• Users Online: 410
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

Ahead of print publication  

Insulin therapy among outpatient department patients of diabetes mellitus in a tertiary care hospital: Do they have adequate knowledge about insulin?

 Department of Community Medicine, AFMC, Pune, Maharashtra, India

Date of Submission01-Sep-2021
Date of Decision12-Feb-2022
Date of Acceptance06-Apr-2022
Date of Web Publication20-Oct-2022

Correspondence Address:
Arun Kumar Yadav,
Department of Community Medicine, AFMC, Pune, Maharashtra
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_113_21


Introduction: Insulin is one of the most effective agents in reducing hyperglycemia when used in appropriate doses. However, insulin may have risks if used inappropriately. Insufficient knowledge of insulin self-injection can result in complication, adverse patient outcomes, and invariably poor glycemic control. Methods: A cross-sectional observational study was conducted among patients with diabetes mellitus attending the outpatient department of the hospital in western Maharashtra. Data on sociodemographic factors and knowledge and attitude with insulin syringes were collected. Results: A total of 93 participated in the study. The mean age of the participant was 55.5 years, and most were male (52, 55.9%). Seventy-five (80.7%, 95% confidence interval [CI]: 71.1–88.1) were having adequate knowledge. Higher education was associated with adequate knowledge. The attitude was adequate in 24 (25.8%, 95% CI: 17.2–35.9) participants. Higher duration of illness of diabetes mellitus was associated with good attitude. Conclusion: The study found that there are gaps in knowledge and attitude for the use of insulin syringes. Opportunistic or one-to-one health education may be taken to improve knowledge and attitude regarding insulin syringes.

Keywords: Diabetes, insulin, knowledge and attitude

How to cite this URL:
Teli PT, Ekambaram T, Yadav AK. Insulin therapy among outpatient department patients of diabetes mellitus in a tertiary care hospital: Do they have adequate knowledge about insulin?. J Mar Med Soc [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=359150

  Introduction Top

Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from a relative or absolute insulin deficiency. The World Health Organization has estimated that 366 million people will be affected by diabetes mellitus in the world by 2030.[1] More than 3 million patients die annually with underlying diabetes mellitus. In some urban Indian societies, one out of five adults has diabetes.[2]

Insulin is the most effective agent in reducing hyperglycemia when used in appropriate doses.[3],[4] However, insulin may have risks if used inappropriately. For this reason, it is identified as one of the five “high alert” medications that have the greatest risk of causing adverse effects to patients because of medication errors.[5],[6] Regular insulin therapy is essential in the maintenance of strict glycemic control among insulin-requiring patients with diabetes. Knowledge about diabetes mellitus is a prerequisite for individuals and communities for its prevention and control. Insufficient knowledge of insulin self-injection can result in a complication, adverse patient outcomes, and invariably poor glycemic control.[7] Many insulin-dependent diabetes patients possess poor knowledge of insulin use and are not conversant with some important terms such as ketoacidosis, insulin reaction, and hypoglycemia.[8],[9],[10] There are many studies on knowledge, awareness, and practice among diabetes but few for insulin knowledge among those who are taking insulin.[9],[11] Hence, the present study is conducted to estimate the knowledge and attitude regarding insulin therapy in patients with insulin-dependent diabetes mellitus and describe the association between the knowledge and attitude regarding insulin therapy with the selected study variables.

  Methods Top

The study was conducted among the patients attending the outpatient department in a tertiary care hospital in western Maharashtra. The study design is a hospital-based cross-sectional study. Inclusion criteria included adult patients with diabetes mellitus receiving insulin injections for more than 6 months. Participants, who were not physically or mentally able to respond to the interview, aged <18 years, and not willing to participate, were excluded from the study. The study was conducted from February 2021 to April 2021. All consecutive patients of insulin-dependent diabetes mellitus were approached to participate in the study.

The questionnaire for assessing the knowledge and attitude was developed with the help of experts in the field, epidemiologists, and medical educationists. The face and content validity of the questionnaire was done by distributing it to the subject experts and taking their feedback. The questionnaire was pretested in twenty participants with cognitive technique. The questionnaire was modified with the help of the feedback received during the pilot testing. The questionnaire consists of two parts. In the first part, information about sociodemographic variables was collected, and in the second part, information about knowledge and attitude was collected.

A knowledge score and an attitude score were calculated by summing up an individual questionnaire. It was assumed that 70% of knowledge score and attitude score would be taken as good knowledge and attitude scores. The study was given ethical clearance by the institute's ethical committee. A written informed consent form was taken from the participants.

The sample size was determined using a single population proportion formula, with the assumption of 40% having adequate knowledge with 10% of absolute precision with a 95% of confidence interval (CI).[8] The calculated sample size was 92.

