Background characteristics of patients (socio demographic and insulin usage factors):
Three hundred and sixty (360) patients who are using insulin as part of their treatment completed the study. Socio demographic characteristics of the participants were summarised in Table 1. Majority (64.2%) of them were female and mean age of the participants was 58.19(Range: 12-89).Two hundred fifty five of them (60.8%) reported completion of secondary school and 11 of them (3.1%) never attended a school. Most of them (86.4%) married and 27 (7.5%) were widowed. Two hundred and twenty three (61.9%) of them were falls into low income category (Less than Rs.25000 family income) and 33.3% were in middle income category (Rs-25001-Rs50000).
The background characteristics of insulin usage among the patients were summarized in Table 2. Majority (38.9%) of them were using insulin for 1-5 years and 124 (34.4%) were using it for more than 5 years. Main reason for the insulin initiation was oral hypoglycaemic failure (81.7%) and 17 patients (4.7%) preferred insulin over oral hypoglycaemic agents. Among the 360 insulin users 22 (6.1%CI: 4.0-9.0) were identified as Type I Diabetes. Majority of them (80.0%) were using twice daily premixed insulin regime followed by daily basal insulin (11.4%) and basal bolus insulin (5.6%) were common regime in use. Eight seven patients (24.2%) believed they can stop insulin at point in future. Concomitant use of oral hypoglycaemic agents were common among patients (55.8%).Metformin was the common oral hypoglycaemic agent (49.4%) prescribed as showed in Figure 1.
Insulin techniques related practices among participants
Various insulin technique related practices assessed among participants and results were summarized in Table 3.Large number (293) of participants (81.4%) reported they do cleaning of the injection site before injection site and 89.7% usually rotate the injection site while 8.9% do some times. As showed in Figure 2, 78 patients (21.7%) mentioned the use abdomen as sole injection site, 72 patients (20.0%) inject in upper arm only and 35 patients (9.7%) solely inject on thigh. Remaining participants (48.6%) use multiple sites of the body for injecting insulin.
Approximately half of the participants (50.8%) inject insulin themselves while approximately same percentage (49.2%) use other for injecting insulin. Majority patients (56.1%) pinch the skin before injection, 71.9% inject at the angle around 45degrees while 22.5% inject at 90 degree angle. Most the participants use syringes (91.4%) and only 8.6% uses pen insulin type. Significant proportion reported reusing the needles for injection (16.4%CI: 12.8- 20.5%) and 35% of participants disposing needle into common garbage pin. Further 11.4% of them disposing into garbage dump and 1.7 % dumping into the toilet pits. Significant proportion (48.6%CI: 43.5%-53.8%) of patients not received any health education regarding disposal of needles.
Injection site complications
Common complications assessed were tabulated in Table 4.Ninety participants (25%; CI: 20.7-29.7%) identified suffered from skin changes, followed by 15.3% (95%CI: 11.8-19.2) with persistent swelling and 7.8 %:( 95%CI: 5.3%-10.9%) were reported wasting or thinning of skin. Association between skin changes and different injection techniques were analysed and summarized in Table 5.Among the several factors analysed angle of injection (P-0.039) and insulin regime (P<0.001) statistically significant association. Rotating the site, cleaning the site, reusing the needle, pinch the skin before injection, type of insulin used (Syringe vs. Pen) and who inject insulin were not significantly associated with skin changes (P>0.05).Angle of injection practices (which was significantly associated with skin changes) analysed with several demographic factors to see whether in significant differences and results summarised in Table 6.Factors sex, civil status, family income and educational status not significantly influencing on angle injecting insulin practice(P>0.05).
Insulin storage practices:
Majority of the participants (91.1%) reported storing the insulin in refrigerator but 7.2% reported storing in natural containers and 1.7% storing in room temperature. Among the participants who storing in refrigerators 69.8% storing at door while 3.7% storing at deep freezer and 26.5% storing in shelf. While travelling 30.2 of them carrying in container with ice pack but 37.8% mentioned they carry in hand bag (Table-7).
Hypoglycaemia and associated factors:
Quite significant proportion of participants 68.6% (95%CI: 63.7%-73.2%) experienced hypoglycaemia. Most commonly they reported palpitation and sweating (28.6%) symptoms followed by sweating only (12.2%), palpitation only (8.1%), and 5.3% reported palpitation and headache.4.7% reported loss of consciousness and palpitation and 2.2% reported loss of conscious only (Table-8). Seventy three patients (20.3%) reported they miss meals after injection and also majority of them (64.4%) getting insulin injection after meals. Seventy one of the participants (19.7%) adjust their insulin doses on their own and 68.9% of them have glucometer but only 73.8% of them only used the glucometer less than one week duration before interview. Also majority of them (56.4%) did not carry glucose /jelly beans in case any hypoglycaemic event. Various factors examined to explore the association with hypoglycaemic events (Table-9). Type of insulin (Syringe) (P-0.033) and missing meals (P-0.012) were significantly associated with hypoglycaemic event. But socio demographic factors such as sex and educational status, concomitant use of oral hypoglycaemic or adjusting the insulin dose by themselves not significantly associated with hypoglycaemic events(P>0.05).Using syringes 2.21times (95%CI-1.05-4.64) more risk of developing hypoglycaemia compare to pen users. Likewise missing meals 2.22 times more risk of hypoglycaemic events (95%CI: 1.18-4.17). Finally as showed in Figure 3, 37.2% of participants received information regarding insulin usage from doctors and for 21.39% main source was nursing officers. Meanwhile 28.3% of them were reported they get information from both doctors and nursing staffs.