Does the development of diabetes technology reduce parents fear of hypoglycemia? - A validation study

Does the development of diabetes technology reduce parents fear of hypoglycemia? - A validation study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Does the development of diabetes technology reduce parents fear of hypoglycemia? - A validation study Mária Dóra Horváth, László Kátai, Zsanett Tesch, Norbert Buzás, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9003021/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Parents' fear of hypoglycemia may hinder optimal glycemic control in the treatment of their children with type 1 diabetes. Currently, there is no Hungarian adaptation of the Hypoglycemia Fear Survey-Parents version. The main aim of our study is to validate this questionnaire in a sample of parents of children aged 5–14 with type 1 diabetes. We also examined the relationship between parents' fear of hypoglycemia and the characteristics of their children's diabetes-specific clinical profile (e.g., severe hypoglycemic episodes, continuous glucose monitoring use). Methods 403 parents of children aged 5–14 suffering from type 1 diabetes (94.5% female, mean age = 41.5+/-5.70 years) completed the Hypoglycemia Fear Survey-Parents and the Diabetes Distress Survey Parent Version (The Problem Area in Diabetes-Parent) in the form of an online questionnaire. Results The results of the confirmatory factor analysis confirmed the three-factor structure of the survey (χ2(116) = 287; CFI = 0.948; TLI = 0.939; RMSEA = 0.0605). The reliability of the entire scale was good (α = 0.892), together with the „Maintaining High Blood Sugar” (α = 0.854) and the „Helplessness” subscales (α = 0.893). The internal consistency of the „Worry about Negative Social Consequences” subscale (α = 0.658) was acceptable. As evidence of convergent validity, the total score of the Hypoglycemia Fear Survey-Parents and the Diabetes Distress Survey Parent showed a significant, weak, positive correlation ( rs (401) = 0.393, p < 0.001). The occurrence of severe hypoglycemic episodes in the medical history was associated with significantly higher parents’ fear (U = 7290, p = 0.008 ). In the usage of modern technology, only the subscale „Maintaining High Blood Sugar” (U = 12046, p = 0.095) showed significant difference on a tendency level. Linear regression analysis showed that fear of hypoglycemia was significantly predicted by higher diabetes distress, perception of more diabetes-related problems, longer duration of diagnosis, and younger age of the child with diabetes. Conclusions The 17-item Hypoglycemia Fear Survey-Parents proved to be a valid and reliable measure of parental fear in the Hungarian sample. A history of severe hypoglycemia and the child’s younger age were predictive factors for its development. It helps to identify parents during diabetes control examinations with clinically significant fear, thus organize additional, personalized educational and supportive programs. The usage of modern technology increased the maladaptive strategy of „Maintaining High Blood Sugar”. T1DM Hypoglycemia Fear Survey-Parents version glycemic control technology confirmatory factor analysis Introduction Type 1 diabetes mellitus (T1DM) is one of the most common chronic endocrine disorders in children and adolescents, with a rapidly increasing incidence (Patterson et al., 2019). Despite significant advances in diabetes treatment technology over the past decade (e.g., CGM, CSII), a considerable proportion of children and adolescents with T1DM have suboptimal glycemic control (Van Name et al., 2017). Given that parents in this population have a significant responsibility in making daily treatment decisions, the psychological state of parents, e.g., anxiety, may affect their child's glucose control. According to international research, one of the barriers to optimal glycemic control in children is parents' pathological fear of hypoglycemia (FoH, Abitbol & Palmert, 2020; Martyn-Nemeth et al., 2017; Zhang et al., 2022). Hypoglycemia and fear of hypoglycemia Hypoglycemia is one of the most common acute complications of diabetes, which may be accompanied by characteristic adrenergic (e.g., sweating, trembling) and neuroglycopenic symptoms (e.g., dizziness, mental confusion) (Yale et al., 2018). Given the unpleasant symptoms and the potentially life-threatening nature of hypoglycemia, it is not surprising that both children and their parents may develop a pathological fear of hypoglycemia over time (Bloomgarden, 2016). This fear is considered adaptive as long as it facilitates appropriate corrective measures (Yale et al., 2018). Pathological FoH refers to an abnormal, irrational fear of hypoglycemic episodes (their symptoms and negative consequences), which can lead to maladaptive compensatory behavior patterns specific to the individual and, in more severe cases, phobic avoidance (Green et al., 2000; Krawczyk et al., 2021; Przezak et al., 2022). Martyn-Németh et al. (2017) examined the characteristics of diabetes management motivated by FoH. In their study, FoH was associated with maladaptive corrective measures, such as reduced physical activity, unwarranted reductions in insulin dosage, and excessive calorie intake above specified limits. If these dysfunctional strategies persist in treatment in the long term, suboptimal glycemic control may lead to a significant deterioration in the quality of life of patients and their caregivers. Diabetes technology and parents' FoH The biomedical approach primarily sees the solution to reducing FoH in the development of diabetes technology (Jaser et al., 2017; Macaulay et al., 2019; Monzon et al., 2019; Youngkin et al., 2020). For example, CGM is capable of continuously measuring interstitial glucose levels with a subcutaneous sensor, providing parents with real-time data on their child's current glucose levels. Given that parents of young children often report concerns about nocturnal hypoglycemia, the device's alarm function may be particularly useful in alleviating parents' nocturnal management burdens (Van Name et al., 2017). Despite its benefits, research findings do not consistently confirm the FoH-reducing effect of modern diabetes technology. For instance, qualitative studies emphasize distrustful attitudes toward devices, which may often be driven by fear of malfunction (Macaulay et al., 2019). Maladaptive corrective measures taken as a result of nocturnal FoH, such as eating more than necessary before bedtime, can lead to increased blood glucose fluctuations, more frequent nocturnal blood glucose monitoring, hyperglycemia, and glycosuria (sugar in the urine), which can fragment the nighttime sleep of children and their parents (Macaulay et al., 2019; Martyn-Nemeth et al., 2018; Richmond, 2014; Van Name et al., 2017). The relationship between FoH and glycemic control The results of studies examining the relationship between FoH and glycemic control are also inconsistent (Driscoll et al., 2016). Haugstvedt et al. (2010) found a positive correlation between parents' FoH and their children's HbA1c values in their study, but other international studies have found no connection between the two (Patton et al., 2008). One of the reasons why higher FoH does not necessarily lead to elevated HbA1c values lies in Martyn-Nemeth et al. (2018) biobehavioral finding, in which there is a link between high FoH and high glycemic variability. They also point out that large glucose fluctuations may increase the risk of micro- and macrovascular complications through oxidative stress (e.g., endothelial dysfunction). Advances in CGM technology are making it increasingly possible to monitor blood glucose fluctuations. Another possible explanation for the inconsistent results lies in the complexity of avoidance strategies, such as maladaptive coping strategies that do not lead to hyperglycemia but result in a significant reduction in quality of life, e.g., through obsessive blood glucose monitoring (Martyn-Nemeth et al., 2017). The relationship between hypoglycemic anamnesis and FoH According to previous studies, the most reliable predictor of pathological FoH is the frequency of severe hypoglycemic episodes in the history of hypoglycemia (Gonder-Frederick et al., 2006). Severe hypoglycemic episodes can cause loss of consciousness and seizures, requiring external assistance to stabilize blood sugar levels, e.g., intramuscular glucagon injection (Yale et al., 2018). In contrast, another study found that parents' FoH was significantly lower when they were confident that their child carried fast-absorbing carbohydrates with them, and their FoH level was independent of whether their child had experienced a severe traumatic hypoglycemic episode in the past (Gonder-Frederick et al., 2006). Measuring fear of hypoglycemia In research, parents' fear is most often measured using the original English-language HFS-P. The 25-item questionnaire for parents of children and adolescents was adapted by Shepard et al. (2014) from the original HFS questionnaire for adults (Cox et al., 1987). The subscales of the original questionnaire measure two components: concern and behavior. The former subscale contains items related to diabetes management, while concern consists of items related to hypoglycemic episodes and fear of their consequences. Shepard et al. (2014) first conducted an exploratory factor analysis of the HFS-P questionnaire with 250 parents to gain a deeper understanding of the FoH construct. They recommend a four-factor structure and identified two subscales within the Concern scale ("Helplessness" and "Negative Social Consequences") and within the Behavior scale ("Maintain High Blood Glucose" and "Avoid Low Blood Glucose"). Within the Concern scale, the "Helplessness" subscale specifically measures the helplessness and loss of control experienced during a hypoglycemic episode, e.g., "My child does not recognize that their blood sugar level is low." The "Negative Social Consequences" subscale covers potential discomfort and anxiety-inducing social situations related to hypoglycemia, e.g., "My child embarrasses himself or his friends/family in social situations because of low blood sugar." Within the Behavior scale, the "Maintain High Blood Glucose" subscale encompasses maladaptive behaviors aimed at maintaining blood glucose at a higher than recommended level in order to prevent hypoglycemia, e.g. "I keep my child's blood glucose level higher when he or she plans to be away from me for a while." The "Avoidance" subscale consists of other measures used to avoid hypoglycemia, including adaptive items such as "I reduce my child's insulin dose when I think their blood sugar level is too low." The reliability of the "Avoidance of Low Blood Sugar" subscale tended toward the lower limit of the acceptable range. As a possible reason the authors highlight that several items on the "Avoiding Low Blood Sugar" subscale represent appropriate and medically recommended behavior for preventing low blood sugar levels, meaning that these items may be less related to the FoH construct, e.g. "I make sure my child avoids strenuous physical activity if I think his or her blood sugar level is low" (Shepard et al. 2014). In sum, the Concern subscale consists of 10 items, and the scores reflect the degree of parents' concern about hypoglycemia. The Behavior subscale (15 items) measures the adaptive and maladaptive strategies parents use to reduce their fears. Each item is rated on a five-point Likert scale (0: never; 1: rarely; 2: sometimes; 3: often; 4: almost always). O'Donnell et al. (2022) recently found a three-factor solution to be valid for describing the factor structure of the HFS-P in a confirmatory factor analysis involving a significantly larger sample of 1,035 parents of children with T1DM, as opposed to a four-factor solution. Similar to previous research, the “Avoidance of Low Blood Sugar” subscale showed low internal consistency and was therefore ultimately removed from the questionnaire. In addition, one item was also removed from the "Maintaining High Blood Sugar" subscale, which cannot be determined on its own, without follow-up questions, whether it represents maladaptive behavior: "I give my child plenty to eat before bedtime." According to their results, mothers show a greater fear of hypoglycemia than fathers, and parents raising younger children show greater fear than those raising older children. A further finding is that children whose parents most often keep their blood sugar levels higher have lower HbA1c levels than children whose parents engage in such behaviors less frequently (O'Donnell et al., 2022). The original English-language HFS-P questionnaire has been adapted into several different languages. The Italian (Tumini et al., 2021) and Greek (Kostopoulou et al., 2023) versions have proven to be reliable and valid measures of FoH. In the Norwegian version, the Concern subscale is reliable, while the validity of the Behavior subscale should be further investigated (Haugsvedt et al., 2015). Methods Participants The sample consisted of 403 parents (381 women, 22 men) of children and adolescents aged 5–14 suffering from T1DM who primarily manage the diabetes in their family. The questionnaires could be completed online on social media platforms in the form of a questionnaire package. We used a targeted sampling method and asked healthcare professionals working with young people with diabetes and their parents to help in distributing the questionnaire package. The demographic data of the sample is shown in Table 1 . Table 1 Key demographic and diabetes-related data of our sample Gender of parent N % Male 22 5.5% Female 381 94.5% Gender of child living with T1D Male 222 55.1% Female 181 44.9% Highest level of education Primary school 5 1.2% High school 96 23.8% Technical qualification 50 12.4% Advanced qualification 53 13.2% College or university degree 195 48.4% PhD 4 1.0% Family status Single 10 2.5% Divorced 29 7.2% Married 287 71.2% In a relationship 73 18.1% Widow 4 1% Tool used for insulin administration MDI 257 63.8% CSII 146 36.2% Tool used for measuring blood glucose levels SMBG 89 22.1% CGM 313 77,8% Mean (SD) Range Age of parent in years 41.5 (5.7) 25–57 Age of child living with T1D in years 9.83 (2.74) 5–14 Years spent in diagnosis of T1D 3.25 (2.71) 0.08-13 HbA1c based on self-report 7.09 (0.961) 4.4–11.7 T1D - Type 1 Diabetes mellitus; MDI - Multiple Daily Injections; CSII - Continuous Subcutaneous Insulin Infusion; SMBG - Self-Monitoring of Blood Glucose; CGM - Continuous Glucose Monitoring; HbA1c - Hemoglobin-A1c Measurements The questionnaire package contained several questionnaires. For validation purposes, parents had to complete two questionnaires, and we also recorded the relevant clinical parameters of the children based on the parents' self-reports, e.g., the most recently measured HbA1c value, insulin intake method, and CGM use. Hypoglycemia Fear Survey- Parent version (HFS-P) The first part of the Hypoglycemia