The categorical variable was described as number and percentage and the continuous variable as mean and standard deviation. Chi-square and unpaired “t” tests were used. Data were analyzed using StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX, USA: StataCorp LLC. P < 0.05 was taken as statistically significant.

  Results Top

A total of 113 patients were approached and 93 (82.3%) responded during the study period. Out of 93, 52 (55.9%) were male and the majority of them belonged to urban areas (75.3%). A total of 59 (63.4%) of the patients were either retired or homemakers. The mean age of the participants was 55.5 years (standard deviation = 11.8 years). A total of 46 (49.5%) were diabetic for more than 5 years. Around 35 (37.6%) of the patients had a family history of diabetes mellitus. A total of 83 (89.2%) belonged to Type II DM (NIDDM) and 10 (10.8%) belonged to Type I DM (IDDM) [Table 1]. A total of 85 (91.4%) were self-administering the insulin. Ninety (96.8%) were using pen type for delivery of the insulin.
Table 1: Association of knowledge and attitude score with sociodemographic factors

Click here to view

Seventy-seven (82.8%) agreed that insulin correctly reduces blood glucose levels, and 47 (50.5%) felt that insulin injections were a painful method and felt reluctant about it. The response to individual questions for knowledge and attitude is given in [Figure 1] and [Figure 2]. According to predefined criteria, 75 (80.7%, 95% CI: 71.1–88.1) were having adequate knowledge. Higher education was associated with adequate knowledge (P = 0.03) [Table 1]. The attitude was adequate only in 24 (25.8%, 95% CI: 17.2–35.9). A higher duration of illness (DM) was associated with a good attitude (P = 0.03). There was no statistically significant difference in knowledge and attitude of patients of two types of diabetes (P = 0.5).
Figure 1: Responses for knowledge regarding insulin intake

Click here to view
Figure 2: Responses about attitude regarding insulin intake

Click here to view

  Discussion Top

In our study, around 50% were diabetic for >5-year duration and 37.6% had a family history of diabetes which may be the reason for the better knowledge about DM which implies that if the patients were adequately counseled and if better methods of insulin delivery are available, the acceptability of the insulin in the early phase of disease course would be more.

The majority of the patients (91.4%) were self-administering insulin, hence the knowledge about correct storage, administration techniques, and complications/warning signs is a must for better compliance in the long term. In our study, majority (80.7%) have adequate knowledge about DM and adverse effects, which is similar to other studies conducted elsewhere.[11],[12]

In one study, around 51.9% felt that insulin injections were painful; in our study also, 50.5% felt that the insulin syringe is a painful method and felt reluctant about it.[13] In our study, the majority of the users were pen-type users. Hence, they did not feel that insulin syringe administration is tiresome. Whereas other studies observed that 30% felt not easy and 19.2% felt inconvenient.[13]

Our study revealed that 26% of the people were still not aware of the symptoms of hypoglycemia. Since the majority of our population were old aged, it is highly essential to improve the knowledge at the individual level and at the community level to reduce vulnerability to succumb to hypoglycemia. A study found a significant lack of knowledge on insulin therapy, <20% of the patients were only aware of the complications of diabetes mellitus, 64% of the patients found insulin as a last resort of treatment, 91% of the patients did not self-adjust their insulin dose without consulting physicians, only 28% of the patients were aware of the type of insulin, and 100% were aware that the insulin injection site needs to be rotated.[14]

Another important finding of the study is that education was associated with higher knowledge. The knowledge and attitude are associated with better compliance as observed in a study conducted in Saudi Arabia which finds a significant impact of education on insulin treatment compliance.[15] Another study finds an association between poor attitude toward treatment and lack of knowledge with the complication of diabetes mellitus.[16] Although the present study did not study compliance, similar findings may be extrapolated to our study. We suggest that every single contact with the health-care facility should be taken as an opportunity to teach the patients about insulin use. Interpersonal communication and behavior change communication are required for changing the attitude of the personnel.

The study has certain limitations. There is a nonresponse of 18% of the participants. The baseline data from nonresponders could not be collected, so no comparison with the responders was done. This may introduce a responder's bias in the study. However, the nonresponders are within 20% limit. As the study was done only in one center, in an urban part of western Maharashtra, hence, the generalizability of the study is limited. Second, compliance and common myths associated with insulin were not studied. The study observed knowledge and attitude gaps in using insulin. Two factors associated with knowledge and attitude were education and duration. Hence, the study emphasized the need for counseling or opportunistic health education to modify the attitude of patients. The health belief model can be used to minimize DM complications. One-to-one demonstration of insulin injection technique can be tried to improve insulin administering knowledge and practice.[17] The need for educating patients is especially important for cases of diabetes mellitus, who have been recently shifted to insulin for treatment. It is further recommended that group counseling sessions may be given to these patients to improve their knowledge and attitude. Self-help groups consisting of the diabetic patient where there can share best practices and their experience which may go a long way in motivating and compliance of diabetic patients on insulin treatment.


