Health System. Data will first be analyzed with ANCOVA to compare attitudes and self-care behaviors of those with and without IAH while holding recognized covariates constant. Then, we will perform a cluster analysis using Ward’s minimum variance method to determine what attitude and self-care patterns correspond most with IAH classification in adults with T1DM. Finally, we will perform qualitative directed content analysis of interviews of individuals with IAH who were clustered into the group determined to correspond best with IAH to explain results. This fellowship application will provide the applicant training and research experiences necessary to become an independent nurse researcher with developing expertise in self-care, attitudes, and IAH in individuals with T1DM. This proposal aligns with NINR Innovative Questions Initiative in symptom science, as it addresses how psychosocial factors influence symptoms in chronic illness. This study is anticipated to help identify targetable points of intervention for future research as I develop my career as an emerging nurse scientist.