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Diabetes and endocrinology
Original research
Knowledge, attitude and practices of insulin therapy among patients with type 2 diabetes: a cross-sectional study
  1. Ayesha Almheiri1,
  2. Eman Ali Binjab1,
  3. Maha Murad Albloushi1,
  4. Mohamed Taryam Alshamsi1,
  5. Hamda Hassan Khansaheb1,
  6. Marwan Zidan1,
  7. Ahmed Abdul Karim Hassoun2
  1. 1Dubai Academic Health Corporation, Dubai, UAE
  2. 2Fakeeh University Hospital, Dubai, UAE
  1. Correspondence to Dr Ayesha Almheiri; ayesha_saeed90{at}outlook.com

Abstract

Objectives This study aimed to assess the knowledge, attitude and practices of patients with type 2 diabetes on insulin regarding insulin therapy.

Design A cross-sectional study.

Setting This study was conducted at the Dubai Diabetes Center from 1 December 2018 to 1 March 2020.

Participants Face-to-face interviews were conducted for 350 participants with type 2 diabetes at the Dubai Diabetes Center. Interviews followed the structured format of a questionnaire designed to obtain demographic details and score participants on knowledge, attitude and practices. We included patients aged >18 years and receiving insulin therapy. Patients with type 1 diabetes, pregnant women with gestational diabetes, those aged <18 years or those with a history of dementia were excluded.

Results The median age of participants was 61 years (first quartile, 53 years; third quartile, 67 years); 35.7% were male individuals and 64.3% were female individuals. The median percentage scores for knowledge, attitude and practices were 62.5% (62.5%, 75%), 85.7% (71.4%, 100%) and 77.7% (66.6%, 88.8%), respectively. Highly educated participants had a high level of knowledge. Significant negative correlations were found between the percentage knowledge scores and participants’ age and between the participants’ percentage attitude scores and haemoglobin A1C levels; Spearman’s correlations were −0.182 (p<0.001) and −0.14 (p=0.008), respectively. A significant positive Spearman’s correlation of 0.123 (p=0.021) was found between the percentage knowledge and percentage practice scores. No correlations were found among knowledge levels, participants’ haemoglobin A1c levels and duration of insulin use.

Conclusion Patients with type 2 diabetes receiving insulin therapy and attending the Dubai Diabetes Center had adequate knowledge, a positive attitude and correct practice regarding insulin therapy. However, knowledge of specific facts did not always translate into correct behaviours and practices.

  • DIABETES & ENDOCRINOLOGY
  • Chronic Disease
  • General diabetes
  • Health Education

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-079693

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • The study had a representative sample size (350) and a high response rate (100%).

    • This was a cross-sectional study, and causal relationships could not be confirmed.

    • Convenience sampling was used to recruit participants, and selection bias cannot be ruled out.

    Introduction

    Diabetes is a highly prevalent, progressive and disabling chronic disease. The global prevalence of diabetes has escalated rapidly over the past two decades, and according to the International Diabetes Federation, there are 463 million people with diabetes worldwide.1 This number is expected to increase to 578 million by 2030 and reach 700 million by 2045.1 In 2019, the International Diabetes Federation reported that the number of people with diabetes aged 20–79 years in the Middle East and North Africa was 55 million, and by 2024, this number is estimated to reach 108 million, an increase of 96%.1 In the United Arab Emirates, the estimated prevalence of diabetes among people aged 20–79 years was 12.2% in 2019, as declared by the International Diabetes Federation.1

    Diabetes significantly affects patients’ health and quality of life, leading to permanent organ dysfunction.2 It can shorten life expectancy by as much as 15 years, with cardiovascular disease being the major cause of death.3 Moreover, it poses a huge financial burden on patients, healthcare systems and communities.4 Direct costs include prescription costs and the expenses of the healthcare services provided.4 Indirect costs include reduced work productivity due to absenteeism, reduced work performance, increased unemployment due to chronic disability and premature mortality.5 In the United Arab Emirates, the medical costs attributable to type 2 diabetes are estimated to be approximately US$563 million (AED 2.07 billion) annually, which may increase to US$8.52 billion (AED 31.27 billion) over the next 10 years.6

    The management plan for type 2 diabetes requires patient participation. Therefore, patients require a multidisciplinary approach to help them understand the disease and treatment options, practice self-care and prevent complications.7 8 Moreover, patients must adopt lifestyle changes such as following a healthy diet, engaging in regular physical activity, self-monitoring their blood glucose levels, complying with their medication, receiving immunisations and coping with the disease.9 10