Fear Survey (Shepard et al., 2014 ) measures the fear of hypoglycemia that parents of children living with T1D experience. All items are rated on a 5-point Likert scale (0 = “never” to 4 = “almost always”). It has three subscales: the “Maintain High Blood Glucose” subscale assesses the extent to which an individual engages in behaviors to prevent hypoglycemia by purposefully maintaining blood glucose levels higher than medically recommended. The “Helplessness/Worry About Low Blood Glucose” subscale assesses worry about hypoglycemia and related feelings of helplessness, such as having low blood glucose while asleep. The “Worry About Negative Social Consequences” subscale assesses worry about social consequences of hypoglycemia, such as the child doing something embarrassing. Items are summed to create an overall hypoglycemia fear score, where higher score indicates higher fear. The Cronbach’s alpha of all the items in our sample was 0.892. The second part of the survey contains questions regarding the history of hypoglycemic episodes (severe hypoglycemic episodes in the past 12 months, moderate episodes in the past month, and mild episodes in the past week) and how upsetting parents found these episodes. For all of these, respondents marked their answers on a scale of 0–9, which represents the number of episodes experienced. Furthermore, parents also report the last HbA1c value and the target range of blood sugar level of the child (Cox et al., 1987 ; Gonder-Frederick et al., 2006 ; O’Donnell et al., 2022; Shepard et al., 2014 ). The HSF-P questionnaire was used with the author’s consent (Shepard et al., 2014 ). Its translation was carried out according to the method specified by the author: three independent experts translated the items, and the translations were then reconciled. The reconciled version was back-translated and approved by the original author. The original Cronbach's alpha values of the questionnaire in terms of subscales: both “Maintain High Blood Glucose” (α = 0.83) and “Helplessness/Worry About Low Blood Glucose” (α = 0.90) subscales are good, whereas “Worry about negative social consequences” (α = 0.78) is acceptable. The Problem Areas in Diabetes-Parent (PAID-P) The PAID-P (Evans et al., 2019 ) measures diabetes-specific emotional distress related to the daily care demands of parents with children living with T1D face. It is scored using a 6-point Likert scale (1. Not a Problem, 6. Big/Serious Problem). Responses target how much each diabetes-related experience bothers/upsets the individual respondent over the past month. It has two subscales: emotional burden and child regimen-specific distress. Items are summed to create an overall distress score, with higher scores indicating greater emotional distress (Evans et al., 2019 ). Cronbach’s alpha in our sample was 0.935. We used the questionnaire with the author’s consent. The translation of the questionnaire was carried out according to the method specified by the original author: three independent experts translated the questionnaire, and the translations were then reconciled. The reconciled version was back-translated and approved by the original author. The Cronbach’s alpha value of the original scale is α = 0.92. In our research, we used the questionnaire for convergent validity. Self-efficacy related to diabetes management and perceived diabetes management problems This is a self-developed, custom-designed questionnaire that we used in a previous study conducted with parents of children with T1D (Buzas et al., 2023). Five statements about self-efficacy related to diabetes management probed the commitment levels of the respondents to the treatments they used and the extent on a five-point Likert scale of their trust in their abilities to manage these tools (example of a statement: “I can effectively treat my child’s diabetes.” 1 = I strongly disagree; 5 = I strongly agree). Cronbach’s alfa of the scale in our sample was 0.806. Higher agreement indicated higher self-efficacy. The perceived diabetes management problems were determined via participant ratings on a five-point Likert scale (where 1 = Not a problem at all; 5 = A very big problem) of how problematic they considered the following three issues: controlling the blood glucose level, and adapting to lifestyle changes precipitated by diabetes (example of a statement: „Controlling blood sugar levels by night.”) (Buzás et al., 2023 ). Cronbach’s alfa of these three items in our sample was 0.732. Procedure Our study was conducted as part of a larger research project. The project title was: "User profiles based on attitudes toward modern diabetes technology and perceived barriers to its use among parents of children with type 1 diabetes" (Medical Research Council of Hungary’s ethical approval number: IV/9901-1/2021/EKU). The questionnaire was completed by parents of children with type 1 diabetes aged 5–14 years. Recruitment was done online and by contacting diabetes clinics. Sampling was completed by both online and paper-based methods. Data were collected by psychology students and the first author. Completion was entirely voluntary; respondents were informed of the purpose of the study and assured that completion would be anonymous and that data would be kept confidential. By accepting the information and completing the form, participants gave their consent to participate in the research. Respondents did not receive any monetary or other compensation for completing the survey, which took on average 30 minutes. Statistical analysis The data were processed using the statistical software Jamovi (Version 2.5) (Jamovi, 2024). A p-value of < 0.05 was accepted as a statistically significant difference. Confirmatory factor analysis was used to confirm the factor structure of the HFS-P questionnaire. The degree of goodness of fit of the factor structure of the test was indicated by the CFI, TLI, and RMSEA indicators (Hu & Bentler, 1998 ). We then examined the psychometric properties of the full scale as well as the subscales, e.g., the internal reliability using Cronbach's α. To examine the associations of other variables with fear of hypoglycemia, we applied a linear regression model using the Enter method, in which all predetermined predictors were entered into the model simultaneously, allowing for the assessment of their combined effect on the dependent variable. Results Descriptive Statistics The questionnaire was completed by a total of 403 parents aged 25–57 (M = 41.5, SD = 5.70) who were raising children aged 5–14 (M = 9.83, SD = 2.74) with T1DM. In our sample, 243 respondents (62.1%) had a higher education degree. In terms of insulin delivery, 146 (36.2%) of the 403 respondents used CSII, while 257 (63.8%) parents treated their children with multiple daily insulin injections. Of the 395 respondents, 306 (77.5%) currently used a CGM during treatment, while 89 (22.5%) checked their blood sugar levels with a traditional blood glucose meter. Data relevant to our research was the number of severe hypoglycemic episodes experienced in the past 12 months. 13.4% (54) of mothers reported a severe hypoglycemic episode in the past year. Another important finding is that the average self-reported HbA1c values, an objective biomarker of glycemic control, fell above the accepted target value for T1DM (≤ 7.0) in our Hungarian sample (M = 7.09%, min = 4.4, max = 11.7, SD = 0.961). The HFS-P scores of the respondents were as follows: the full HFS-P scale ( M = 20.7, SD = 12.6), the „Maintain High Blood Glucose” subscale ( M = 3.89, SD = 2.96), the „Helplessness” subscale ( M = 13.7 SD = 9.26), and the „Negative Social Consequences” subscale ( M = 3.19, SD = 3.20). It can be said that, among the subscales, parents scored lowest on the "Negative Social Consequences" subscale and highest on the "Helplessness" subscale (see in Table 2 ). Table 2 Descriptive statistics of Hypoglycemia Fear Survey - Parents version HFS-P (full scale) N M SD Cronbach-α 403 20.7 12.6 0.892 Maintain High Blood Glucose 403 3.89 2.96 0.854 Helplessness 403 13.7 9.26 0.893 Negative Social Consequences 403 3.19 3.20 0.658 M – Mean, SD – Standard Deviation, HFS-P – Hypoglycemia Fear Survey-Parents Structural analysis of the Hungarian version of the HFS-P First, we examined the four-factor structure (25 items) of the HFS-P questionnaire recommended by Shepard et al. ( 2014 ) using confirmatory factor analysis. We considered the model fit to be adequate if the chi-square (χ2) test result supported our model, i.e., if the test result was not significant and the value obtained was lower than twice the degrees of freedom. The χ2 test is sensitive to the normality of the sample, so if normality is violated, the test results often suggest rejecting the model, making the results less informative for us. The fit indices of the first model fell short of expectations ( χ2 (116) = 287; CFI = 0.894; TLI = 0.882; RMSEA = 0.0600). In order to improve the fit, taking into account the modification indices, we removed item A7, “My child behaves ‘strangely’ or seems clumsy due to low blood sugar levels,” which improved the fit of our model the most ( χ2 (116) = 287; CFI = 0.932; TLI = 0.924; RMSEA = 0.0490). The fit indices of the first model (Model 1, M1) of the three-factor (18-item) solution also fell short of expectations ( χ2 (132) = 458; CFI = 0.906; TLI = 0.891; RMSEA = 0.0783). Based on the results of the modification indices, similar to the four-factor model, the fit indices improved the most by removing item A7. Overall, CFA confirmed the three-factor structure in our sample, and after removing a single item, the three-factor model ultimately had stronger fit indices than the four-factor solution ( χ2 (116) = 287; CFI = 0.948; TLI = 0.939; RMSEA = 0.0605) (see Table 3 ). Table 3 Fit indices of HFS-P in a Hungarian sample Model χ2 df p CFI TLI RMSEA M1(4F) 659 269 p < 0.001 0.894 0.882 0.054 M2(4F) 484 246 p < 0.001 0.932 0.924 0.0490 M1(3F) 458 132 p < 0.001 0.906 0.891 0.078 M2(3F) 287 116 p < 0.001 0.948 0.939 0.061 M1(4F) - fit indices of the original four-factor (25-item) solution; M2(4F) - fit indices of the four-factor (24-item) solution after removing item A7, M1(3F): the fit indices of the three-factor (18-item) solution, M2(3F): the fit indices of the three-factor (17-item) solution after removing item A7 df – degree of freedom, CFI - comparative fit index, TLI - Tucker-Lewis index, RMSEA - Root mean square error of approximation, HFS-P – Hypoglycemia Fear Survey-Parents Reliability To determine the internal consistency of the questionnaire, we calculated Cronbach's alpha values for the HFS-P for each subscale separately and for the entire scale. We considered values above 0.6 to be acceptable and values above 0.8 to be good. In the four-factor model, the internal consistency of the "Avoiding Low Blood Sugar" subscale was low (α = 0.448), so, similar to the international research, we finally decided on a three-factor solution for the Hungarian sample and performed further calculations with M2(3F). The complete 17-item scale showed good internal consistency (Cronbach's α = 0.892). The Cronbach's alpha values for the subscales ranged from 0.658 to 0.893. Reliability is good for both the "Helplessness" (Cronbach's α = 0.893) and "Maintaining High Blood Sugar" (α = 0.854) subscales, while the reliability of the "Negative Social e Consequences" (α = 0.658) subscale is acceptable (See Table 2 ). Convergent validity Given that neither PAID-P nor HFS-P met the normality criterion, we used Spearman's rank correlation to examine the convergent validity of the HFS-P questionnaire. There was a statistically significant correlation between the FoH total score and the PAID-P total score ( rs (401) = 0.393, p < 0.001), indicating a weak, positive association between the FoH and the constructs of diabetes distress as applied to parents. Looking at the subscales, we found a statistically significant, weak, positive correlation for all three subscales: „Maintaining High Blood Sugar” ( rs (401) = 0.280, p < 0.001), „Helplessness” ( rs (401) = 0.295, p < 0.001), „Negative Social Consequences” ( rs (401) = 0.320, p < 0.001) (see Table 4 ). Table 4 Correlations between HFS-P and PAID-P HFS-P sum score PAID-P sum score 0.393*** Maintain high bood glucose 0.280*** Helplessness 0.295*** Negative Social Consequences 0.320*** HFS-P - Hypoglycemia Fear Survey-Parent, PAID-P - The Problem Area in Diabetes-Parent. ***p < 0.001 The relationship between severe hypoglycemic episodes and FoH One person was excluded from this analysis due to missing data of the question about severe hypoglycemic episodes. Due to deviations from normality, group differences were assessed using non-parametric methods (Mann–Whitney U tests). On the total HFS-P scale (U = 7290, p = 0.008), as well as on the "Helplessness" (U = 7750, p = 0.038) and "Negative Social Consequences" (U = 7243, p = 0.006) subscales, there was a statistically significant difference in mean scores between those who reported severe hypoglycemic episodes in the past year and those who did not report those. However, in the case of the "Maintaining High Blood Sugar" subscale (U = 8425, p = 0.219), there was no statistically significant difference between the groups (See Table 5 ). Table 5 The relationship between severe hypoglycemic episodes and HFS-P HFS-P (full scale) Grouping based on: SHE in the past 12 month N M SD p no 348 20.06 12.29 0.008 yes 54 25.07 14.20 Maintain High Blood Glucose no yes 348 54 3.82 4.41 2.92 3.20 0.219 Helplessness no 348 13.29 9.08 0.038 yes 54 15.93 10.23 Negative Social Consequences no yes 348 54 2.95 4.74 2.94 4.23 0.006 Results of the Mann-Whitney test revealing the difference between parents who reported/did not report severe hypoglycemic episodes in the past 12 months (SHE(12M)) and statistical indicators of the scores achieved by the two groups on the full scale and subscales of the HFS-P questionnaire. SHE - severe hypoglycemic episodes, M – Mean, SD – Standard Deviation, HFS-P - Hypoglycemia Fear Survey-Parent The relationship between glycemic control, child age and FoH Of the 403 respondents, only 350 provided data about HbA1c values. Two groups, suboptimal (HbA1c value > 7.0%) and optimal (HbA1c value ≤ 7.0%), were formed based on the medically recommended target values mentioned in the introduction (ISPAD, 2022). There was no statistically significant difference between the mean scores of the groups regarding the total scale ( U = 13644, p = 0.102), the "Maintaining High Blood Sugar" (U = 14695, p = 0.601) and the "Negative Social Consequences" (U = 14199, p = 0.290) subscales. However, on the "Helplessness" subscale, parents whose children did not reach the glycemic target achieved significantly higher average scores (U = 13011, p = 0.021) (see Table 6 ) . In terms of age distribution, parents of children aged 5–9 achieved significantly higher scores on the "Maintaining High Blood Sugar" subscale than parents of children aged 10–14 (U = 15045, p = 0.011), but no