Development of a Measure to Assess Attitudes Towards Nasal versus Autoinjector Glucagon Delivery Devices for Treatment of Severe Hypoglycemia

Figures & data

Table 1 Revisions to GDAQ

Item	Original Wording	Revision
A1	How complicated would it be to follow the instructions	IF PWD SHOW: How complicated would it be for your family member or friend to follow the instructions for
A3	How intimidating is it to use	IF PWD SHOW: How intimidating is it for your family member/friend to use IF CG/AQ SHOW: How intimidating is it for you to use
A6	How likely [IF PWD SHOW “is your family member/friend” IF CG OR AC SHOW “are you”] to feel panicky using	IF PWD SHOW: How likely is your family member/friend to feel panicky because of using IF CG/AQ SHOW: How likely are you to feel panicky because of using
A11	How concerned are you about the time it takes to deliver glucagon with	How concerned are you about the time it takes to prepare the device for administration with
A15	[PWD AND CG ONLY] How confident would you be in asking others for help if you had	How comfortable would you be in asking others for help to administer glucagon in an emergency if you had
A16	How secure would you feel having with you	How reassured would you feel having with you
A20	How convenient do you think it would be to use	IF PWD SHOW: How convenient do you think it would be for your family member/friend to use
A30	Overall, how easy is it for children to use	30. Overall, how easy is it for children under 12 years old to use
		30a. Overall, how easy is it for teenagers to use
A34	Assuming the 2 devices are the same price and are not too expensive, how likely are you to purchase	Assuming the 2 devices are both available, are the same price and are not too expensive, how likely are you to purchase
A35	SHOW TO PWDs ONLY If it were available, how likely are you to carry around	SHOW TO PWDs ONLY If both were available, how likely are you to carry around
B1	Which do you prefer when it comes to	Which do you prefer when it comes to
	b. Less complicated,	b. Being less complicated,
	f. Causes less worry,	f. Causing less worry,
	m. Carry around device,	m. Carrying around device,
	n. Easier to learn to use,	n. Being easier to learn to use,
	o. Less likely to hesitate in using device,	o. Being less likely to hesitate in using device

Abbreviations: AQ, acquaintance; CG, caregiver; PWD, person with diabetes.

Table 2 Final Factor Loadings for Scales by Respondent Group

Scale		Respondent Group
		Persons With Diabetes		Caregivers		Acquaintances
		(n=405)		(n=313)		(n=305)
		NG	AI	NG	AI	NG	AI
		Factor Loading	Factor Loading	Factor Loading	Factor Loading	Factor Loading	Factor Loading
Prepared and Protected	Likely to use the device correctly	0.28	0.28	0.25	0.39	0.13	0.28
	Confident get/gave full dose	0.34	0.35	0.35	0.45	0.21	0.24
	Feel reassured	0.55	0.61	0.62	0.63	0.56	0.61
	Comfortable to use	0.47	0.57	0.60	0.72	0.64	0.73
	Convenient to use	0.60	0.70	0.65	0.76	0.62	0.77
	Feel prepared and protected	0.92	0.88	0.88	0.92	0.86	0.88
	Feel safe	0.91	0.86	0.89	0.90	0.84	0.86
Hesitation	Complicated to follow instructions*	0.81	0.78	0.77	0.74	0.55	0.72
	Difficulty in finding location*	0.85	0.81	0.79	0.74	0.56	0.76
	Intimidating to use*	0.87	0.81	0.85	0.89	0.72	0.87
	Fearful getting hurt/hurting someone*	0.87	0.78	0.78	0.81	0.72	0.85
	Hesitate in using*	0.79	0.81	0.73	0.77	0.78	0.82
	Feel panicky*	0.79	0.78	0.75	0.82	0.78	0.81
	Likelihood making mistake*	0.85	0.86	0.75	0.82	0.83	0.85
	Mix up with another diabetes device*	0.76	0.72	0.71	0.60	0.70	0.61
	Concerned about the time it may take to prepare*	0.84	0.77	0.68	0.73	0.66	0.70
	Nervous or anxious about use*	0.88	0.88	0.77	0.84	0.77	0.85
	Embarrassed*	0.68	0.58	0.69	0.62	0.51	0.56
	Stressed*	0.85	0.77	0.77	0.80	0.50	0.66
Device Perceptions by Others	Feel panicky (other people)*	0.88	0.90	0.82	0.86	0.89	0.86
	Hesitate in using (other people)*	0.92	0.89	0.88	0.88	0.88	0.86
	Likelihood making mistake (other people)*	0.81	0.72	0.79	0.82	0.74	0.76
	Likely to use device correctly (other people)	0.16	0.16	0.22	0.32	0.30	0.53
	Anxious or worried about use (other people)*	0.81	0.84	0.80	0.80	0.81	0.78
	Difficulty in finding location (other people)*	0.48	0.58	0.37	0.60	0.27	0.60
	Comfortable to use (other people)	0.21	0.22	0.45	0.53	0.39	0.54

Notes: All items rated twice, one for each device, on a scale from 1 to 7. Items with an * were reverse scored such that higher ratings indicate more favorable responses. Since the loading for factors that the attribute was not assigned to was zero, we reported all the loadings in one column.