The study brought out the gap in knowledge and attitude among insulin user. There is need for counseling patients for insulin use before shifting them to insulin.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Day 2016. Available from: https://www.ibtimes.co.uk/science/health. [Last accessed on 2018 Jul 15].  Back to cited text no. 1
Thomas N, Kapoor N, Velavan J, Vasan SK, editors. A Practical Guide to Diabetes Mellitus. 7th ed. New Delhi, India: Jaypee Brothers Medical; 2015.  Back to cited text no. 2
Gerensea H, Moges A, Shumiyee B, Abrha F, Yesuf M, Birihan T, et al. Knowledge and attitude on insulin self administration among type one diabetic patients in Mekele Hospital, Tigray, Ethiopia, 2015. Adv Surg Sci 2015;3:32-6.  Back to cited text no. 3
Shetty SB, Ramachandrappa L, Rudramunisetty AK. Knowledge, attitude and practices amongst subjects with diabetes on insulin therapy: A need to bridge the gap. Glob J Med Res 2017;17:1-7.  Back to cited text no. 4
Derr RL, Sivanandy MS, Bronich-Hall L, Rodriguez A. Insulin-related knowledge among health care professionals in internal medicine. Diabetes Spectr 2007;20:177-85.  Back to cited text no. 5
Montesi G, Lechi A. Prevention of medication errors: detection and audit. Br J Clin Pharmacol 2009;67:651-5.  Back to cited text no. 6
Garg MK. Current perspective in insulin therapy in the management of diabetes mellitus. J Indian Med Assoc 2002;100:194-95, 202.  Back to cited text no. 7
Majra JP, Acharya D. Awareness regarding self care among diabetes in Rural India. Middle East J Fam Med 2009;7:25-6.  Back to cited text no. 8
Priscilla S, Malarvizhi S, Das AK, Natarajan V. The level of knowledge and attitude on insulin therapy in patients with diabetes mellitus in a teaching hospital of Southern India. J Family Med Prim Care 2019;8:3287-91.  Back to cited text no. 9
[PUBMED]  [Full text]  
Reducing the Burden of Diabetes Management through Flexible and Discreet Insulin Delivery. Available from: https://openaccessgovernment.org. [Last accessed on 2021 Jul 04].  Back to cited text no. 10
Surendranath A, Nagaraju B, Padmavathi G, Anand S, Fayaz P, Balachandra G. A study to assess the knowledge and practice of Insulin self-administration among patients with Diabetes Mellitus. Asian J Pharm Clin Res 2012;5:25-30.  Back to cited text no. 11
Namita S. A Descriptive Study to assess the knowledge and attitude regarding Self administration of Insulin Injection among DM Patients in Kempa Chaluvamba General Hospital at Malleswaram, Bangalore 2005. [Last accessed on 2021 Jul 07].  Back to cited text no. 12
Beneby N, Isaacs C, King L, LeonW F, Taylor A. Knowledge, attitudes and perceptions of patients towards insulin therapy at primary care Centers in Trinidad. J Community Med Public Health Care 2015;2:1978;DOI:10.24966/CMPH-1978/100004.  Back to cited text no. 13
Gawand KS, Gawali UP, Kesari HV. A study to assess knowledge, attitude and practice concerning insulin use in adult patients with diabetes mellitus in tertiary care centre. Indian J Med Res Pharm Sci 2016;3:36-40.  Back to cited text no. 14
Megeid FY, El-Sayed MM. Health education intervention improves knowledge, attitude and practices of mothers of insulin dependent diabetes mellitus. World Appl Sci J 2012;17:1398-404.  Back to cited text no. 15
Parvin N, Jahan SN, Rahman MS, Ahamed MU, Roy SK, Bhuiyan MR. A Cross Sectional Study on Knowledge and Attitude among Diabetic Patients about Diabetes and Its Complications European Academic Research 2014;2:6750-4.  Back to cited text no. 16
Available from: https://www.researchgate.net/publication/331967122. [Last accessed on 2021 Jul 13].  Back to cited text no. 17


  [Figure 1], [Figure 2]

  [Table 1]


     Search Pubmed for
    -  Teli PT
    -  Ekambaram T
    -  Yadav AK
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded2    

Recommend this journal