When assessing patients’ knowledge and practice levels, our study revealed that the overall median knowledge of the study samples on insulin storage and handling techniques were moderately adequate, while the practice levels were fair. The overall knowledge and practice scores represented as a median of all the knowledge and practice levels by summing up the individual patients’ scores. Proper knowledge and good practices on insulin storage and administration habits have a noteworthy outcome on the control of acute and chronic insulin administration-related complications of DM. Most of DM patients lacked awareness of the consequences of improper insulin handling practices and had poor management skills. The knowledge levels observed in our study was almost comparable with reports (62.13%) from another study conducted in Ethiopia , but higher than reports (57.55%) from Nepal  and India . However, the practice levels found in our study was lower than what is reported in Nepal (73.98%) . Perhaps for this reason, the patients in the study areas might be less committed, and not confident in their practices. In addition, there might be little reinforcement has been reflected by HCP for what patients did. For improving knowledge and practice levels, patients are still in need of further professional innervations on instructions, and commands, and to be compliant to it. Articles, which published previously had revealed that DM patients have poor knowledge of disease management and self-care practices [25, 26].
In the present study, residency, payment status to get insulin, mocked demonstrations of injection technique during the first visit, education levels, duration of insulin therapy and duration of illness affected the patients’ knowledge levels. Similar to the study done in Nepal, educated patients (vs illiterates) are very likely to understand and practice instructions and commands of storage and administration techniques . Similarly, participants who stayed with the disease longer, and those who took insulin for a longer period of time had better knowledge levels, which enabled them to do the recommended practices. This illustrates that more frequent insulin self-administration might improve the patients’ knowledge and practice levels. It is clear that as time spent on insulin therapy increases, their exposures to information also increases. Moreover, patients might have get an opportunity to learn from the bad consequences of poor insulin handling manners. The findings of the present study were aligned with what Surendranath A. et al. reported, which stated that the patients’ level of knowledge meaningfully influenced the duration of insulin self-administration techniques (P<0.05) . According to studies, numerous recommendations on the insulin injections and storage had no enough logical and scientific supports, but rather it is based on the community habits and traditions [2, 10]. Insulin handling knowledge, practice and skills can be significantly improved if patients are trained with both verbally and practically. This is because applying both verbal and practical trainings could be a complement with each other and help patients to easily understand and remember. Practical mock demonstration of the administration procedures at first visit had positive effects on the respondents’ level of knowledge for insulin storage and administration techniques. In the diabetic self-care process, allowing patients to do mock injection demonstrations in a private diabetic injection training room during their first encounter could possibly build their confidence.
Patients might benefit from regular assessments of their storage and injection practices. In addition, reinforcing them on these practices in subsequent follow-up visits could enhance their knowledge and practice levels than their counterparts. From the occupation perspective, students had the best practice levels than others did. This is possibly, students can read and search the given instructions and recommendations. Besides, they might request clarification on instructions and recommendations that they could not understand. The correlation coefficient test showed a positive linear relationship between knowledge and practice levels of insulin injection. In addition, the Kruskal-Wallis H test also revealed that the patients’ knowledge levels had significant effects on practice levels and handling skills. These all indicate that patients’ injection practice levels may improve with better patients’ knowledge levels in insulin handling techniques.
From the practical skill observational checklist, which assessed the insulin-self administration technique, a significant number of respondents showed the injection sites (94.6%), properly indicated how to rotate the injection sites (70%), and practiced the injection sites rotations (60.8%). This indicates that most of the patients were aware that regular injection site rotations could prevent painful injections, and lipodystrophy, and safeguard the normal tissue for normal absorption. This is supported by a number of articles [10, 27, 28].
Our study revealed that 73.3% of the patients mixed the cloudy insulin (NPH) prior to use. Proper preparation of NPH involves tipping or rolling the vial 20 times. However, we found that only 55.4% of the patients correctly shake the NPH vail. Adequate numbers of rolls or tips of the insulin vails allowed patients to make the suspensions to solutions. Failure to do this could make uneven concentrations of insulin that may possibly lead to hypo- or hyperglycemia. The practices of mixing insulin before use in the present study seem higher than what was reported in India (66.3%). Also, higher numbers of patients (97%) in India  tip or roll the vial 10 times or less. The difference of the results between our study and reports from India might be attributed to the smaller sample size of the present study.
Generally, about half of the respondents either performed incorrectly or skipped very important practical skills and critical steps of insulin delivery recommendations. Even though, the study results indicated that the patients’ knowledge and practice level were moderately adequate and fair, respectively, their practical skills were significantly poor. Herein, patients might be unwilling to practice what they had already known and counseled by professionals, or they had forgotten and might have difficulties of in remembering all critical steps. In addition, diabetic patients are commonly frustrated and stigmatized for the needle injections, which could be a driving force for patients to search for other means of insulin delivery rather than injections. This is also might be another challenge for the patients and possibly render them not to be passionate about adapting the appropriate instructions of insulin delivery methods and handling practices. Thus, educating and changing DM patients wrong perceptions, beliefs and attitudes towards storage and administering techniques should be an additional goal of professionals .
The present study has not left without limitations. Since we included only patients who visited the randomly selected hospitals during the data collection period, not all potential respondents might be included. Due to the small sample size and the limited number of hospitals, it might be difficult to generalize the findings to the multi-cultural and highly diverse Ethiopian population. In addition, as the study was conducted in the hospitals where healthcare professionals were available all the time, patients might feel under pressure as they may think would be blamed for their poor practices.