    Insulin therapy can be used alone to treat patients with type 2 diabetes, or it can be used in combination with other antidiabetic medications based on the patient’s current haemoglobin A1C (HbA1c) level. Insulin reduces HbA1c levels and enables glycaemic targets to be attained.11 Despite this, several factors might impact a patient’s acceptance of and adherence to insulin therapy, including insufficient knowledge, a busy schedule, travel, skipping meals, anxiety or stress, or embarrassment.12 13 Recent evidence suggests that 33.2% of patients with type 1 or type 2 diabetes who take insulin skip their insulin dose on an average of 3.3 days monthly for similar reasons.13 Hence, patients with type 2 diabetes receiving insulin therapy must be educated and trained on the indications for insulin therapy, treatment adherence, side effects and practice of self-administration.14

    The global prevalence of diabetes is rising, the burden of the disease is escalating, the long-term complications are aggravating and the hesitancy of patients with type 2 diabetes to adhere to insulin is intensifying. Therefore, assessing the knowledge, attitude and practices of patients with type 2 diabetes regarding insulin therapy has become vital for driving behavioural adjustments and compliance with diabetes management.

    Multiple studies have been conducted in the United Arab Emirates on the prevalence of type 2 diabetes and the knowledge, attitude and practices of patients with this disease. However, to the best of our knowledge, no studies have assessed the knowledge, attitude and practices regarding insulin therapy among patients with type 2 diabetes in the United Arab Emirates.

    Therefore, this study aimed to assess the knowledge, attitude and practices of patients with type 2 diabetes regarding insulin therapy. It also explored the association between the level of knowledge and patients’ practices, age, education level and duration of insulin therapy and evaluated the relationship between HbA1c levels and knowledge and attitude.

    Materials and methods

    Setting

    This study was conducted at the Dubai Diabetes Center (DDC) from 1 December 2018 to 1 March 2020. The DDC was established in 2009 and is the largest diabetes centre in Dubai; its multidisciplinary team provides world-class, comprehensive diabetes care.

    Study participants

    The criteria for inclusion were all patients with type 2 diabetes, aged >18 years, attending the DDC, on insulin therapy and willing to participate in the study. Patients with type 1 diabetes, pregnant women with gestational diabetes, patients aged <18 years or patients with a history of dementia were excluded. In total, 350 participants who fulfilled the inclusion criteria were interviewed. Written informed consent was obtained from all participants before the start of the study. The confidentiality of the participants’ information was assured.

    Sample size

    The DDC’s 2018 annual report states that the estimated total number of registered patients with type 2 diabetes on insulin therapy is approximately 2300. A sample size was calculated to estimate the prevalence (percentage) of correct answers to each question with a 95% CI, 5% margin of error and 50% prevalence. Using the sample size calculator on https://www.surveysystem.com/sscalc.htm, the required sample size for this study was calculated to be 350 patients. Convenience sampling was used for participant selection.

    Study design

    This cross-sectional study was conducted through face-to-face interviews with participants using a questionnaire customised according to the study’s objectives. Questions for the questionnaire were obtained from different studies after obtaining approval from the corresponding authors.15–17 The questionnaire was validated by conducting a pilot study with 20 participants, and appropriate modifications were subsequently made (online supplemental file).

    During the interview, the interviewer asked the participants structured questions to obtain their demographic data and clinical characteristics. Other questions assessed their knowledge, attitude and practices towards insulin therapy. The demographic and clinical characteristics included age, sex, education level attained, occupation, duration of diabetes, duration of insulin therapy, number of antidiabetic medications, reasons for starting insulin therapy, type of insulin, recent HbA1c level, frequency of blood sugar monitoring and complications of diabetes.

    The questionnaire comprised 24 questions, including 8 questions in the knowledge domain that assessed patients’ knowledge about diabetes, treatment options and complications associated with insulin use. The attitude domain comprised seven questions that addressed patients’ psychosocial aspects in terms of embarrassment and fears associated with insulin therapy, impact on daily life and coping with the disease. The practice domain comprised nine questions that evaluated the participants’ insulin injection technique. In the knowledge and practice domains, each correct answer was given a score of 1, and each wrong answer was given a score of 0. For the attitude domain, answers that reflected a positive attitude were given a score of 1 and answers that reflected a negative attitude were given a score of 0. Four authors conducted the interviews once a week, on Thursdays.

    On completion of the patient interview, the authors reviewed and documented the recent HbA1c level from the patients’ electronic medical records (EMRs). EMRs were used to ensure the accuracy of the information gathered from the participants, and any necessary corrections were made accordingly.

    Patient and public involvement

    Patients and the public were not involved at any stage of the research.