significant differences were found on the other subscales: „Helplessness” ( U = 15898, p = 0.083) and „Negative Social Consequences” ( U = 17047, p = 0.510). Table 6 The associations between HbA1c and HFS-P scores HFS-P (sum score) Grouping based on the HbA1c values N M SD p ≤ 7.0% 191 19.41 11.74 0.102 > 7.0 159 21.97 13.38 Maintain High Blood Sugar ≤ 7.0% 191 3.84 2.82 0.601 > 7.0 159 4.09 3.08 Helplessness ≤ 7.0% 191 14.56 8.82 0.021 > 7.0 159 12.57 9.51 Negative Social Consequences ≤ 7.0% > 7.0 191 159 3.00 3.33 3.06 3.20 0.290 Results of the Mann-Whitney test including the number of items (N), Mean (M) and Standard Deviation (SD), revealing the difference between the suboptimal group (HbA1c value > 7.0%) and the optimal group (HbA1c value ≤ 7.0%). HFS-P - Hypoglycemia Fear Survey-Parent, HbA1c - Hemoglobin-A1c) The relationship between CGM use and FoH This analysis included participants who used a CGM or SMBG on a permanent basis, i.e., participants who used the CGM temporarily (e.g., only in case of illness) were not included in the analysis. Looking at the average scores of parents, there was no statistically significant difference between parents who used CGM and those who did not, either on the full scale (U = 12126, p = 0.116) or on the individual subscales: „Helplessness” ( U = 12718, p = 0.342), „Negative Social Consequences” ( U = 12512, p = 0.239). Only the subscale „Maintaining High Blood Sugar” ( U = 12046, p = 0.095) showed significance on a tendency level (see Table 7 ). Table 7 Group differences between CGM use and HFS-P scores HFS-P (sum score) Group N M SD p CGM SBGM 306 89 21.25 19.06 12.75 12.43 0.116 Maintaining High Blood Sugar CGM SBGM 306 89 4.01 3.48 2.91 3.10 0.095 Helplessness CGM SBGM 306 89 13.96 12.70 9.42 8.81 0.342 Negative Social Consequences CGM SBGM 306 89 3.28 2.88 3.23 3.09 0.239 Results of the Mann-Whitney test revealing differences between groups created based on CGM use, and statistical indicators describing the scores achieved by the two groups on the full scale and on the subscales, including the number of items (N), the Mean (M) and Standard Deviation (SD) + overall scores achieved on the questionnaire. HFS-P - Hypoglycemia Fear Survey-Parent, CGM - Continuous Glucose Monitoring, SBGM - Self-Monitoring of Blood Glucose Examination of the effects of factors predicting parental fear of hypoglycemia The dependent variable in the model was the average HFS-P score. The model proved to be significant (F(13,298) = 7.26, p < 0.001, R 2 adj = 0.207). The independent variables explain 20.7 percent of the variance of the dependent variable. Fear of hypoglycemia is significantly predicted by higher diabetes distress, more perceived problems with diabetes management, longer duration of diagnosis, and younger age of the child with diabetes. Significant and non-significant predictors are shown in Table 8 . Table 8 Linear regression analysis for HSF-P score as dependent variable Independent variable β t p Parents’ age 0.072 1.210 0.227 Child's gender -0.088 -0.850 0.396 Child's Age -0.141 -2.287 0.023 Time spent in diagnosis 0.147 2.539 0.012 Having higher education level 0.111 1.013 0.312 Mode of blood glucose monitoring 0.219 1.553 0.122 Mode of insulin Insertion 0.038 0.327 0.744 Severe hypoglicemic episode 0.011 0.067 0.947 HbA1c level 0.023 0.42 0.675 PAID 0.268 4.201 < .001 DKT 0.006 0.122 0.903 Self-efficacy -0.092 -1.631 0.104 Perceived management problems 0.183 2.854 0.005 HFS-P - Hypoglycemia Fear Survey-Parent; HbA1c - Hemoglobin-A1c; PAID - The Problem Area in Diabetes-Parent; DKT – Diabetes Knowledge Test Discussion Our results confirm the psychometric suitability of the HFS-P questionnaire on a Hungarian sample. During confirmatory factor analysis, we achieved adequate fit indices by removing a single item, thus confirming the 17-item, three-factor structure. Based on Cronbach's alpha values (similar to the results obtained during the original validation of the international questionnaire) the entire questionnaire has good (nearly excellent) internal reliability (O'Donell et al., 2022). Looking at the individual subscales, the Cronbach's alpha values for the "Helplessness" subscale and the "Maintaining High Blood Sugar" subscale are adequate, while those for the "Negative Social Consequences" subscale indicate acceptable internal consistency. In both the Hungarian and international samples, the "Negative Social Consequences" subscale showed the weakest reliability (O'Donell et al., 2022; Shepard et al., 2014 ). As evidence of convergent validity, the HFS-P total score showed a significant, weak positive correlation with the PAID-P total score, which points out that caregivers' higher FoH is associated with greater levels of diabetes-specific emotional distress. When examining the relationship between FoH and glycemic control, we obtained significant results only for the “Helplessness” subscale, which suggests that parents’ fears are primarily centered around loss of control due to hypoglycemia, rather than fears of negative judgments from their environment. The results of the age group analysis warn that parents of young children (aged 5–9) may more often use the maladaptive strategy of keeping their child's blood sugar level higher than recommended for safety reasons (Van Name, 2017). One methodological criticism that has been raised is that most studies use HbA1c as a measure of glycemic control, which does not allow for a more nuanced exploration of the relationship between FoH and glucose control, e.g., it does not provide information on glucose variability, only about the average blood glucose level over the past 2–3 months (Martyn-Nemeth et al., 2017 ). Higher levels of fear of hypoglycemia (FoH) were predicted by greater diabetes-related distress, more perceived problems in diabetes management, longer duration of diagnosis, and younger age of children living with diabetes. These findings highlight the importance of regular screening for diabetes-related distress during routine annual check-ups, particularly among parents of younger children (aged 5–9 years) who have already experienced a severe hypoglycemic episode in the past year. Considering the role of modern technology in measuring blood sugar, which should help parents to feel the control in diabetes management, the ones who use CGM, also more often use the maladaptive strategy of keeping their child's blood sugar level higher. This result contradicts our expectations, but should be handled with caution due to its lower significance (p = 0.095). Therefore, evidence regarding the effectiveness of modern diabetes technologies in reducing fear of hypoglycemia (FoH) remains inconclusive. Exploring parents’ diverse experiences with diabetes devices through semi-structured qualitative interviews may be valuable, with particular attention to nighttime management and the degree of trust placed in the technology. Qualitative approaches could provide a more nuanced understanding of individual patterns of complex coping strategies. In addition, future research should examine glycemic variability using continuous glucose monitoring (CGM) data. Our findings suggest that parents who were subjectively more distressed by their child’s hypoglycemic episodes reported higher levels of emotional distress and FoH. This highlights the importance of subjective experience in FoH development and suggests that predictive factors such as parental trait anxiety may also play a role. Parents with higher trait anxiety may be more prone to catastrophizing physical symptoms, potentially amplifying fear responses to hypoglycemic events. Limitations A limitation of the study is that we relied on parental reports to obtain glycemic data rather than objective data (from medical databases). Based on these the glycemic values of the children were below the medically suitable target. Furthermore, the respondents were mainly highly educated women. Hence, we do not consider our results to be representative. One obstacle to the clinical use of the questionnaire is that, to our knowledge, there is still no consensus on the threshold values required for clinical diagnosis. Conclusions The strength of the study is that our research was the first to examine parents' FoH in a Hungarian sample and adapted a psychometrically suitable questionnaire into Hungarian for FoH research. In the future, a more holistic, biopsychosocial approach will be essential for understanding and treating psychological factors relevant to optimal glycemic control, such as FoH. We hope that the validated Hungarian-language HFS-P questionnaire, combined with a semi-structured interview, will be the first step in screening parents struggling with pathological FoH in the diabetes care system. It is important that those affected have access to personalized psychoeducation, which can help them develop more conscious diabetes management. Beyond the validation of the Hungarian version of the HFS-P, this study examined the relationships between parental fear of hypoglycemia and key psychosocial and clinical factors. Our findings indicate that fear of hypoglycemia in parents is closely associated with diabetes-related distress, perceived difficulties in diabetes management, child age, and disease duration. While the protective role of modern diabetes technologies remains inconclusive, these results underscore the importance of regular psychosocial screening to identify parents at increased risk and inform tailored clinical support. Abbreviations T1DM (type 1 diabetes mellitus) HFS P (Hypoglycemia Fear Survey-Parents) FoH (Fear of Hypoglycemia) HbA1c (Hemoglobin A1c) CGM (continuous glucose monitoring) SBGM (Self Monitoring of Blood Glucose) CSII (Continuous Subcutaneous Insulin Infusion) MDI (Multiple Daily Injections) SHE (severe hypoglycemic episode) PAID P (The Problem Area in Diabetes-Parent) GV (glycemic variability) Declarations Ethics approval and consent to participate The authors declare that the research plan was worked out and the research was conducted in accordance with the provisions of the World Medical Association Declaration of Helsinki and was approved by the Medical Research Council of Hungary (Approval number: IV/9901-1/2021/EKU). Dear Sir/Madam, We would like to invite you to participate in fullfilling a questionnaire for parents regarding the management of their children’s diabetes, which is a non-interventional, observational scientific data collection. The data will be collected based on the questionnaires you complete. The study does not impose any other burden on you beyond completing the questionnaires. Our study is conducted anonymously, in full compliance with medical confidentiality, for the purpose of developing medicines that meet the needs of patients. Please check the box below to confirm that you are participating in the study voluntarily. Your consent can be withdrawn at any time. o I acknowledge the contents of the Patient Information Sheet, I have read the details of the research, and I voluntarily agree to participate in the study. Name of study participant: ______________________ Consent for publication Not applicable. Availability of data and materials Research data can be found online in Mendeley Data at "Horvath, Maria Dora; Katai, Laszlo; Tesch, Zsanett; Buzas, Norbert; Papp-Zipernovszky, Orsolya (2026), “Does the development of diabetes technology reduce parents fear of hypoglycemia? - A validation study”, Mendeley Data, V1, doi: 10.17632/vpnc9vdjdj.1" Competing interests The authors declare no competing interest. Funding The research was supported by the Digital Society Competence Centre of the Humanities and Social Sciences Cluster of the Centre of Excellence for Interdisciplinary Research, Development and Innovation of the University of Szeged, where the authors MH and OPZ are members of the "Well-being and Health in the Digital Age" research group. Author Contributions MDH : had a major role in the conceptualization of the research, and analyzed and interpreted the data. She also took part in funding aqcuisition and was a major contributor in writing the original draft of the manuscript. LK : analyzed the data and was a major contributor in writing the original draft of the manuscript. ZsT : had a role in the conceptualization of the research and searched eligible organizations for data collection. NB : had a major role in the conceptualization of the research, provided supervision during the work and led the project administration. He also contributed to the writing of the manuscript. O P-Z : had a major role in the conceptualization of the research, and interpreted the results. She also took part in funding aqcuisition and was a contributor in writing the original draft of the manuscript. All authors read and approved the final manuscript. References Aalders J, Hartman E, Nefs G, Nieuwesteeg A, Hendrieckx C, Aanstoot H-J, et al. Mindfulness and fear of hypoglycaemia in parents of children with Type 1 diabetes: results from Diabetes MILES Youth - The Netherlands. Diabet Med. 2018;35:650–7. doi: 10.1111/dme.13594 Abitbol L, Palmert MR. When low blood sugars cause high anxiety: Fear of hypoglycemia among parents of youth with type 1 diabetes mellitus. Can J Diabetes . 2020;45:403-10. doi:10.1016/j.jcjd.2020.08.098 Abraham MB, Karges B, Dovc K, Naranjo D, Arbelaez AM, Mbogo J, et al. ISPAD Clinical Practice Consensus Guidelines: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022;20,238:1322–40. doi: 10.1111/pedi.13443 Bloomgarden Z. Fear of hypoglycemia. J Diabetes. 2016;9:108–10. doi: 10.1111/1753-0407.12491 Cox DJ, Irvine A, Gonder-Frederick L, Nowacek G, Butterfield J. Fear of hypoglycemia: quantification, validation, and utilization. Diabetes Care. 1987;10:617–21. doi: 10.2337/diacare.10.5.617. Buzás N, Horváth MD, Tesch Zs, Hallgató E. How online peer support affects management efficacy and mitigates difficulties of parents caring for children with type 1 diabetes. Prim Care Diabetes. 2023;17:607-11. doi: 10.1016/j.pcd.2023.09.003. Driscoll KA, Raymond J, Naranjo D, Patton SR. Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes. Curr Diab Rep. 2016;16:77. doi: 10.1007/s11892-016-0762-2. Evans MA, Weil LEG, Shapiro JB, Anderson LM, Vesco AT, Rychlik K, et al. Psychometric Properties of the Parent and Child Problem Areas in Diabetes Measures. J Pediatr Psychol. 2019;44:703-13. doi: 10.1093/jpepsy/jsz018. Gonder-Frederick LA, Fisher CD, Ritterband LM, Cox DJ, Hou L, DasGupta AA, et al. Predictors of fear of hypoglycemia in adolescents witht ype 1 diabetes and their parents. Pediatr Diabetes. 2006;7:215–22. doi: 10.1111/j.1399-5448.2006.00182.x. Grammes J, Schäfer M, Benecke A, Löw U, Klostermann A-L, Kubiak T, et al. Fear of hypoglycemia in patients with type 2 diabetes: The role of interoceptive accuracy and prior episodes of hypoglycemia. J Psychosom Res. 2018;105:58–63. doi: 10.1016/j.jpsychores.2017.12.010. Green L, Feher M, Catalan J. Fears and phobias in people with diabetes. Diabetes Metab Res Rev. 2000;16:287–293. doi: 10.1002/1520-7560(2000)9999:99993.0.CO;2-T. Haugstvedt A, Wentzel-Larsen T, Aarflot M, Rokne B, Graue M. Assessing fear of hypoglycemia in a population-based study among parents of children with type 1 diabetes – psychometric properties of the hypoglycemia fear survey – parent version. BMC Endocr Disord. 