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ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 137-145  

Effect of a diabetes education camp on perception of insulin therapy in patients of type-2 diabetes mellitus


1 Department of Medicine, 7 Air Force Hospital, Kanpur, Uttar Pradesh, India
2 Department of Cardiology, Cardiac Catheterization Laboratory, Command Hospital (WC), Panchkula, Haryana, India

Date of Web Publication18-May-2018

Correspondence Address:
Anil Kumar
Cardiac Catheterization Laboratory, Command Hospital (WC), Chandimandir, Panchkula - 134 107, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_155_17

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  Abstract 


Introduction: Type-2 Diabetes Mellitus is a pandemic now and most of the patients are treated on OHAs. There are very specific indications to initiate insulin therapy. However, very often, physician's attempt to introduce insulin is met with stiff resistance from the patient. Methods: This was a single-centre, cross-sectional, interviewer-administered survey study, conducted in order to assess the perception of Insulin therapy among patients with type 2 Diabetes Mellitus as well to see the effects of a structured 'Diabetes Education Program' on this perception. Pre-Education & Post-Education data was compiled and analyzed. Result: Out of 88 subjects, 60 were males and 28 females. 14 subjects were on non-pharmaceutical management, 67 were on OHAs only and 7 were taking OHAs+Insulins. Worst Pre-Education perceptions were about: feeling fault of self (in the sense of inability to control diabetes), feeling that insulin therapy means that disease has become much worse. Younger patients and better educated patients had better perceptions about insulin therapy. There was significant Post-Education improvement was found in perception, across all four groups. Conclusion: This Study could identify the worst perception problems for initiation of insulin therapy in patients of type-2 diabetes. A structured 'Diabetes Education Program was highly effective in improving patients' perception about insulin therapy. Patient's education level and availability of 'Diabetes Education Program' were the two most important factors in determining the level of perception of insulin therapy in serving soldiers & their families.

Keywords: Compliance, diabetes, insulin, perception


How to cite this article:
Goyal A, Kumar A. Effect of a diabetes education camp on perception of insulin therapy in patients of type-2 diabetes mellitus. Med J DY Patil Vidyapeeth 2018;11:137-45

How to cite this URL:
Goyal A, Kumar A. Effect of a diabetes education camp on perception of insulin therapy in patients of type-2 diabetes mellitus. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Jul 2];11:137-45. Available from: http://www.mjdrdypv.org/text.asp?2018/11/2/137/232643




  Introduction Top


Lifestyle-related diseases are on rise, and type-2 diabetes is the most prominent among them. It is a pandemic that is taking more and more people in its grip. Its most rapid spread is seen in South Asia. There was a time when inadequate food production, lack of electricity, and lack of transport facilities were the most important problems in human society. Average human being had to do a lot of physical work to earn or to fulfill daily requirements. Human race has progressed now, malnutrition is far less prevalent (and the remaining cases are due to improper food distribution, rather than less food production), electricity and related appliances have reduced our physical burden, and easy access to personal or public transport has reduced our walking. Hence, food is available in excess, tastier, and richer in calories, and physical work has become bare minimum. Outcome is spreading pandemic of diabetes (and other lifestyle diseases).

Managing diabetes is a challenge for a patient as well as medical care providers; as we all know, this disease is not curable till now. The patient has to learn to control it and live with it. Some of the patients of type-2 diabetes can achieve good glycemic control on oral medication. However, there is a subset of patients who require insulin therapy at some time in lifetime, on short- or long-term basis, due to varying reasons. Insulin resistance is at the core of type-2 diabetes. At the onset of the disease, insulin levels are normal (or high). However, as the disease progresses, insulin deficiency appears and gradually becomes more severe, leading to failure of oral medication, thus necessitating insulin therapy. Acute infections or other serious illnesses, pregnancy, major surgery, acute cardiac conditions, kidney disease, and liver disease are some other situations where insulin therapy is required. With passage of time, better forms of insulin have become available. Now, we have a wider choice and hence can have more flexible approach toward insulin therapy. However, worldwide, initiation of insulin therapy is a tricky matter. There is evidence that negative beliefs and attitudes toward insulin predict lower readiness to initiate insulin therapy.[1] Patients are often terrified at the first suggestion of insulin therapy, and many physicians are reluctant to initiate insulin therapy. Both problems have their reasons such as patient factors are fear about insulin such as hypoglycemia, weight gain, reaction, and permanent dependence on insulin.[2],[3] Further needle prick pain, social image, difficulty in keeping insulin injection, and taking dose of injection at workplaces also prohibit patients to initiate insulin therapy.[4],[5]