    Statistical analyses

    Statistical analyses were conducted using the Statistical Package for Social Sciences Statistics for Windows V.24 software (IBM Corp.). The knowledge score was calculated by determining the total number of knowledge questions answered correctly; the practice score was calculated by determining the total number of questions for which correct practice was indicated, and the attitude score was calculated by determining the total number of questions for which a positive attitude was indicated. The percentage score for each domain was calculated by dividing the domain score by the number of questions in that domain and multiplying it by 100. The normality of the numerical variables was tested using the Kolmogorov-Smirnov test. As all numerical variables were skewed, the median (first quartile, third quartile) was used to summarise the results, which were presented as counts (percentages). Inferential statistics including Spearman’s correlation analysis was used to assess the correlation between numerical variables, and Kruskal-Wallis test was used to test the difference in the median scores’ medians between the educational level groups. All the tests were two tailed. Statistical significance was set at p<0.05.

    Results

    Participant characteristics

    Three hundred and fifty patients with type 2 diabetes who met the inclusion criteria and attended the DDC participated in this study. The median age of the study population was 61 (53, 67) years. The proportion of male and female participants was 35.7% (n=125) and 64.3% (n=225), respectively. More than half of the participants (190 (54.3%)) had a school-level education, and 275 (78.8%) were unemployed. In total, 153 (43.7%) patients were taking long-acting insulin, whereas 166 (47.4%) were taking both long-acting and short-acting insulin; 216 (61.7%) patients were taking more than 3 antidiabetic medications. The median duration of diabetes was 18 (12, 23.25) years, whereas the median duration of insulin use was 6 (3, 10) years. The most recent median HbA1c level was 7.8% (7%, 8.83%) (table 1).

    View this table:
    Table 1

    Demographic data and characteristics of the study population

    Assessment of knowledge, attitude and practices

    The median percentage knowledge score of the participants was 62.5% (62.5%, 75%). The median percentage positive attitude score towards insulin was 85.7% (71.4%, 100%), and the median percentage correct practice score was 77.7% (66.6%, 88.8%). The individual questions used to assess knowledge, attitude and practices and the respective participants’ percentages are shown in table 2. Almost all the patients (99%) knew that insulin vials should be stored in a refrigerator or a cool place and what the sites for insulin injection were (99.4%); only 23% of the participants knew that insulin is not always the last option available for treating diabetes. Most patients (92%) were not concerned that people would know they had diabetes if they were on insulin treatment, and 58% believed that injecting insulin was painful. Most patients regularly rotated the injection sites (97%) and injected insulin regularly at the times instructed (95%). Only 39% of participants disposed of the used needles in a special container at home.

    View this table:
    Table 2

    Questions in the knowledge, attitude and practice domains with the percentages of patients with type 2 diabetes who had the correct knowledge, a positive attitude and correct practices regarding insulin therapy

    The knowledge domain consisted of eight questions that assessed patients’ knowledge of diabetes, treatment options and complications related to insulin use. The attitude domain consisted of seven questions that addressed patients’ psychosocial aspects in terms of embarrassment and fears associated with insulin therapy, impact on daily life and coping with the disease. The practice domain consisted of nine questions that evaluated the participants’ insulin injection techniques.

    Association between knowledge level and duration of insulin therapy, age, level of education and practices

    The correlation between the duration of insulin use and knowledge was assessed using Spearman’s correlation; no correlation was found (0.03; p=0.589). Assessing the correlation between age and knowledge using Spearman’s correlation demonstrated a negative but significant correlation (−0.14; p=0.008). Spearman’s correlation showed a significant positive correlation between knowledge and practices (0.123; p=0.021).

    The differences in the percentage knowledge scores between the groups differentiated by the level of education were significant. The medians and quartiles for ‘no formal education’, ‘school-level education’ and ‘higher education’ were 62.5% (50%, 75%), 62.5% (62.5%, 75%) and 75% (62.5%, 87.5%), respectively (p<0.001; figure 1).

    Figure 1
    Figure 1

    Comparison of the percentage knowledge scores between education groups. The median (the line inside the box) and quartiles (lower and upper lines of the box) for ‘no formal education’ were 62.5% (50%, 75%), those for ‘school level’ were 62.5% (62.5%, 75%), and those for ‘higher education’ were 75% (62.5%, 87.5%) (p<0.001). The upper whisker represents the range of the highest 25% of the percentage scores, and the lower whisker represents the range of the lowest 25% of the percentage scores except for the ‘school-level’ group, which has outliers. Three participants scored 100% (outliers), and the other three scored below 40% (outliers). The numbers listed on these dots represent the participant’s serial numbers.