2015;15:2. doi: 10.1186/1472-6823-15-2. Haugstvedt A, Wentzel-Larsen T, Graue M, Søvik O, Rokne B. Fear of hypoglycaemia in mothers and fathers of children with Type 1 diabetes is associated with poor glycaemic control and parental emotional distress: a population-based study. Diabet Med. 2010;27:72–8. doi: 10.1111/j.1464-5491.2009.02867.x. Hu L, Bentler PM. Fit indices in covariance structure modeling: Sensitivity to under parameterized model misspecification. Psychol Methods. 1998;3:424–453. doi: 10.1037/1082-989X.3.4.424. Jaser SS, Foster NC, Nelson BA, Kittelsrud JM, DiMeglio LA, Quinn M, et al. Sleep in children with type 1 diabetes and their parents in the T1D Exchange. Sleep Med. 2017;39:108-15. doi: 10.1016/j.sleep.2017.07.005. Kostopoulou E, Andreopoulou O, Daskalaki S, Kotanidou E, Vakka A, Galli-Tsinopoulou A, et al. Translation and Validation Study of the Hypoglycemia Fear Survey in a Greek Population of Children and Adolescents with Type 1 Diabetes Mellitus and their Parents. Children (Basel). 2023;10:1458. doi: 10.3390/children10091458. Krawczyk J, Duda-Sobczak A, Zozulińska-Ziółkiewicz D. Fear of hypoglycaemia—from normality to pathology. Diagnostic criteria and the terapeutic directions. Clin Diabetol. 2021;9:479–84. doi: 10.5603/DK.2020.0046. Macaulay GC, Boucher SE, Yogarajah A, Galland BC, Wheeler BJ. Sleep and Night-time Caregiving in Parents of Children and Adolescents with Type 1 Diabetes Mellitus – A Qualitative Study. Behav Sleep Med. 2019;1–15.doi:10.1080/15402002.2019.1647207. Martyn-Nemeth P, Phillips SA, Mihailescu D, Schwarz Farabi S, Park C, Lipton R, et al. Poor sleep quality is associated with nocturnal glycaemic variability and fear of hypoglycaemia in adults with type 1 diabetes. J Adv Nurs. 2018;74:2373-80. doi: 10.1111/jan.13765. Martyn-Nemeth P, Quinn L, Penckofer S, Park C, Hofer V, Burke L. Fear of hypoglycemia. Influence on glycemic variability and self-management behavior in young adults with type 1 diabetes. J Diabetes Complications. 2017;31:735–41. Martyn-Nemeth P, Schwarz Farabi S, Mihailescu D, Nemeth J, Quinn L. Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention - a review. J Diabetes Complications. 2016;30:167–77. doi: 10.1016/j.jdiacomp.2015.09.003. Monzon A, McDonough R, Meltzer LJ, Patton SR. Sleep and type 1 diabetes inchildren and adolescents: Proposed the or etical model and clinical implications. Pediatr Diabetes. 2019;20: 78-85. doi: 10.1111/pedi.12797. O’Donell HK, Johnson SB, Sileo D, Majidi S, Gonder-Frederick L, Driscoll KA. Psychometric Properties of the Hypoglicemia Fear Survey in a Clinical Sample of Adolescents with Type1 Diabetes and Their Caregivers. J Pediatr Psychol. 2022;47:195-205. doi: 10.1093/jpepsy/jsab093. Patterson CC, Karuranga S, Salpea P, Saeedi P, Dahlquist G, Soltesz Gy, et al. Worldwide estimates of incidence, prevalence and mortality of type 1 diabetes in children and adolescents: Results from the International Diabetes Federation Diabetes Atlas, 9th edn. Diabetes Research and Clinical Practice. 2019;157: 107842. doi: 10.1016/j.diabres.2019.107842. Patton SR, Dolan LM, Henry R, Powers SW. Fear of Hypoglycemia in Parents of Young Children with Type1 Diabetes Mellitus. J Clin Psychol Med. 2008;15:252–59. doi: 10.1007/s10880-008-9123-x. Przezak A, Bielk W, Moleda P. Fear of hypoglycemia - An underestimated problem. Brain Behav. 2022;12:e2633. doi: 10.1002/brb3.2633. Richmond J. Effects of hypoglycaemia: patients perceptions and experiences. Br J Nurs. 2014;5:1054-59. doi: 10.12968/bjon.1996.5.17.1054. Shepard JA, Vajda K, Nyer M, Clarke W, Gonder-Frederick L. Understanding the Construct of Fear of Hypoglycemia in Pediatric Type 1 Diabetes. J Pediatr Psychol. 2014; 39:1115–25. doi: 10.1093/jpepsy/jsu068. The jamovi project (2024). jamovi. (Version 2.5) [Computer Software]. Retrieved from https://www.jamovi.org. Tumini S, Fioretti E, Rossi I, Cipriano P, Franchini S, Guidone PI, et al. Fear of hypoglycemia in children with type 1 diabetes and their parents: Validation of the Italian version of the Hypoglycemia Fear Survey for Children and for Parents. Pediatr Diabetes. 2021;23:126-38. doi: 10.1111/pedi.13301. Van Name MA, Hilliard ME, Boyle CT, Miller KM, DeSalvo DJ, Anderson BJ, et al. Nighttime is the worst time: parental fear of hypoglycemia in young children with type 1 diabetes. Pediatr Diabetes. 2017;19:114–20. doi: 10.1111/pedi.12525. Yale JF, Paty B, Senior A. Hypoglycemia. Can J Diabetes. 2018;42:S104–S108. doi: 10.1016/j.jcjd.2017.10.010. Youngkin EM, Majidi S, Noser AE, Stanek KR, Clements MA, Patton SR. Continuous Glucose Monitoring Decreases Hypoglycemia Avoidance Behaviors, but not Worry in Parents of Youth With New Onset Type 1 Diabetes. J Diabetes Sci Technol. 2020;15:1093-97. doi: 10.1177/193229682092942. Zhang L, Xu H, Liu L, Bi Y, Li X, Kan Y, et al. Related factors associated with fear of hypoglycemia in parents of children and adolescents with type 1 diabetes - A systematic review. J Pediatr Nurs. 2022;66:125-35. doi: 10.1016/j.pedn.2022.05.022. Additional Declarations No competing interests reported. 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Despite significant advances in diabetes treatment technology over the past decade (e.g., CGM,\u0026nbsp;CSII), a considerable proportion of children and adolescents with T1DM have suboptimal glycemic control (Van Name et al., 2017). Given that parents in this population have a significant responsibility in making daily treatment decisions, the psychological state of parents, e.g., anxiety, may affect their child's glucose control. According to international research, one of the barriers to optimal glycemic control in children is parents' pathological fear of hypoglycemia (FoH, Abitbol \u0026amp; Palmert, 2020; Martyn-Nemeth et al., 2017; Zhang et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHypoglycemia and fear of hypoglycemia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHypoglycemia is one of the most common acute complications of diabetes, which may be accompanied by characteristic adrenergic (e.g., sweating, trembling) and neuroglycopenic symptoms (e.g., dizziness, mental confusion) (Yale et al., 2018). Given the unpleasant symptoms and the potentially life-threatening nature of hypoglycemia, it is not surprising that both children and their parents may develop a pathological fear of hypoglycemia over time (Bloomgarden, 2016). This fear is considered adaptive as long as it facilitates appropriate corrective measures (Yale et al., 2018). Pathological FoH refers to an abnormal, irrational fear of hypoglycemic episodes (their symptoms and negative consequences), which can lead to maladaptive compensatory behavior patterns specific to the individual and, in more severe cases, phobic avoidance (Green et al., 2000; Krawczyk et al., 2021; Przezak et al., 2022).\u003c/p\u003e\n\u003cp\u003eMartyn-Németh et al. (2017) examined the characteristics of diabetes management motivated by FoH. In their study, FoH was associated with maladaptive corrective measures, such as reduced physical activity, unwarranted reductions in insulin dosage, and \u0026nbsp;excessive calorie intake above specified limits. If these dysfunctional strategies\u0026nbsp;persist in \u0026nbsp;treatment in the long term, suboptimal glycemic control may lead to a significant deterioration in the quality of life of patients and their caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiabetes technology and parents' FoH\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe biomedical approach primarily sees the solution to reducing FoH in the development of diabetes technology (Jaser et al., 2017; Macaulay et al., 2019; Monzon et al., 2019; Youngkin et al., 2020). For example, CGM is capable of continuously measuring interstitial glucose levels with a subcutaneous sensor, providing parents with real-time data on their child's current glucose levels. Given that parents of young children often report concerns about nocturnal hypoglycemia, the device's alarm function may be particularly useful in alleviating parents' nocturnal management burdens (Van Name et al., 2017). Despite its benefits, research findings do not consistently confirm the FoH-reducing effect of modern diabetes technology. For instance, qualitative studies emphasize distrustful attitudes toward devices, which may often be driven by fear of malfunction (Macaulay et al., 2019). Maladaptive corrective measures taken as a result of nocturnal FoH, such as eating more than necessary before bedtime, can lead to increased blood glucose fluctuations, more frequent nocturnal blood glucose monitoring, hyperglycemia, and glycosuria (sugar in the urine), which can fragment the nighttime sleep of children and their parents (Macaulay et al., 2019; Martyn-Nemeth et al., 2018; Richmond, 2014; Van Name et al., 2017).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eThe relationship between FoH and glycemic control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of studies examining the relationship between FoH and glycemic control are also inconsistent (Driscoll et al., 2016). Haugstvedt et al. (2010) found a positive correlation between parents' FoH and their children's HbA1c values in their study, but other international studies have found no connection between the two (Patton et al., 2008). One of the\u0026nbsp;reasons why higher FoH does not necessarily lead to elevated HbA1c values lies in Martyn-Nemeth et al. (2018) biobehavioral finding, in which there is a link between high FoH and high glycemic variability. They also point out that large glucose fluctuations may increase the risk of micro- and macrovascular complications through oxidative stress (e.g., endothelial dysfunction). Advances in CGM technology are making it increasingly possible to monitor blood glucose fluctuations.\u003c/p\u003e\n\u003cp\u003eAnother possible explanation for the inconsistent results lies in the complexity of avoidance strategies, such as maladaptive coping strategies that do not lead to hyperglycemia but result in a significant reduction in quality of life, e.g., through obsessive blood glucose monitoring (Martyn-Nemeth et al., 2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe relationship between hypoglycemic anamnesis and FoH\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to previous studies, the most reliable predictor of pathological FoH is the frequency of severe hypoglycemic episodes in the history of hypoglycemia (Gonder-Frederick et al., 2006). Severe hypoglycemic episodes can cause loss of consciousness and seizures, requiring external assistance to stabilize blood sugar levels, e.g., intramuscular glucagon injection (Yale et al., 2018). In contrast, another study found that parents' FoH was significantly lower when they were confident that their child carried fast-absorbing carbohydrates with them, and their FoH level was independent of whether their child had experienced a severe traumatic hypoglycemic episode in the past (Gonder-Frederick et al., 2006).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasuring fear of hypoglycemia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn research, parents' fear is most often measured using the original English-language HFS-P. The 25-item questionnaire for parents of children and adolescents was adapted by Shepard et al. (2014) from the original HFS questionnaire for adults (Cox et al., 1987). The subscales of the original questionnaire measure two components: concern and behavior. The former subscale contains items related to diabetes management, while concern consists of items related to hypoglycemic episodes and fear of their consequences.\u003c/p\u003e\n\u003cp\u003eShepard et al. (2014) first conducted an exploratory factor analysis of the HFS-P questionnaire with 250 parents to gain a deeper understanding of the FoH construct. They recommend a four-factor structure and identified two subscales within the Concern scale (\"Helplessness\" and \"Negative Social Consequences\") and within the Behavior scale (\"Maintain High Blood Glucose\" and \"Avoid Low Blood Glucose\"). Within the Concern scale, the \"Helplessness\" subscale specifically measures the helplessness and loss of control experienced during a hypoglycemic episode, e.g., \"My child does not recognize that their blood sugar level is low.\" The \"Negative Social Consequences\" subscale covers potential discomfort and anxiety-inducing social situations related to hypoglycemia, e.g., \"My child embarrasses himself or his friends/family in social situations because of low blood sugar.\" Within the Behavior scale, the \"Maintain High Blood Glucose\" subscale encompasses maladaptive behaviors aimed at maintaining blood glucose at a higher than recommended level in order to prevent hypoglycemia, e.g. \"I keep my child's blood glucose level higher when he or she plans to be away from me for a while.\" The \"Avoidance\" subscale consists of other measures used to avoid hypoglycemia, including adaptive items such as \"I reduce my child's insulin dose when I think their blood sugar level is too low.\" The reliability of the \"Avoidance of Low Blood Sugar\" subscale tended toward the lower limit of the acceptable range. As a possible reason the authors highlight that several items on the \"Avoiding Low Blood Sugar\" subscale represent appropriate and medically recommended behavior for preventing low blood sugar levels, meaning that these items may be less related to the FoH construct, e.g. \"I make sure my child avoids strenuous physical activity if I think his or her blood sugar level is low\" (Shepard et al. 2014).\u003c/p\u003e\n\u003cp\u003eIn sum, the Concern subscale consists of 10 items, and the scores reflect the degree of parents' concern about hypoglycemia. The Behavior subscale (15 items) measures the adaptive and maladaptive strategies parents use to reduce their fears. Each item is rated on a five-point Likert scale (0: never;\u0026nbsp;1: rarely;\u0026nbsp;2: sometimes;\u0026nbsp;3: often;\u0026nbsp;4: almost always).\u003c/p\u003e\n\u003cp\u003eO'Donnell et al. (2022) recently found a three-factor solution to be valid for describing the factor structure of the HFS-P in a confirmatory factor analysis involving a significantly larger sample of 1,035 parents of children with T1DM, as opposed to a four-factor solution. Similar to previous research, the “Avoidance of Low Blood Sugar” subscale showed low internal consistency and was therefore ultimately removed from the questionnaire. In addition, one item was also removed from the \"Maintaining High Blood Sugar\" subscale, which cannot be determined on its own, without follow-up questions, whether it represents maladaptive behavior: \"I give my child plenty to eat before bedtime.