As a consequence to these barriers, insulin therapy is often delayed till a stage when its use becomes an absolute emergency. Many of these factors are based on hearsay and misconceptions. It is possible to overcome them by regular effective communication with the patient (and caretakers) as well as training the health-care providers. The physicians have often faced reluctance on part of the patient, to initiate insulin therapy and often spend several minutes in educating each patient (who requires insulin therapy) in outpatient department (OPD), often bringing gradual positive change in the patients' attitude toward insulin therapy. However, the process is exhaustive and time-consuming. In a busy OPD, giving 15–20 min to one patient not only means a lot of stress on the doctor but grossly delays the turn of other waiting patients. Community health education carries several benefits over educating individual patients in an OPD. Besides saving of time, it also helps patients interact with each other. Multiple modes of communication can be utilized (e.g., on-screen presentations, pamphlets, videos, posters, exhibition, demonstrations, and discussion sessions) instead of only verbal counseling. There are many scholarly papers available which recommend the use of patient education and communication for overcoming barriers to initiation of insulin therapy in type-2 diabetes.[6] However, we did not come across any study that quantitatively assesses effects of any structured patient education program on the resistance to initiation of insulin therapy.

Objectives

  • To assess the common perception about insulin therapy in soldiers and their dependent families
  • To assess the reasons for resistance to initiating insulin therapy in this group of patients
  • To assess the effects of a “Diabetes Education Camp” on the perception about insulin therapy in this group of patients.



  Methods Top


“Diabetes Education Camp” was conducted at the Institute of Aerospace Medicine, Indian Air Force, Bengaluru. Theme of the program was “Epidemic of Diabetes: Stem the Tide in Time.” It covered the surrounding population of serving soldiers and their families. Patients, their families, as well as other people, attended the program (approximate attendance was about 300). Known cases of type-2 diabetes were registered for the study. We used a questionnaire which is a highly modified form of Insulin Treatment Appraisal Scale7 (Appendix A),[7] to suit the population covered under our study. Free registration was done at inauguration of camp and a questionnaire was given. Elderly and illiterate persons were given help by relatives or friends. Educative sessions were then conducted consisting of lectures on various aspects of diabetes, along with audio-visual aids, display gallery of diabetes-related posters. Exhibition of diabetes-related equipment such as glucometer, insulin syringes, oral medications, insulins, pen devices, continuous glucose monitoring system, and insulin pump was there at the meeting. Along with this live demonstration on storage, dosing and injections of insulin were done. Finally, second (posteducation), answering of the same questionnaire was collected and analyzed. Pre- and post-education scores were compared for each individual, subgroup, group, and overall. The difference in pre- and post-education scores was analyzed and discussed further. Student t-test (two-tailed, independent) has been used to find the significance of study parameters on continuous scale between two groups (intergroup analysis) on metric parameters. Analysis of variance has been used to find the significance of study parameters between three or more groups of patients. Student t-test (two-tailed, dependent) has been used to find the significance of study parameters on continuous scale within each group.




  Results Top


A total of 88 patients of diabetes (type-2) participated in the program. Of these, 60 were males and 28 were females [Table 1]. Thirty-one patients were educated more that intermediate level, 54 had education between primary and intermediate level (i.e., between 6th and 12th standard), and three were educated up to primary level only (i.e., up to 5th standard) [Table 1]. None of the participants was illiterate. Age of participants ranged from 34 to 74 years; most of the patients were in the age ranges of 41–50 and 51–60 years (42.04% and 31.81%, respectively) [Table 1].
Table 1: Distribution of sample according to demographic and therapeutic variables (n=88; mean±standard deviation: 47.68±8.09)

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Total duration of diabetes varied greatly from 1 month to 25 years (mean ± standard deviation: 45.03 ± 55.55 months) [Table 1]. Out of 88 patients, 14 (15.91%) patients were on nonpharmacological management of diabetes, 67 (76.13%) patients were taking oral therapy for diabetes, and 7 (7.95%) patients were on combination of oral drugs with insulin [Table 1]. None of them was on insulin monotherapy or any other injectable drug.