    Association between knowledge, attitude and HbA1c levels

    A significant negative correlation was found between the attitude score and the most recent HbA1c level: Spearman’s correlation coefficient of −0.182 (p<0.001) indicated that the higher the positive attitude score, the lower the HbA1c level. No significant correlation was found between the percentage knowledge score and the most recent HbA1c level.

    Discussion

    Several studies have demonstrated that patients with type 2 diabetes have a gap in knowledge, a negative attitude and incorrect practices regarding insulin therapy.15 18–22 However, the present study’s findings showed that patients with type 2 diabetes receiving insulin therapy have adequate knowledge, positive attitudes and correct practices regarding their insulin therapy. The present study’s results are consistent with those of several international studies.23 24

    The studies by Lafta et al2 and Das Choudhury et al7 revealed that patients with type 2 diabetes receiving insulin therapy had a good knowledge level and positive attitude. While Lafta et al2 did not assess the study participants’ practices towards insulin therapy, Das Choudhury et al7 concluded that their study participants had deficiencies in their practices.

    Multiple factors could explain the results of the present study. First, this study was conducted at the DDC, a specialised tertiary centre that provides multidisciplinary care. Patients visit several healthcare providers—consultant endocrinologists, diabetes educators, dietitians, podiatrists, exercise specialists, psychologists and retinal imaging specialists—on the same day at the centre and are followed up regularly as scheduled. During the patient’s appointment, an extensive review of the patient’s knowledge of diabetes, current conditions and inquiries, results of the investigations, medication lists, medication side effects and disease complications is conducted. A visit to each healthcare provider can last up to 60 min, allowing healthcare providers sufficient time to answer patients’ inquiries, correct any myths or inaccurate concepts and adjust patients’ medications. All these activities contribute to the good knowledge of insulin therapy possessed by the current study’s participants.

    Second, all patients receiving insulin therapy had multiple visits to diabetes educators to assess their injection techniques and correct their practices. Face-to-face consultations with a diabetes educator are conducted quarterly. Other patients, especially those who have recently started insulin therapy, have monthly visits to evaluate their practices and correct them accordingly. This may be a leading factor that contributed to fewer incorrect practices and correct medication administration. Third, the study participants were found to have a positive attitude towards insulin therapy, which might be correlated with spiritual, social and cultural factors that affect patients’ acceptance and adaptation to long-term illnesses. Culturally, individuals in the United Arab Emirates tend to share their experiences with others, which could lead to greater acceptance of insulin therapy and contribute to a more positive attitude towards insulin. Moreover, the psychologists at the DDC have a comprehensive approach to helping patients understand and cope with the disease and insulin therapy.

    Although the present study showed that patients with type 2 diabetes receiving insulin therapy have adequate knowledge of their insulin therapy, they were unaware of the indications for starting and escalating insulin therapy. This result is consistent with that reported by Yilmaz et al.16 Furthermore, the current study showed that patients with type 2 diabetes on insulin therapy had correct insulin therapy practices. However, several errors in the technique for administering insulin injections were observed. Only 39% of the study participants disposed used insulin needles in a special container at home. The improper disposal of insulin needles has been reported in multiple studies. Ebrahim et al15 reported that only 4% of their study participants (n=100) disposed used insulin needles in a special container. Shetty et al25 also reported that 98.2% (n=440) and 1.2% (n=8) disposed both used insulin pens and needles in the general waste and medical waste, respectively.

    The present study participants (42%) reported that injecting insulin is painful. Similarly, Shetty et al25 found that 49.9% of their participants (n=448) felt that insulin injections are painful. Furthermore, Fu et al17 found that 66.9% of their study participants (n=306) had a negative attitude towards insulin therapy as injecting insulin is painful.

    In our study, no correlation was found between knowledge level and duration of insulin therapy, and Gholap et al26 reported similar results. The results of the current study demonstrated that the study participants had good knowledge, regardless of how long they had been using insulin therapy, which might be attributed to the patient’s adherence to their scheduled appointments; 95% (n=331) of the study population attended their follow-up appointments regularly. Netere et al27 found that the longer the duration of insulin therapy, the better the level of knowledge. Furthermore, a study published in Iraq in 2011 demonstrated that the Iraqi population had good knowledge about insulin therapy and attributed this to a long duration of diabetes, wherein patients gained knowledge from their experiences and acquaintanceships with other patients in the centre.2

    Several studies have found no significant association between the level of knowledge of patients with type 2 diabetes regarding insulin therapy and their age.16 26 Interestingly, the current study found a negative correlation between the age of the participants and their knowledge of insulin therapy. An increase in comorbidities and age-related disabilities, such as reduced vision, impaired cognitive function, frailty and dependence on caregiver support, may explain the results obtained.