\" According to their results, mothers show a greater fear of hypoglycemia than fathers, and parents raising younger children show greater fear than those raising older children. A further finding is that children whose parents most often keep their blood sugar levels higher have lower HbA1c levels than children whose parents engage in such behaviors less frequently (O'Donnell et al., 2022).\u003c/p\u003e\n\u003cp\u003eThe original English-language HFS-P questionnaire has been adapted into several different languages. The Italian (Tumini et al., 2021) and Greek (Kostopoulou et al., 2023) versions have proven to be reliable and valid measures of FoH. In the Norwegian version, the Concern subscale is reliable, while the validity of the Behavior subscale should be further investigated (Haugsvedt et al., 2015).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe sample consisted of 403 parents (381 women, 22 men) of children and adolescents aged 5\u0026ndash;14 suffering from T1DM who primarily manage the diabetes in their family. The questionnaires could be completed online on social media platforms in the form of a questionnaire package. We used a targeted sampling method and asked healthcare professionals working with young people with diabetes and their parents to help in distributing the questionnaire package. The demographic data of the sample is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKey demographic and diabetes-related data of our sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender of parent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender of child living with T1D\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest level of education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTechnical qualification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced qualification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or university degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn a relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTool used for insulin administration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMDI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCSII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTool used for measuring blood glucose levels\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMBG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCGM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e313\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77,8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of parent in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.5 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of child living with T1D in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.83 (2.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears spent in diagnosis of T1D\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.25 (2.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.08-13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHbA1c based on self-report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.09 (0.961)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026ndash;11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eT1D - Type 1 Diabetes mellitus; MDI - Multiple Daily Injections; CSII - Continuous Subcutaneous Insulin Infusion; SMBG - Self-Monitoring of Blood Glucose; CGM - Continuous Glucose Monitoring; HbA1c - Hemoglobin-A1c\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMeasurements\u003c/h2\u003e \u003cp\u003eThe questionnaire package contained several questionnaires. For validation purposes, parents had to complete two questionnaires, and we also recorded the relevant clinical parameters of the children based on the parents' self-reports, e.g., the most recently measured HbA1c value, insulin intake method, and CGM use.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHypoglycemia Fear Survey- Parent version (HFS-P)\u003c/h3\u003e\n\u003cp\u003eThe first part of the Hypoglycemia Fear Survey (Shepard et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) measures the fear of hypoglycemia that parents of children living with T1D experience. All items are rated on a 5-point Likert scale (0 = \u0026ldquo;never\u0026rdquo; to 4 = \u0026ldquo;almost always\u0026rdquo;). It has three subscales: the \u0026ldquo;Maintain High Blood Glucose\u0026rdquo; subscale assesses the extent to which an individual engages in behaviors to prevent hypoglycemia by purposefully maintaining blood glucose levels higher than medically recommended. The \u0026ldquo;Helplessness/Worry About Low Blood Glucose\u0026rdquo; subscale assesses worry about hypoglycemia and related feelings of helplessness, such as having low blood glucose while asleep. The \u0026ldquo;Worry About Negative Social Consequences\u0026rdquo; subscale assesses worry about social consequences of hypoglycemia, such as the child doing something embarrassing. Items are summed to create an overall hypoglycemia fear score, where higher score indicates higher fear. The Cronbach\u0026rsquo;s alpha of all the items in our sample was 0.892.\u003c/p\u003e \u003cp\u003eThe second part of the survey contains questions regarding the history of hypoglycemic episodes (severe hypoglycemic episodes in the past 12 months, moderate episodes in the past month, and mild episodes in the past week) and how upsetting parents found these episodes. For all of these, respondents marked their answers on a scale of 0\u0026ndash;9, which represents the number of episodes experienced.\u003c/p\u003e \u003cp\u003eFurthermore, parents also report the last HbA1c value and the target range of blood sugar level of the child (Cox et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1987\u003c/span\u003e; Gonder-Frederick et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; O\u0026rsquo;Donnell et al., 2022; Shepard et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe HSF-P questionnaire was used with the author\u0026rsquo;s consent (Shepard et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Its translation was carried out according to the method specified by the author: three independent experts translated the items, and the translations were then reconciled. The reconciled version was back-translated and approved by the original author. The original Cronbach's alpha values of the questionnaire in terms of subscales: both \u0026ldquo;Maintain High Blood Glucose\u0026rdquo; (α\u0026thinsp;=\u0026thinsp;0.83) and \u0026ldquo;Helplessness/Worry About Low Blood Glucose\u0026rdquo; (α\u0026thinsp;=\u0026thinsp;0.90) subscales are good, whereas \u0026ldquo;Worry about negative social consequences\u0026rdquo; (α\u0026thinsp;=\u0026thinsp;0.78) is acceptable.\u003c/p\u003e\n\u003ch3\u003eThe Problem Areas in Diabetes-Parent (PAID-P)\u003c/h3\u003e\n\u003cp\u003eThe PAID-P (Evans et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) measures diabetes-specific emotional distress related to the daily care demands of parents with children living with T1D face. It is scored using a 6-point Likert scale (1. Not a Problem, 6. Big/Serious Problem). Responses target how much each diabetes-related experience bothers/upsets the individual respondent over the past month. It has two subscales: emotional burden and child regimen-specific distress. Items are summed to create an overall distress score, with higher scores indicating greater emotional distress (Evans et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Cronbach\u0026rsquo;s alpha in our sample was 0.935. We used the questionnaire with the author\u0026rsquo;s consent. The translation of the questionnaire was carried out according to the method specified by the original author: three independent experts translated the questionnaire, and the translations were then reconciled. The reconciled version was back-translated and approved by the original author. The Cronbach\u0026rsquo;s alpha value of the original scale is α\u0026thinsp;=\u0026thinsp;0.92. In our research, we used the questionnaire for convergent validity.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSelf-efficacy related to diabetes management and perceived diabetes management problems\u003c/h2\u003e \u003cp\u003eThis is a self-developed, custom-designed questionnaire that we used in a previous study conducted with parents of children with T1D (Buzas et al., 2023). Five statements about self-efficacy related to diabetes management probed the commitment levels of the respondents to the treatments they used and the extent on a five-point Likert scale of their trust in their abilities to manage these tools (example of a statement: \u0026ldquo;I can effectively treat my child\u0026rsquo;s diabetes.\u0026rdquo; 1\u0026thinsp;=\u0026thinsp;I strongly disagree; 5\u0026thinsp;=\u0026thinsp;I strongly agree). Cronbach\u0026rsquo;s alfa of the scale in our sample was 0.806. Higher agreement indicated higher self-efficacy.\u003c/p\u003e \u003cp\u003eThe perceived diabetes management problems were determined via participant ratings on a five-point Likert scale (where 1\u0026thinsp;=\u0026thinsp;Not a problem at all; 5\u0026thinsp;=\u0026thinsp;A very big problem) of how problematic they considered the following three issues: controlling the blood glucose level, and adapting to lifestyle changes precipitated by diabetes (example of a statement: \u0026bdquo;Controlling blood sugar levels by night.\u0026rdquo;) (Buz\u0026aacute;s et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Cronbach\u0026rsquo;s alfa of these three items in our sample was 0.732.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eOur study was conducted as part of a larger research project. The project title was: \u003cem\u003e\"User profiles based on attitudes toward modern diabetes technology and perceived barriers to its use among parents of children with type 1 diabetes\"\u003c/em\u003e (Medical Research Council of Hungary\u0026rsquo;s ethical approval number: IV/9901-1/2021/EKU). The questionnaire was completed by parents of children with type 1 diabetes aged 5\u0026ndash;14 years. Recruitment was done online and by contacting diabetes clinics. Sampling was completed by both online and paper-based methods. Data were collected by psychology students and the first author. Completion was entirely voluntary; respondents were informed of the purpose of the study and assured that completion would be anonymous and that data would be kept confidential. By accepting the information and completing the form, participants gave their consent to participate in the research. Respondents did not receive any monetary or other compensation for completing the survey, which took on average 30 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were processed using the statistical software Jamovi (Version 2.5) (Jamovi, 2024). A p-value of \u0026lt;\u0026thinsp;0.05 was accepted as a statistically significant difference. Confirmatory factor analysis was used to confirm the factor structure of the HFS-P questionnaire. The degree of goodness of fit of the factor structure of the test was indicated by the CFI, TLI, and RMSEA indicators (Hu \u0026amp; Bentler, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). We then examined the psychometric properties of the full scale as well as the subscales, e.g., the internal reliability using Cronbach's α. To examine the associations of other variables with fear of hypoglycemia, we applied a linear regression model using the Enter method, in which all predetermined predictors were entered into the model simultaneously, allowing for the assessment of their combined effect on the dependent variable.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDescriptive Statistics\u003c/h2\u003e \u003cp\u003eThe questionnaire was completed by a total of 403 parents aged 25\u0026ndash;57 (M\u0026thinsp;=\u0026thinsp;41.5, SD\u0026thinsp;=\u0026thinsp;5.70) who were raising children aged 5\u0026ndash;14 (M\u0026thinsp;=\u0026thinsp;9.83, SD\u0026thinsp;=\u0026thinsp;2.74) with T1DM. In our sample, 243 respondents (62.1%) had a higher education degree. In terms of insulin delivery, 146 (36.2%) of the 403 respondents used CSII, while 257 (63.8%) parents treated their children with multiple daily insulin injections. Of the 395 respondents, 306 (77.5%) currently used a CGM during treatment, while 89 (22.5%) checked their blood sugar levels with a traditional blood glucose meter. Data relevant to our research was the number of severe hypoglycemic episodes experienced in the past 12 months. 13.4% (54) of mothers reported a severe hypoglycemic episode in the past year. Another important finding is that the average self-reported HbA1c values, an objective biomarker of glycemic control, fell above the accepted target value for T1DM (\u0026le;\u0026thinsp;7.0) in our Hungarian sample (M\u0026thinsp;=\u0026thinsp;7.09%, min\u0026thinsp;=\u0026thinsp;4.4, max\u0026thinsp;=\u0026thinsp;11.7, SD\u0026thinsp;=\u0026thinsp;0.961). The HFS-P scores of the respondents were as follows: the full HFS-P scale (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20.7, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.6), the \u0026bdquo;Maintain High Blood Glucose\u0026rdquo; subscale (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.89, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.96), the \u0026bdquo;Helplessness\u0026rdquo; subscale (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13.7 \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.26), and the \u0026bdquo;Negative Social Consequences\u0026rdquo; subscale (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.19, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.20). It can be said that, among the subscales, parents scored lowest on the \"Negative Social Consequences\" subscale and highest on the \"Helplessness\" subscale (see in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics of Hypoglycemia Fear Survey - Parents version\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHFS-P (full scale)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCronbach-α\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaintain High Blood Glucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHelplessness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative Social Consequences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.658\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eM \u0026ndash; Mean, SD \u0026ndash; Standard Deviation, HFS-P \u0026ndash; Hypoglycemia Fear Survey-Parents\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStructural analysis of the Hungarian version of the HFS-P\u003c/h2\u003e \u003cp\u003eFirst, we examined the four-factor structure (25 items) of the HFS-P questionnaire recommended by Shepard et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) using confirmatory factor analysis. We considered the model fit to be adequate if the chi-square (χ2) test result supported our model, i.e., if the test result was not significant and the value obtained was lower than twice the degrees of freedom. The χ2 test is sensitive to the normality of the sample, so if normality is violated, the test results often suggest rejecting the model, making the results less informative for us.