Abbreviations: AI, autoinjector glucagon; NG, nasal glucagon.

Figure 1 Principal component analysis results for total sample: Scree plot and variance explained for NG rating items.

Abbreviation: NG, nasal glucagon.

Figure 2 Principal component analysis results for total sample: Scree plot and variance explained for AI rating items.

Abbreviation: AI, autoinjector glucagon.

Table 3 Fit Metrics for Confirmatory Factor Analysis

Metric	Respondent Group
	Persons With Diabetes		Caregivers		Acquaintances
	(n=405)		(n=313)		(n=305)
	NG	AI	NG	AI	NG	AI
CFI	0.782	0.783	0.803	0.840	0.781	0.825
RMSEA	0.124	0.116	0.104	0.101	0.101	0.103
RMSEA 90% CI	0.119–0.129	0.111–0.121	0.098–0.109	0.095–0.106	0.095–0.107	0.097–0.109
SRMR	0.137	0.119	0.101	0.089	0.097	0.084

Abbreviations: AI, autoinjector glucagon; CFI, Comparative Fit Index; CI, confidence interval; NG, nasal glucagon; RMSEA, Root Mean Square Error of Approximation; SRMSE, Standardized Root Mean Square Residual.

Table 4 Descriptive Statistics for Device Rating Items Not Included in Factor Analyses by Respondent Group

Global Device Rating Item		Respondent Group
		Persons With Diabetes		Caregivers		Acquaintances
		(n=405)		(n=313)		(n=305)
		NG	AI	NG	AI	NG	AI
		Mean	SD	Mean	SD	Mean	SD
Likely to prefer (other people)	Mean ± SD	5.49 ± 1.52	4.01 ± 1.69	5.67 ± 1.41	4.21 ± 1.68	5.75 ± 1.34	3.90 ± 1.63
	Min, Max	1, 7	1, 7	1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)	10 (2.5)	31 (7.7)	6 (1.9)	26 (8.3)	7 (2.3)	29 (9.5)
	7 - very likely, n (%)	136 (33.6)	36 (8.9)	114 (36.4)	24 (7.7)	115 (37.7)	18 (5.9)
Likely to tell other people about	Mean, SD	5.60 ± 1.57	5.30 ± 1.60	6.08 ± 1.24	5.56 ± 1.59	5.10 ± 1.76	4.79 ± 1.82
	Min, Max	1, 7	1, 7	1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)	15 (3.7)	15 (3.7)	2 (0.6)	7 (2.2)	20 (6.6)	27 (8.9)
	7 - very likely, n (%)	156 (38.5)	118 (29.1)	168 (53.7)	124 (39.6)	93 (30.5)	75 (24.6)
Overall perceived ease of use for children	Mean, SD	4.68 ± 1.77	3.29 ± 1.75	4.95 ± 1.69	3.30 ± 1.77	4.50 ± 1.67	3.00 ± 1.58
	Min, Max	1, 7	1, 7	1, 7	1, 7	1, 7	1, 7
	1 - very difficult, n (%)	19 (4.7)	67 (16.5)	9 (2.9)	61 (19.5)	14 (4.6)	65 (21.3)
	7 - very easy, n (%)	76 (18.8)	28 (6.9)	66 (21.1)	14 (4.5)	41 (13.4)	8 (2.6)
Overall perceived ease of use for teenagers	Mean, SD	5.74 ± 1.30	4.82 ± 1.50	6.03 ± 1.20	4.89 ± 1.69	5.78 ± 1.31	4.71 ± 1.53
	Min, Max	1, 7	1, 7	1, 7	1, 7	1, 7	1, 7
	1 - very difficult, n (%)	4 (1.0)	7 (1.7)	1 (0.3)	13 (4.2)	4 (1.3)	7 (2.3)
	7 - very easy, n (%)	143 (35.3)	60 (14.8)	146 (46.7)	58 (18.5)	111 (36.4)	38 (12.5)
Overall perceived ease of use	Mean, SD	5.90 ± 1.37	5.16 ± 1.57	6.19 ± 1.14	5.19 ± 1.64	5.83 ± 1.33	4.75 ± 1.67
	Min, Max	1, 7	1, 7	2, 7	1, 7	2, 7	1, 7
	1 - not at all, n (%)	8 (2.0)	7 (1.7)	0 (0.0)	7 (2.2)	0 (0.0)	13 (4.3)
	7 - extremely, n (%)	177 (43.7)	102 (25.2)	168 (53.7)	78 (24.9)	123 (40.3)	46 (15.1)
Likelihood to purchase	Mean, SD	5.72 ± 1.62	5.18 ± 1.70	6.07 ± 1.30	5.27 ± 1.72	5.43 ± 1.81	4.40 ± 1.97
	Min, Max	1, 7	1, 7	1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)	15 (3.7)	22 (5.4)	3 (1.0)	14 (4.5)	20 (6.6)	40 (13.1)
	7 - very likely, n (%)	181 (44.7)	104 (25.7)	168 (53.7)	93 (29.7)	119 (39.0)	53 (17.4)
Overall like or dislike	Mean, SD	5.53 ± 1.64	5.22 ± 1.50	5.91 ± 1.47	5.18 ± 1.74	5.73 ± 1.40	4.69 ± 1.67
	Min, Max	1, 7	1, 7	1, 7	1, 7	1, 7	1, 7
	1 - dislike a lot, n (%)	4 (1.0)	5 (1.2)	1 (0.3)	16 (5.1)	1 (0.3)	14 (4.6)
	7 - like a lot, n (%)	156 (38.5)	85 (21.0)	153 (48.9)	84 (26.8)	120 (39.3)	47 (15.4)
Likely to call 911 before use* (CGs and AQs only)	Mean ± SD	na		4.35 ± 2.19	4.19 ± 2.17	4.09 ± 2.23	3.85 ± 2.19
	Min, Max			1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)			46 (14.7)	49 (15.7)	65 (21.3)	69 (22.6)
	7 - very likely, n (%)			79 (25.2)	70 (22.4)	67 (22.0)	54 (17.7)
Likely to call 911 after use* (CGs and AQs only)	Mean ± SD	na		2.58 ± 1.83	2.50 ± 1.81	2.03 ± 1.63	1.99 ± 1.59
	Min, Max			1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)			136 (43.5)	144 (46.0)	182 (59.7)	184 (60.3)
	7 - very likely, n (%)			12 (3.8)	133 (32.8)	13 (4.3)	11 (3.5)
Comfortable asking others to administer in an emergency (PWDs & CGs only)	Mean ± SD	4.09 ± 2.16	3.99 ± 2.09	4.20 ± 2.17	3.94 ± 2.11	na
	Min, Max	1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)	72 (17.8)	70 (17.3)	57 (18.2)	62 (19.8)
	7 - very likely, n (%)	73 (18.0)	59 (14.6)	57 (18.2)	47 (15.0)
Easy to carry around (PWDs & CGs only)	Mean ± SD	5.70 ± 1.69	5.25 ± 1.75	6.25 ± 1.29	5.75 ± 1.60	na
	Min, Max	1, 7	1, 7	1, 7	1, 7
	1 - very unlikely, n (%)	17 (4.2)	12 (3.0)	5 (1.6)	8 (2.6)
	7 - very likely, n (%)	193 (47.7)	133 (32.8)	197 (62.9)	150 (47.9)
Likelihood to carry around (PWDs only)	Mean ± SD	5.79 ± 1.62	5.23 ± 1.73	na		na
	Min, Max	1, 7	1, 7
	1 - very unlikely, n (%)	16 (4.0)	20 (4.9)
	7 - very likely, n (%)	193 (47.7)	118 (29.1)