    The current study found that the level of education might impact patients' knowledge of insulin therapy; the higher a patient’s level of education, the better their knowledge regarding insulin. The present results are consistent with those of a cross-sectional study conducted in India to assess the knowledge, attitude and practices of insulin administration among patients with diabetes and their caregivers.28 Patients with diabetes with graduate and postgraduate degrees are reported to be significantly more knowledgeable about insulin therapy than patients who are illiterates and those who have undergraduate degrees.28 A possible explanation for this result is that educated patients might not have barriers to obtaining knowledge; they are able to access information through social media and the Internet.

    Our study also demonstrated a positive correlation between the level of knowledge and the practice of insulin administration. The results of our study are consistent with those reported in a study conducted by Huang et al29 in southern Taiwan. Besides patient knowledge, several factors could be attributed to correct practice, such as the level of education, disease duration, insulin therapy duration and self-care behaviours.29

    Surprisingly, no correlation was found between knowledge and HbA1c levels in the current study, whereas attitude was negatively correlated with HbA1c levels. There are several possible explanations for this result. First, in the attitude section of the cross-sectional survey (table 2), 58% of patients were afraid that insulin injection would be painful; this could lower insulin therapy compliance and subsequently increase HbA1c levels. Second, glycaemic control requires behavioural changes that address diet, exercise, management of obesity and other comorbidities. These changes require patient motivation, awareness and knowledge of the disease. Finally, other factors that might have played a role include disease duration and severity. The current study’s findings almost mirror the results of a study conducted in India to assess the knowledge, attitude and practices regarding insulin administration among patients with diabetes and their caregivers.28 The study found no notable correlation between HbA1c levels and scores for knowledge, attitude and practices among patients with type 2 diabetes on insulin therapy but found that patients’ HbA1c levels were poorly controlled.28

    Strengths and limitations of this study

    To the best of our knowledge, this is the first study conducted in the United Arab Emirates to assess the knowledge, attitude and practices regarding insulin therapy among patients with type 2 diabetes. The study had a representative sample size of participants (350) and a high response rate (100%). However, this study had several limitations. First, it used a cross-sectional design; therefore, causal relationships could not be confirmed. Second, convenience sampling was used to recruit participants; thus, selection bias could not be ruled out. Third, data were collected only once a week when the authors were scheduled to rotate at the DDC; therefore, some eligible patients may have been missed. Nevertheless, to ensure diversity and eliminate selection bias, the authors did their best to recruit participants by including all eligible visitors at the centre regardless of their age, sex and level of education after obtaining their consent to participate in the study. Fourth, the study had a lower number of male participants. Fifth, the study findings cannot be generalised as the study was conducted in a single specialised diabetes centre; however, the findings are valuable and worth sharing.

    Conclusion

    Patients with type 2 diabetes receiving insulin therapy and attending the DDC had adequate knowledge, a positive attitude and correct practices with regard to insulin therapy. This is attributed to several factors, including continuity of care, patient compliance and extensive training and education received at the centre; patients’ education level was a significant contributing factor. However, our study demonstrated that more knowledge was not correlated with better glycaemic control. Our study also demonstrated that knowledge of specific facts did not necessarily translate into correct behaviours and practices. These findings will benefit physicians treating patients with type 2 diabetes on insulin therapy as they provide insight into the need to rectify specific knowledge regarding insulin therapy, such as indications, duration and titration of insulin therapy. They also highlight the necessity to correct specific practices regarding insulin therapy, for example, checking the name and type of insulin and disposing insulin needles in a particular container at home. Moreover, concerted efforts are needed to build intervention programmes targeting patients’ awareness of the importance of HbA1c levels—including classes or support group sessions that might help patients better control the disease and improve their HbA1c levels. Future research to address other factors that might impact HbA1c levels positively or negatively in patients with diabetes on insulin therapy is needed in United Arab Emirates.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by Dubai Scientific Research Ethics Committee Dubai Health Authority Reference number DSREC/RRP/2018/11. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    This study was conducted at the Dubai Diabetes Center. The authors thank the centre’s team for their help with data collection.

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    Footnotes

    • Contributors AA, MMA, EAB and MTA designed the study methodology, collected and analysed the data and wrote the manuscript. HHK, AAKH and MZ reviewed the methodology, assisted with data analysis and critically revised the manuscript. AA, MMA, EAB and MTA accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.