\u003c/p\u003e \u003cp\u003eThe fit indices of the first model fell short of expectations (\u003csup\u003e\u003cb\u003eχ2\u003c/b\u003e\u003c/sup\u003e(116)\u0026thinsp;=\u0026thinsp;287; CFI\u0026thinsp;=\u0026thinsp;0.894; TLI\u0026thinsp;=\u0026thinsp;0.882; RMSEA\u0026thinsp;=\u0026thinsp;0.0600). In order to improve the fit, taking into account the modification indices, we removed item A7, \u0026ldquo;My child behaves \u0026lsquo;strangely\u0026rsquo; or seems clumsy due to low blood sugar levels,\u0026rdquo; which improved the fit of our model the most (\u003csup\u003e\u003cb\u003eχ2\u003c/b\u003e\u003c/sup\u003e(116)\u0026thinsp;=\u0026thinsp;287; CFI\u0026thinsp;=\u0026thinsp;0.932; TLI\u0026thinsp;=\u0026thinsp;0.924; RMSEA\u0026thinsp;=\u0026thinsp;0.0490).\u003c/p\u003e \u003cp\u003eThe fit indices of the first model (Model 1, M1) of the three-factor (18-item) solution also fell short of expectations (\u003csup\u003e\u003cb\u003eχ2\u003c/b\u003e\u003c/sup\u003e(132)\u0026thinsp;=\u0026thinsp;458; CFI\u0026thinsp;=\u0026thinsp;0.906; TLI\u0026thinsp;=\u0026thinsp;0.891; RMSEA\u0026thinsp;=\u0026thinsp;0.0783). Based on the results of the modification indices, similar to the four-factor model, the fit indices improved the most by removing item A7. Overall, CFA confirmed the three-factor structure in our sample, and after removing a single item, the three-factor model ultimately had stronger fit indices than the four-factor solution (\u003csup\u003e\u003cb\u003eχ2\u003c/b\u003e\u003c/sup\u003e(116)\u0026thinsp;=\u0026thinsp;287; CFI\u0026thinsp;=\u0026thinsp;0.948; TLI\u0026thinsp;=\u0026thinsp;0.939; RMSEA\u0026thinsp;=\u0026thinsp;0.0605) (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFit indices of HFS-P in a Hungarian sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eχ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM1(4F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.882\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM2(4F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.932\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.0490\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM1(3F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.891\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eM2(3F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e287\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eM1(4F) - fit indices of the original four-factor (25-item) solution;\u003c/p\u003e \u003cp\u003eM2(4F) - fit indices of the four-factor (24-item) solution after removing item A7, M1(3F): the fit indices of the three-factor (18-item) solution,\u003c/p\u003e \u003cp\u003eM2(3F): the fit indices of the three-factor (17-item) solution after removing item A7\u003c/p\u003e \u003cp\u003edf \u0026ndash; degree of freedom, CFI - comparative fit index, TLI - Tucker-Lewis index, RMSEA - Root mean square error of approximation, HFS-P \u0026ndash; Hypoglycemia Fear Survey-Parents\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eReliability\u003c/h2\u003e \u003cp\u003eTo determine the internal consistency of the questionnaire, we calculated Cronbach's alpha values for the HFS-P for each subscale separately and for the entire scale. We considered values above 0.6 to be acceptable and values above 0.8 to be good. In the four-factor model, the internal consistency of the \"Avoiding Low Blood Sugar\" subscale was low (α\u0026thinsp;=\u0026thinsp;0.448), so, similar to the international research, we finally decided on a three-factor solution for the Hungarian sample and performed further calculations with M2(3F).\u003c/p\u003e \u003cp\u003eThe complete 17-item scale showed good internal consistency (Cronbach's α\u0026thinsp;=\u0026thinsp;0.892). The Cronbach's alpha values for the subscales ranged from 0.658 to 0.893. Reliability is good for both the \"Helplessness\" (Cronbach's α\u0026thinsp;=\u0026thinsp;0.893) and \"Maintaining High Blood Sugar\" (α\u0026thinsp;=\u0026thinsp;0.854) subscales, while the reliability of the \"Negative Social e Consequences\" (α\u0026thinsp;=\u0026thinsp;0.658) subscale is acceptable (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eConvergent validity\u003c/h2\u003e \u003cp\u003eGiven that neither PAID-P nor HFS-P met the normality criterion, we used Spearman's rank correlation to examine the convergent validity of the HFS-P questionnaire. There was a statistically significant correlation between the FoH total score and the PAID-P total score (\u003cem\u003ers\u003c/em\u003e(401)\u0026thinsp;=\u0026thinsp;0.393, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a weak, positive association between the FoH and the constructs of diabetes distress as applied to parents. Looking at the subscales, we found a statistically significant, weak, positive correlation for all three subscales: \u0026bdquo;Maintaining High Blood Sugar\u0026rdquo; (\u003cem\u003ers\u003c/em\u003e(401)\u0026thinsp;=\u0026thinsp;0.280, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), \u0026bdquo;Helplessness\u0026rdquo; (\u003cem\u003ers\u003c/em\u003e(401)\u0026thinsp;=\u0026thinsp;0.295, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), \u0026bdquo;Negative Social Consequences\u0026rdquo; (\u003cem\u003ers\u003c/em\u003e (401)\u0026thinsp;=\u0026thinsp;0.320, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between HFS-P and PAID-P\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHFS-P sum score\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePAID-P sum score\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.393***\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintain high bood glucose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.280***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHelplessness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.295***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Social Consequences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.320***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHFS-P - Hypoglycemia Fear Survey-Parent, PAID-P - The Problem Area in Diabetes-Parent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e***p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eThe relationship between severe hypoglycemic episodes and FoH\u003c/h2\u003e \u003cp\u003eOne person was excluded from this analysis due to missing data of the question about severe hypoglycemic episodes. Due to deviations from normality, group differences were assessed using non-parametric methods (Mann\u0026ndash;Whitney U tests). On the total HFS-P scale (U\u0026thinsp;=\u0026thinsp;7290, p\u0026thinsp;=\u0026thinsp;0.008), as well as on the \"Helplessness\" (U\u0026thinsp;=\u0026thinsp;7750, p\u0026thinsp;=\u0026thinsp;0.038) and \"Negative Social Consequences\" (U\u0026thinsp;=\u0026thinsp;7243, p\u0026thinsp;=\u0026thinsp;0.006) subscales, there was a statistically significant difference in mean scores between those who reported severe hypoglycemic episodes in the past year and those who did not report those. However, in the case of the \"Maintaining High Blood Sugar\" subscale (U\u0026thinsp;=\u0026thinsp;8425, p\u0026thinsp;=\u0026thinsp;0.219), there was no statistically significant difference between the groups (See Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between severe hypoglycemic episodes and HFS-P\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHFS-P\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(full scale)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrouping based on:\u003c/p\u003e \u003cp\u003eSHE in the past 12 month\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eno\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e348\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.06\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.29\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eyes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintain High Blood Glucose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eno\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eyes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e348\u003c/p\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003cp\u003e4.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHelplessness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eno\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eyes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Social Consequences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eno\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eyes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e348\u003c/p\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.95\u003c/p\u003e \u003cp\u003e4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.94\u003c/p\u003e \u003cp\u003e4.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults of the Mann-Whitney test revealing the difference between parents who reported/did not report severe hypoglycemic episodes in the past 12 months (SHE(12M)) and statistical indicators of the scores achieved by the two groups on the full scale and subscales of the HFS-P questionnaire.\u003c/p\u003e \u003cp\u003eSHE - severe hypoglycemic episodes, M \u0026ndash; Mean, SD \u0026ndash; Standard Deviation, HFS-P - Hypoglycemia Fear Survey-Parent\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eThe relationship between glycemic control, child age and FoH\u003c/h2\u003e \u003cp\u003eOf the 403 respondents, only 350 provided data about HbA1c values. Two groups, suboptimal (HbA1c value\u0026thinsp;\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;7.0%) and optimal (HbA1c value\u0026thinsp;\u0026le;\u0026thinsp;7.0%), were formed based on the medically recommended target values mentioned in the introduction (ISPAD, 2022). There was no statistically significant difference between the mean scores of the groups regarding the total scale \u003cem\u003e(\u003c/em\u003eU\u0026thinsp;=\u0026thinsp;13644, p\u0026thinsp;=\u0026thinsp;0.102), the \"Maintaining High Blood Sugar\" (U\u0026thinsp;=\u0026thinsp;14695, p\u0026thinsp;=\u0026thinsp;0.601) and the \"Negative Social Consequences\" (U\u0026thinsp;=\u0026thinsp;14199, p\u0026thinsp;=\u0026thinsp;0.290) subscales. However, on the \"Helplessness\" subscale, parents whose children did not reach the glycemic target achieved significantly higher average scores (U\u0026thinsp;=\u0026thinsp;13011, p\u0026thinsp;=\u0026thinsp;0.021) (see Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. In terms of age distribution, parents of children aged 5\u0026ndash;9 achieved significantly higher scores on the \"Maintaining High Blood Sugar\" subscale than parents of children aged 10\u0026ndash;14 (U\u0026thinsp;=\u0026thinsp;15045, p\u0026thinsp;=\u0026thinsp;0.011), but no significant differences were found on the other subscales: \u0026bdquo;Helplessness\u0026rdquo; (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15898, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.083) and \u0026bdquo;Negative Social Consequences\u0026rdquo; (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;17047, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.510).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe associations between HbA1c and HFS-P scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHFS-P (sum score)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrouping based on the HbA1c values\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;\u003cb\u003e7.0%\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e191\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e19.41\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e11.74\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e159\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e21.97\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e13.38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintain High Blood Sugar\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;\u003cb\u003e7.0%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e191\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.84\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.82\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.601\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e159\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e4.09\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.08\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHelplessness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;\u003cb\u003e7.0%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e191\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e14.56\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e8.82\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e159\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e12.57\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e9.51\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Social\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eConsequences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;\u003cb\u003e7.0%\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e191\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e159\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3.00\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3.33\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.06\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e3.20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults of the Mann-Whitney test including the number of items (N), Mean (M) and Standard Deviation (SD), revealing the difference between the suboptimal group (HbA1c value\u0026thinsp;\u003cb\u003e\u0026gt;\u003c/b\u003e\u0026thinsp;7.0%) and the optimal group (HbA1c value\u0026thinsp;\u0026le;\u0026thinsp;7.0%). HFS-P - Hypoglycemia Fear Survey-Parent, HbA1c - Hemoglobin-A1c)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eThe relationship between CGM use and FoH\u003c/h2\u003e \u003cp\u003eThis analysis included participants who used a CGM or SMBG on a permanent basis, i.e., participants who used the CGM temporarily (e.g., only in case of illness) were not included in the analysis. Looking at the average scores of parents, there was no statistically significant difference between parents who used CGM and those who did not, either on the full scale (U\u0026thinsp;=\u0026thinsp;12126, p\u0026thinsp;=\u0026thinsp;0.116) or on the individual subscales: \u0026bdquo;Helplessness\u0026rdquo; (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12718, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.342), \u0026bdquo;Negative Social Consequences\u0026rdquo; (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12512, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.239). Only the subscale \u0026bdquo;Maintaining High Blood Sugar\u0026rdquo; (\u003cem\u003eU\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12046, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.095) showed significance on a tendency level (see Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGroup differences between CGM use and HFS-P scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHFS-P\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(sum score)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCGM\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSBGM\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e306\u003c/p\u003e \u003cp\u003e89\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.25\u003c/p\u003e \u003cp\u003e19.06\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.75\u003c/p\u003e \u003cp\u003e12.43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaintaining High Blood Sugar\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCGM\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSBGM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e306\u003c/p\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.01\u003c/p\u003e \u003cp\u003e3.