“Preeducation” responses to various questions are given as per [Table 2], [Table 3], [Table 4] (in order of “best to worse” and in order of “worst to best”). Ten best and ten worst “preeducation” perceptions are given in [Table 2], [Table 3], [Table 4]. “Posteducation” responses to various questions are given as per [Table 2], [Table 3], [Table 4] (in order of “best to worse and in order of “worst to best”). Ten best and ten worst “posteducation” perceptions are given in [Table 2], [Table 3], [Table 4]. Question-wise responses and improvements are given in [Table 5]. Overall responses and improvements are summarized in [Table 6]. There was strongly significant overall “posteducation” improvement in our study [Table 6]. Best-improved and least-improved perceptions about insulin therapy are given in [Table 5]. Significance level of improvement in 71–80 years' age group could not be calculated due to sample size being “1” only. However, there was about 18% improvement over the “preeducation” response in this age group. All other age groups showed statistically significant improvement. However, the improvement in 61–70 years' age group was less impressive [Table 7].
Table 2: Total response to each question* (out of maximum 264)

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Table 3: Position of questions related to perceptions/improvements in perceptions about insulin therapy

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Table 4: Overall posteducation improvements in perceptions about insulin therapy

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Table 5: Improvement as per demographic and therapeutic variables

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Table 6: Interpretation of responses to questions

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Table 7: Posteducation improvements in perceptions about insulin therapy (question-wise)

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There was no significant difference in preeducation as well as posteducation responses between two gender groups. There was statistically strongly significant “posteducation” improvement in both gender groups [Table 7].

We found that preeducation score was directly related to the education level. Patients with lesser education level had significantly poorer preeducation score. The “posteducation” improvement was statistically significant in all education groups [Table 7].

Preeducation scoring was best in “oral hypoglycemic agent + insulin” group. The “posteducation” improvement was statistically significant in all treatment groups [Table 7].


  Discussion Top


In this study, 68.18% participants were males and 31.81% were females. Generally, it is considered that type-2 diabetes affects men more commonly.[8] However, the male preponderance in our study is also due to the fact that many soldiers have to leave their families at their hometowns due to various reasons.

Age of our participants varied from 34 to 74 years. We did not find young diabetics (type-2) participating in our study. This is because, in this specific subpopulation, regular physical activity is very important part of daily routine, particularly in youngsters. Hence, type-2 diabetes is rare in youngsters. Most of the participants were in the fifth and sixth decades of life (42.04% and 31.81%, respectively). Mohan et al. found that peak prevalence of diabetes is in the seventh decade of life.[9]

About 15.91% patients were on nonpharmaceutical management of diabetes, 76.13% were on oral drugs, and 7.95% were on combination of insulin with oral drugs. The best overall preeducation perceptions about insulin therapy in our study were about efficacy of insulin in achieving glycemic control and preventing complications of diabetes (with overall good effect on health), and being able to take the injection easily, do unrestricted physical activity, socialize or journey easily without any embarrassment and also the awareness to coordinate the insulin injections with meal timings as well as the requirement of frequent small or medium meals. This is a very encouraging finding and can be ascribed to better average educational level as well as more awareness in our study population. However, worst overall preeducation perceptions about insulin therapy in our study were about feeling fault of self (in the sense of inability to control diabetes), feeling that insulin therapy means that disease has become much worse, misconceptions about the method of injection, ignorance about its storage methods, feeling that enjoyable activities will be restricted by taking insulin, worries about consequent weight gain, feeling of inability to take right dose of insulin at right time, and ignorance about insulin therapy indications. Most of these are due to prevailing prejudices in the society about the insulin therapy as well as due to lack of an effective information system about insulin therapy. In a combined study from Brazil/Canada,[10] most common barriers to initiating insulin therapy were fear of side effects, doubts about effectiveness, inconvenience of taking injections, and cost of insulin therapy. A session of educative program about diabetes and insulin therapy, in simple and factual manner (using audio-visual aids as well as posters and physical demonstrations), brought a significant change in the perception of these patients about insulin therapy. The best overall posteducation perceptions about insulin therapy in our study were about efficacy of insulin in achieving glycemic control and preventing complications of diabetes (with overall good effect on health), ease of storing, and injecting insulin (even while on the move).