Notes: All items rated twice, one for each device, on a scale from 1 to 7. Ratings above 4 indicate more favorable responses. Items with an *Were reverse scored such that higher ratings indicate more favorable responses.

Abbreviations: AQs, acquaintances; CGs, caregivers; max, maximum; min, minimum; na, not asked; PWDs, persons with diabetes; SD, standard deviation.

Table 5 Cronbach’s Alpha for Final Scales by Respondent Group

Scale	Respondent Group
	Persons With Diabetes	Caregivers	Acquaintances
	(n=405)	(n=313)	(n=305)
	α	α	α
Prepared and Protected - NG	0.82	0.79	0.76
Prepared and Protected - AI	0.82	0.86	0.82
Hesitation – NG	0.96	0.94	0.91
Hesitation – AI	0.95	0.94	0.94
Device Perceptions by Others – NG	0.81	0.81	0.81
Device Perceptions by Others – AI	0.81	0.86	0.87
Attitudes	0.96	0.96	0.96

Abbreviations: AI, autoinjector glucagon; NG, nasal glucagon.

Table 6 Correlations of Scales with Global Item by Respondent Group

Scale	Respondent Group
	Persons With Diabetes	Caregivers	Acquaintances
	(n=405)	(n=313)	(n=305)
	R	r	r
Prepared and Protected - NG	0.60*	0.60*	0.55*
Prepared and Protected - AI	0.63*	0.74*	0.69*
Hesitation - NG	0.79*	0.72*	0.72*
Hesitation - AI	0.78*	0.76*	0.80*
Device Perceptions by Others - NG	0.37*	0.40*	0.30*
Device Perceptions by Others - AI	0.45*	0.53*	0.58*
Attitude	0.90*	0.86*	0.87*

Notes: “Prepared and Protected” and “Hesitation” scales were correlated with the global item comprising the scale: “Feel prepared and protected”, “Hesitate in using device” (reverse-scored). Device Perceptions by Others” scale was correlated with the item ‘Likelihood to prefer (other people)’. The ‘Attitude’ scale was correlated with the global item ‘Overall preference for device’. *P < 0.001.

Abbreviations: AI, autoinjector glucagon; NG, nasal glucagon.