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.91\u003c/p\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHelplessness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCGM\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSBGM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e306\u003c/p\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.96\u003c/p\u003e \u003cp\u003e12.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.42\u003c/p\u003e \u003cp\u003e8.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNegative Social\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eConsequences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCGM\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSBGM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e306\u003c/p\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.28\u003c/p\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults of the Mann-Whitney test revealing differences between groups created based on CGM use, and statistical indicators describing the scores achieved by the two groups on the full scale and on the subscales, including the number of items (N), the Mean (M) and Standard Deviation (SD) + overall scores achieved on the questionnaire.\u003c/p\u003e \u003cp\u003eHFS-P - Hypoglycemia Fear Survey-Parent, CGM - Continuous Glucose Monitoring, SBGM - Self-Monitoring of Blood Glucose\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eExamination of the effects of factors predicting parental fear of hypoglycemia\u003c/h2\u003e \u003cp\u003eThe dependent variable in the model was the average HFS-P score. The model proved to be significant (F(13,298)\u0026thinsp;=\u0026thinsp;7.26, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003eadj\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;0.207). The independent variables explain 20.7 percent of the variance of the dependent variable. Fear of hypoglycemia is significantly predicted by higher diabetes distress, more perceived problems with diabetes management, longer duration of diagnosis, and younger age of the child with diabetes. Significant and non-significant predictors are shown in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLinear regression analysis for HSF-P score as dependent variable\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParents\u0026rsquo; age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.227\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild's gender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.396\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild's Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e-0.141\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e-2.287\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime spent in diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.147\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.539\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaving higher education level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of blood glucose monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of insulin Insertion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere hypoglicemic episode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.947\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.675\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePAID\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.268\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e4.201\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDKT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceived management problems\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.183\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.854\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eHFS-P - Hypoglycemia Fear Survey-Parent; HbA1c - Hemoglobin-A1c; PAID - The Problem Area in Diabetes-Parent; DKT \u0026ndash; Diabetes Knowledge Test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results confirm the psychometric suitability of the HFS-P questionnaire on a Hungarian sample. During confirmatory factor analysis, we achieved adequate fit indices by removing a single item, thus confirming the 17-item, three-factor structure. Based on Cronbach's alpha values (similar to the results obtained during the original validation of the international questionnaire) the entire questionnaire has good (nearly excellent) internal reliability (O'Donell et al., 2022). Looking at the individual subscales, the Cronbach's alpha values for the \"Helplessness\" subscale and the \"Maintaining High Blood Sugar\" subscale are adequate, while those for the \"Negative Social Consequences\" subscale indicate acceptable internal consistency. In both the Hungarian and international samples, the \"Negative Social Consequences\" subscale showed the weakest reliability (O'Donell et al., 2022; Shepard et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs evidence of convergent validity, the HFS-P total score showed a significant, weak positive correlation with the PAID-P total score, which points out that caregivers' higher FoH is associated with greater levels of diabetes-specific emotional distress.\u003c/p\u003e \u003cp\u003eWhen examining the relationship between FoH and glycemic control, we obtained significant results only for the \u0026ldquo;Helplessness\u0026rdquo; subscale, which suggests that parents\u0026rsquo; fears are primarily centered around loss of control due to hypoglycemia, rather than fears of negative judgments from their environment. The results of the age group analysis warn that parents of young children (aged 5\u0026ndash;9) may more often use the maladaptive strategy of keeping their child's blood sugar level higher than recommended for safety reasons (Van Name, 2017). One methodological criticism that has been raised is that most studies use HbA1c as a measure of glycemic control, which does not allow for a more nuanced exploration of the relationship between FoH and glucose control, e.g., it does not provide information on glucose variability, only about the average blood glucose level over the past 2\u0026ndash;3 months (Martyn-Nemeth et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Higher levels of fear of hypoglycemia (FoH) were predicted by greater diabetes-related distress, more perceived problems in diabetes management, longer duration of diagnosis, and younger age of children living with diabetes. These findings highlight the importance of regular screening for diabetes-related distress during routine annual check-ups, particularly among parents of younger children (aged 5\u0026ndash;9 years) who have already experienced a severe hypoglycemic episode in the past year.\u003c/p\u003e \u003cp\u003eConsidering the role of modern technology in measuring blood sugar, which should help parents to feel the control in diabetes management, the ones who use CGM, also more often use the maladaptive strategy of keeping their child's blood sugar level higher. This result contradicts our expectations, but should be handled with caution due to its lower significance (p\u0026thinsp;=\u0026thinsp;0.095). Therefore, evidence regarding the effectiveness of modern diabetes technologies in reducing fear of hypoglycemia (FoH) remains inconclusive. Exploring parents\u0026rsquo; diverse experiences with diabetes devices through semi-structured qualitative interviews may be valuable, with particular attention to nighttime management and the degree of trust placed in the technology. Qualitative approaches could provide a more nuanced understanding of individual patterns of complex coping strategies. In addition, future research should examine glycemic variability using continuous glucose monitoring (CGM) data. Our findings suggest that parents who were subjectively more distressed by their child\u0026rsquo;s hypoglycemic episodes reported higher levels of emotional distress and FoH. This highlights the importance of subjective experience in FoH development and suggests that predictive factors such as parental trait anxiety may also play a role. Parents with higher trait anxiety may be more prone to catastrophizing physical symptoms, potentially amplifying fear responses to hypoglycemic events.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eA limitation of the study is that we relied on parental reports to obtain glycemic data rather than objective data (from medical databases). Based on these the glycemic values of the children were below the medically suitable target. Furthermore, the respondents were mainly highly educated women. Hence, we do not consider our results to be representative. One obstacle to the clinical use of the questionnaire is that, to our knowledge, there is still no consensus on the threshold values required for clinical diagnosis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe strength of the study is that our research was the first to examine parents' FoH in a Hungarian sample and adapted a psychometrically suitable questionnaire into Hungarian for FoH research. In the future, a more holistic, biopsychosocial approach will be essential for understanding and treating psychological factors relevant to optimal glycemic control, such as FoH. We hope that the validated Hungarian-language HFS-P questionnaire, combined with a semi-structured interview, will be the first step in screening parents struggling with pathological FoH in the diabetes care system. It is important that those affected have access to personalized psychoeducation, which can help them develop more conscious diabetes management.\u003c/p\u003e \u003cp\u003eBeyond the validation of the Hungarian version of the HFS-P, this study examined the relationships between parental fear of hypoglycemia and key psychosocial and clinical factors. Our findings indicate that fear of hypoglycemia in parents is closely associated with diabetes-related distress, perceived difficulties in diabetes management, child age, and disease duration. While the protective role of modern diabetes technologies remains inconclusive, these results underscore the importance of regular psychosocial screening to identify parents at increased risk and inform tailored clinical support.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT1DM (type 1 diabetes mellitus)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHFS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eP (Hypoglycemia Fear Survey-Parents)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFoH (Fear of Hypoglycemia)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHbA1c (Hemoglobin\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eA1c)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCGM (continuous glucose monitoring)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSBGM (Self\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMonitoring of Blood Glucose)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCSII (Continuous Subcutaneous Insulin Infusion)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDI (Multiple Daily Injections)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSHE (severe hypoglycemic episode)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eP (The Problem Area in Diabetes-Parent)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGV (glycemic variability)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research plan was worked out and the research was conducted in accordance with the provisions of the World Medical Association Declaration of Helsinki and was approved by the Medical Research Council of Hungary (Approval number: IV/9901-1/2021/EKU).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDear Sir/Madam,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to invite you to participate in fullfilling a questionnaire for parents regarding the management of their children’s diabetes, which is a non-interventional, observational scientific data collection. The data will be collected based on the questionnaires you complete. The study does not impose any other burden on you beyond completing the questionnaires. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study is conducted anonymously, in full compliance with medical confidentiality, for the purpose of developing medicines that meet the needs of patients. Please check the box below to confirm that you are participating in the study voluntarily. Your consent can be withdrawn at any time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eo \u0026nbsp; \u0026nbsp; I acknowledge the contents of the Patient Information Sheet, I have read the details of the research, and I voluntarily agree to participate in the study.