The worst overall posteducation perceptions about insulin therapy in our study were about feeling fault of self (in the sense of inability to control diabetes), feeling that insulin therapy means that disease has become much worse, its bad effects on weight and figure, worries about reaction and hypoglycemia, worries about possible lifelong requirement of insulin, higher cost of insulin, and feeling of inability to take right dose of insulin at right time. One can easily notice a similar pattern in best and worst responses preeducation as well as posteducation. This may give an impression that educative sessions were ineffective. However, it is not so. In fact, educative sessions proved to be highly successful. There was a significant posteducation improvement in response to each question, thus maintaining the question-wise scoring order nearly similar to preeducation response, except Q23. We hold ourselves responsible for poor improvement regarding Q23 (insulin is costlier than antidiabetic tablets?) as we had not presented a comparative and simplified cost analysis to our participants during the educative sessions. We will include this in the future educative sessions. Overall (all questions included), there was strongly significant improvement in scoring (18.83%, P < 0.001). The best posteducation improvements were about questions regarding storage and methods of injecting insulin and on worries about major organ damage or complications of insulin.

Among various age groups, although all groups had significant posteducation improvement, the younger age groups showed better (strongly significant) results. This may be due to two reasons. One is that younger generation is more active and extrovert, thus getting more information about insulin therapy. The second is that fear of complications and resultant disability increases with age.

Males and females showed almost equal and strongly significant posteducation improvement. This is very encouraging trend as most of the females in our study are homemakers (thus presumably have less access to information). Improving education levels among females is certainly contributing to this positive trend. In a Chinese study, Chen et al.[11] did not find any significant difference of perception between males and females. Most probably, it is related to education levels of the participants, irrespective or their gender. High level of women literacy in services ensures that the level of awareness among males and females is likely to be similar. In a Chinese study, Chen et al.[11] did not find any significant effect on perception due to education levels. In our study, there was a clear pattern of poorer perception in less educated patients. Although there was a significant posteducation improvement in all education groups, it was less pronounced in “up to primary level” group (P = 0.023). Reason for this observation is obvious. More is the education level, more is the amount of prior knowledge, and better is the understanding of information imparted during diabetes education program. All treatment groups showed strongly significant posteducation improvement. A study by Casciano et al.[12] showed much less resistance about insulin injection in patients of type-2 diabetes when they were educated about insulin (28.21% in trained vs. 33.68% in untrained; P < 0.0001).


  Conclusions Top


  1. In our study, following were the ten worst preeducation perceptions about insulin therapy among patients of type-2 diabetes


    1. Taking insulin always means that diabetes has become much worse
    2. One cannot store insulin without a refrigerator
    3. It is difficult to inject the right amount of insulin correctly at the right time every day
    4. It is always patient's failure to control diabetes that he/she has to take insulin
    5. Insulin is always costlier than antidiabetic tablets
    6. No idea that our body also makes insulin
    7. Taking insulin means I have to give up activities I enjoy
    8. I have no idea about the site of insulin injections
    9. Insulin causes weight gain
    10. No clear idea about “Why the doctor prescribes insulin?”


  2. Preeducation perception about insulin therapy: Difference among various groups


    1. Age: Significantly better perception in younger age groups
    2. Gender: No significant difference among males and females
    3. Education level: Significantly poorer perception in less educated patients
    4. Treatment group: Those who were already on insulin therapy had better perception.


  3. Overall pattern of perception was maintained even posteducation. However, the misconceptions became significantly weaker posteducation. This means that the well-structured “Diabetes Education Program” brought significant improvement in average scoring about each question, with a significant improvement in scoring to each question (except Q23)
  4. The only exception was Q23 (about cost of insulins). There was no improvement in scoring to this question posteducation. On analyzing our presentations, we realized that we had not presented a comparative and simplified cost analysis to our participants during the educative sessions. Thus, quantum of improvement in scoring to each question is a direct measurement of efficacy of our education to patient about the particular topic related to that question. This becomes a strong tool for assessment of effectiveness of any educative program
  5. Our “Diabetes Education Program” brought significant improvement in perceptions about insulin therapy. However, improvement was more pronounced in younger patients and well-educated patients. Best improvements in perceptions are as follows:


    1. About storage of insulins
    2. Managing insulin injections do not consume much time and energy
    3. Insulin injection site
    4. Insulin injection is not painful
    5. Insulin provides better sugar control as well as prevents complications of diabetes
    6. Taking insulin does not mean that patient has to give up activities he enjoys
    7. With little training, it is easy to inject the right amount of insulin correctly, at the right time, every day
    8. Insulin does not damage body organs
    9. Insulin does not have many complications and is not generally hazardous


  6. This study establishes following factors as most important ones in ensuring good perceptions about insulin therapy in patients of type-2 diabetes:


    1. General level of education of patient
    2. Availability and quality of “Diabetes Education Program.”


Recommendations

There is a need to do further studies to assess the efficacy of various “Diabetes Education Programs.” This will lead to refinement of educative techniques as well as the education contents, to achieve the optimum level of awareness among the patients. Future questionnaire may include a column about anything the patient wants to convey (but not included in the set questionnaire). One thing that we have not shown in this study, but conducted during our “Diabetes Education Program,” was a “two-way interaction with patients.” During which many patients asked questions about their doubts or difficulties, we tried to answer them. Such “Diabetes Education Programs” should be conducted more frequently in every hospital or clinic. In fact, such programs should be made a routine in OPDs. Giving 30–60 min (using various aids for communication and presentation) will significantly improve the quality of patient care, simultaneously sparing the precious time of one-to-one communication during individual consultations. Such presentations to be extended to other aspects of patient care also, e.g., dietary patterns in diabetes, exercise programs, and self-monitoring of blood glucose. Such programs can be directed not only toward the patients but also toward “healthcare workers,” including doctors. Such programs are to be structured according to the target group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Lynn PP. Predictors of Readiness to Initiate Insulin Therapy in Patients with Type 2 Diabetes when Oral Medications Fail to Control Hyperglycemia. Theses and Dissertations-Nursing, Paper 1; 2011. p. 81.  Back to cited text no. 1
    
2.
Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, et al. Resistance to insulin therapy among patients and providers: Results of the cross-national diabetes attitudes, wishes, and needs (DAWN) study. Diabetes Care 2005;28:2673-9.  Back to cited text no. 2
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Brod M, Kongsø JH, Lessard S, Christensen TL. Psychological insulin resistance: Patient beliefs and implications for diabetes management. Qual Life Res 2009;18:23-32.  Back to cited text no. 3
    
4.
Polonsky WH, Jackson RA. What's so tough about taking insulin? Addressing the problem of psychological insulin resistance in Type 2 diabetes. Clin Diabetes 2004;22:147-50.  Back to cited text no. 4
    
5.
Grant RW, Wexler DJ, Watson AJ, Lester WT, Cagliero E, Campbell EG, et al. How doctors choose medications to treat Type 2 diabetes: A national survey of specialists and academic generalists. Diabetes Care 2007;30:1448-53.  Back to cited text no. 5
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6.
Chen KW, Tseng HM, Huang YY, Chuang YJ. The barriers to initiating insulin therapy among people with Type 2 diabetes in Taiwan – A qualitative study. Diabetes Metab 2012;3:5.  Back to cited text no. 6
    
7.
Snoek FJ, Skovlund SE, Pouwer F. Development and validation of the insulin treatment appraisal scale (ITAS) in patients with Type 2 diabetes. Health Qual Life Outcomes 2007;5:69.  Back to cited text no. 7
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Abate N, Chandalia M. Ethnicity and Type 2 diabetes: Focus on Asian Indians. J Diabetes Complications 2001;15:320-7.  Back to cited text no. 8
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9.
Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of Type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30.  Back to cited text no. 9
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10.
Guimarães C, Marra CA, Gill S, Meneilly G, Simpson S, Godoy AL, et al. Exploring patients' perceptions for insulin therapy in Type 2 diabetes: A Brazilian and Canadian qualitative study. Patient Prefer Adherence 2010;4:171-9.  Back to cited text no. 10
    
11.
Chen CC, Chang MP, Hsieh MH, Huang CY, Liao LN, Li TC, et al. Evaluation of perception of insulin therapy among Chinese patients with Type 2 diabetes mellitus. Diabetes Metab 2011;37:389-94.  Back to cited text no. 11
    
12.
Casciano R, Malangone E, Ramachandran A, Gagliardino JJ. A quantitative assessment of patient barriers to insulin. Int J Clin Pract 2011;65:408-14.  Back to cited text no. 12
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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