\u003c/p\u003e\n\u003cp\u003eName of study participant: ______________________\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch data can be found online in Mendeley Data at \"Horvath, Maria Dora; Katai, Laszlo; Tesch, Zsanett; Buzas, Norbert; Papp-Zipernovszky, Orsolya (2026), “Does the development of diabetes technology reduce parents fear of hypoglycemia? - A validation study”, Mendeley Data, V1, doi: 10.17632/vpnc9vdjdj.1\"\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was supported by the Digital Society Competence Centre of the Humanities and Social Sciences Cluster of the Centre of Excellence for Interdisciplinary Research, Development and Innovation of the University of Szeged, where the authors MH and OPZ are members of the \"Well-being and Health in the Digital Age\" research group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMDH\u003c/strong\u003e: had a major role in the conceptualization of the research, and analyzed and interpreted the data. She also took part in funding aqcuisition and was a major contributor in writing the original draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLK\u003c/strong\u003e:\u0026nbsp;analyzed the data and was a major contributor in writing the original draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eZsT\u003c/strong\u003e: had a role in the conceptualization of the research and searched eligible organizations for data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNB\u003c/strong\u003e: had a major role in the conceptualization of the research, provided supervision during the work and led the project administration. He also contributed to the writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eO P-Z\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003ehad a major role in the conceptualization of the research, and interpreted the results. She also took part in funding aqcuisition and was a contributor in writing the original draft of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAalders J, Hartman E, Nefs G, Nieuwesteeg A, Hendrieckx\u003csup\u003e \u003c/sup\u003eC, Aanstoot H-J, et al. Mindfulness and fear of hypoglycaemia in parents of children with Type 1 diabetes: results from Diabetes MILES Youth - The Netherlands. Diabet Med. 2018;35:650\u0026ndash;7. doi: 10.1111/dme.13594\u003c/li\u003e\n\u003cli\u003eAbitbol L, Palmert MR. When low blood sugars cause high anxiety: Fear of hypoglycemia among parents of youth with type 1 diabetes mellitus. Can J Diabetes\u003cem\u003e.\u003c/em\u003e 2020;45:403-10. doi:10.1016/j.jcjd.2020.08.098 \u003c/li\u003e\n\u003cli\u003eAbraham MB, Karges B, Dovc K, Naranjo D, Arbelaez AM, Mbogo J, et al. ISPAD Clinical Practice Consensus Guidelines: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes. 2022;20,238:1322\u0026ndash;40. doi: 10.1111/pedi.13443\u003c/li\u003e\n\u003cli\u003eBloomgarden Z. Fear of hypoglycemia. J Diabetes. 2016;9:108\u0026ndash;10. doi: 10.1111/1753-0407.12491\u003c/li\u003e\n\u003cli\u003eCox DJ, Irvine A, Gonder-Frederick L, Nowacek G, Butterfield J. Fear of hypoglycemia: quantification, validation, and utilization. Diabetes Care. 1987;10:617\u0026ndash;21. doi: 10.2337/diacare.10.5.617.\u003c/li\u003e\n\u003cli\u003eBuz\u0026aacute;s N, Horv\u0026aacute;th MD, Tesch Zs, Hallgat\u0026oacute; E. How online peer support affects management efficacy and mitigates difficulties of parents caring for children with type 1 diabetes. Prim Care Diabetes. 2023;17:607-11. doi: 10.1016/j.pcd.2023.09.003.\u003c/li\u003e\n\u003cli\u003eDriscoll KA, Raymond J, Naranjo D, Patton SR. Fear of Hypoglycemia in Children and Adolescents and Their Parents with Type 1 Diabetes. Curr Diab Rep. 2016;16:77. doi: 10.1007/s11892-016-0762-2.\u003c/li\u003e\n\u003cli\u003eEvans MA, Weil LEG, Shapiro JB, Anderson LM, Vesco AT, Rychlik K, et al. Psychometric Properties of the Parent and Child Problem Areas in Diabetes Measures. J Pediatr Psychol. 2019;44:703-13. doi: 10.1093/jpepsy/jsz018.\u003c/li\u003e\n\u003cli\u003eGonder-Frederick LA, Fisher CD, Ritterband LM, Cox DJ, Hou L, DasGupta AA, et al. Predictors of fear of hypoglycemia in adolescents witht ype 1 diabetes and their parents. Pediatr Diabetes. 2006;7:215\u0026ndash;22. doi: 10.1111/j.1399-5448.2006.00182.x.\u003c/li\u003e\n\u003cli\u003eGrammes J, Sch\u0026auml;fer M, Benecke A, L\u0026ouml;w U, Klostermann A-L, Kubiak T, et al. Fear of hypoglycemia in patients with type 2 diabetes: The role of interoceptive accuracy and prior episodes of hypoglycemia. J Psychosom Res. 2018;105:58\u0026ndash;63. doi: 10.1016/j.jpsychores.2017.12.010.\u003c/li\u003e\n\u003cli\u003eGreen L, Feher M, Catalan J. Fears and phobias in people with diabetes. Diabetes Metab Res Rev. 2000;16:287\u0026ndash;293. doi: 10.1002/1520-7560(2000)9999:9999\u0026lt;::AID-DMRR123\u0026gt;3.0.CO;2-T.\u003c/li\u003e\n\u003cli\u003eHaugstvedt A, Wentzel-Larsen T, Aarflot M, Rokne B, Graue M. Assessing fear of hypoglycemia in a population-based study among parents of children with type 1 diabetes \u0026ndash; psychometric properties of the hypoglycemia fear survey \u0026ndash; parent version. BMC Endocr Disord. 2015;15:2. doi: 10.1186/1472-6823-15-2.\u003c/li\u003e\n\u003cli\u003eHaugstvedt A, Wentzel-Larsen T, Graue M, S\u0026oslash;vik O, Rokne B. Fear of hypoglycaemia in mothers and fathers of children with Type 1 diabetes is associated with poor glycaemic control and parental emotional distress: a population-based study. Diabet Med. 2010;27:72\u0026ndash;8. doi: 10.1111/j.1464-5491.2009.02867.x.\u003c/li\u003e\n\u003cli\u003eHu L, Bentler PM. Fit indices in covariance structure modeling: Sensitivity to under parameterized model misspecification. Psychol Methods. 1998;3:424\u0026ndash;453. doi: 10.1037/1082-989X.3.4.424.\u003c/li\u003e\n\u003cli\u003eJaser SS, Foster NC, Nelson BA, Kittelsrud JM, DiMeglio LA, Quinn M, et al. Sleep in children with type 1 diabetes and their parents in the T1D Exchange. Sleep Med. 2017;39:108-15. doi: 10.1016/j.sleep.2017.07.005.\u003c/li\u003e\n\u003cli\u003eKostopoulou E, Andreopoulou O, Daskalaki S, Kotanidou E, Vakka A, Galli-Tsinopoulou A, et al. Translation and Validation Study of the Hypoglycemia Fear Survey in a Greek Population of Children and Adolescents with Type 1 Diabetes Mellitus and their Parents. Children (Basel). 2023;10:1458. doi: 10.3390/children10091458.\u003c/li\u003e\n\u003cli\u003eKrawczyk J, Duda-Sobczak A, Zozulińska-Zi\u0026oacute;łkiewicz D. Fear of hypoglycaemia\u0026mdash;from normality to pathology. Diagnostic criteria and the terapeutic directions. Clin Diabetol. 2021;9:479\u0026ndash;84. doi: 10.5603/DK.2020.0046.\u003c/li\u003e\n\u003cli\u003eMacaulay GC, Boucher SE, Yogarajah A, Galland BC, Wheeler BJ. Sleep and Night-time Caregiving in Parents of Children and Adolescents with Type 1 Diabetes Mellitus \u0026ndash; A Qualitative Study. Behav Sleep Med. 2019;1\u0026ndash;15.doi:10.1080/15402002.2019.1647207.\u003c/li\u003e\n\u003cli\u003eMartyn-Nemeth P, Phillips SA, Mihailescu D, Schwarz Farabi S, Park\u003csup\u003e \u003c/sup\u003eC, Lipton R, et al. Poor sleep quality is associated with nocturnal glycaemic variability and fear of hypoglycaemia in adults with type 1 diabetes. J Adv Nurs. 2018;74:2373-80. doi: 10.1111/jan.13765.\u003c/li\u003e\n\u003cli\u003eMartyn-Nemeth P, Quinn L, Penckofer S, Park C, Hofer V, Burke L. Fear of hypoglycemia. Influence on glycemic variability and self-management behavior in young adults with type 1 diabetes. J Diabetes Complications. 2017;31:735\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eMartyn-Nemeth P, Schwarz Farabi S, Mihailescu D, Nemeth J, Quinn L. Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention - a review. J Diabetes Complications. 2016;30:167\u0026ndash;77. doi: 10.1016/j.jdiacomp.2015.09.003.\u003c/li\u003e\n\u003cli\u003eMonzon A, McDonough R, Meltzer LJ, Patton SR. Sleep and type 1 diabetes inchildren and adolescents: Proposed the or etical model and clinical implications. Pediatr Diabetes. 2019;20: 78-85. doi: 10.1111/pedi.12797.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Donell HK, Johnson SB, Sileo D, Majidi S, Gonder-Frederick L, Driscoll KA. Psychometric Properties of the Hypoglicemia Fear Survey in a Clinical Sample of Adolescents with Type1 Diabetes and Their Caregivers. J Pediatr Psychol. 2022;47:195-205. doi: 10.1093/jpepsy/jsab093.\u003c/li\u003e\n\u003cli\u003ePatterson CC, Karuranga S, Salpea P, Saeedi P, Dahlquist G, Soltesz Gy, et al. Worldwide estimates of incidence, prevalence and mortality of type 1 diabetes in children and adolescents: Results from the International Diabetes Federation Diabetes Atlas, 9th edn. Diabetes Research and Clinical Practice. 2019;157: 107842. doi: 10.1016/j.diabres.2019.107842.\u003c/li\u003e\n\u003cli\u003ePatton SR, Dolan LM, Henry R, Powers SW. Fear of Hypoglycemia in Parents of Young Children with Type1 Diabetes Mellitus. J Clin Psychol Med. 2008;15:252\u0026ndash;59. doi: 10.1007/s10880-008-9123-x.\u003c/li\u003e\n\u003cli\u003ePrzezak A, Bielk W, Moleda P. Fear of hypoglycemia - An underestimated problem. Brain Behav. 2022;12:e2633. doi: 10.1002/brb3.2633.\u003c/li\u003e\n\u003cli\u003eRichmond J. Effects of hypoglycaemia: patients perceptions and experiences. Br J Nurs. 2014;5:1054-59. doi: 10.12968/bjon.1996.5.17.1054.\u003c/li\u003e\n\u003cli\u003eShepard JA, Vajda K, Nyer M, Clarke W, Gonder-Frederick L. Understanding the Construct of Fear of Hypoglycemia in Pediatric Type 1 Diabetes. J Pediatr Psychol. 2014; 39:1115\u0026ndash;25. doi: 10.1093/jpepsy/jsu068.\u003c/li\u003e\n\u003cli\u003eThe jamovi project (2024). jamovi. (Version 2.5) [Computer Software]. Retrieved from https://www.jamovi.org.\u003c/li\u003e\n\u003cli\u003eTumini S, Fioretti E, Rossi I, Cipriano P, Franchini S, Guidone PI, et al. Fear of hypoglycemia in children with type 1 diabetes and their parents: Validation of the Italian version of the Hypoglycemia Fear Survey for Children and for Parents. Pediatr Diabetes. 2021;23:126-38. doi: 10.1111/pedi.13301.\u003c/li\u003e\n\u003cli\u003eVan Name MA, Hilliard ME, Boyle CT, Miller KM, DeSalvo DJ, Anderson BJ, et al. Nighttime is the worst time: parental fear of hypoglycemia in young children with type 1 diabetes. Pediatr Diabetes. 2017;19:114\u0026ndash;20. doi: 10.1111/pedi.12525.\u003c/li\u003e\n\u003cli\u003eYale JF, Paty B, Senior A. Hypoglycemia. Can J Diabetes. 2018;42:S104\u0026ndash;S108. doi: 10.1016/j.jcjd.2017.10.010.\u003c/li\u003e\n\u003cli\u003eYoungkin EM, Majidi S, Noser AE, Stanek KR, Clements MA, Patton\u003csup\u003e \u003c/sup\u003eSR. Continuous Glucose Monitoring Decreases Hypoglycemia Avoidance Behaviors, but not Worry in Parents of Youth With New Onset Type 1 Diabetes. J Diabetes Sci Technol. 2020;15:1093-97. doi: 10.1177/193229682092942.\u003c/li\u003e\n\u003cli\u003eZhang L, Xu H, Liu L, Bi Y, Li\u003csup\u003e \u003c/sup\u003eX, Kan Y, et al. Related factors associated with fear of hypoglycemia in parents of children and adolescents with type 1 diabetes - A systematic review. J Pediatr Nurs. 2022;66:125-35. doi: 10.1016/j.pedn.2022.05.022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"T1DM, Hypoglycemia Fear Survey-Parents version, glycemic control, technology, confirmatory factor analysis","lastPublishedDoi":"10.21203/rs.3.rs-9003021/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9003021/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eParents' fear of hypoglycemia may hinder optimal glycemic control in the treatment of their children with type 1 diabetes. Currently, there is no Hungarian adaptation of the Hypoglycemia Fear Survey-Parents version. The main aim of our study is to validate this questionnaire in a sample of parents of children aged 5\u0026ndash;14 with type 1 diabetes. We also examined the relationship between parents' fear of hypoglycemia and the characteristics of their children's diabetes-specific clinical profile (e.g., severe hypoglycemic episodes, continuous glucose monitoring use).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e403 parents of children aged 5\u0026ndash;14 suffering from type 1 diabetes (94.5% female, mean age\u0026thinsp;=\u0026thinsp;41.5+/-5.70 years) completed the Hypoglycemia Fear Survey-Parents and the Diabetes Distress Survey Parent Version (The Problem Area in Diabetes-Parent) in the form of an online questionnaire.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe results of the confirmatory factor analysis confirmed the three-factor structure of the survey (χ2(116)\u0026thinsp;=\u0026thinsp;287; CFI\u0026thinsp;=\u0026thinsp;0.948; TLI\u0026thinsp;=\u0026thinsp;0.939; RMSEA\u0026thinsp;=\u0026thinsp;0.0605). The reliability of the entire scale was good (α\u0026thinsp;=\u0026thinsp;0.892), together with the \u0026bdquo;Maintaining High Blood Sugar\u0026rdquo; (α\u0026thinsp;=\u0026thinsp;0.854) and the \u0026bdquo;Helplessness\u0026rdquo; subscales (α\u0026thinsp;=\u0026thinsp;0.893). The internal consistency of the \u0026bdquo;Worry about Negative Social Consequences\u0026rdquo; subscale (α\u0026thinsp;=\u0026thinsp;0.658) was acceptable. As evidence of convergent validity, the total score of the Hypoglycemia Fear Survey-Parents and the Diabetes Distress Survey Parent showed a significant, weak, positive correlation (\u003cem\u003ers\u003c/em\u003e(401)\u0026thinsp;=\u0026thinsp;0.393, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The occurrence of severe hypoglycemic episodes in the medical history was associated with significantly higher parents\u0026rsquo; fear (U\u0026thinsp;=\u0026thinsp;7290, \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.008\u003c/em\u003e). In the usage of modern technology, only the subscale \u0026bdquo;Maintaining High Blood Sugar\u0026rdquo; (U\u0026thinsp;=\u0026thinsp;12046, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.095) showed significant difference on a tendency level. Linear regression analysis showed that fear of hypoglycemia was significantly predicted by higher diabetes distress, perception of more diabetes-related problems, longer duration of diagnosis, and younger age of the child with diabetes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe 17-item Hypoglycemia Fear Survey-Parents proved to be a valid and reliable measure of parental fear in the Hungarian sample. A history of severe hypoglycemia and the child\u0026rsquo;s younger age were predictive factors for its development. It helps to identify parents during diabetes control examinations with clinically significant fear, thus organize additional, personalized educational and supportive programs. The usage of modern technology increased the maladaptive strategy of \u0026bdquo;Maintaining High Blood Sugar\u0026rdquo;.\u003c/p\u003e","manuscriptTitle":"Does the development of diabetes technology reduce parents fear of hypoglycemia? - A validation study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-13 10:56:13","doi":"10.21203/rs.3.rs-9003021/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"276323608243034076973436172074617089838","date":"2026-04-21T12:14:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T17:18:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46548998335825146288348101740526404965","date":"2026-04-18T15:01:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T10:35:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64356170563926273752044753045587109961","date":"2026-04-09T07:45:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-07T04:52:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-06T12:46:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T04:21:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-14T16:01:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-14T15:56:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b59536d7-6c73-4a9b-bbe3-7df6955343da","owner":[],"postedDate":"April 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T10:56:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-13 10:56:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9003021","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9003021","identity":"rs-9003021","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}