Survey of knowledge-attitude-practice (KAP) concerning insulin

ORIGINAL ARTICLE

Survey of knowledge-attitude-practice (KAP) concerning insulin

use in adult diabetic patients at a tertiary care Hospital
K S Ninama1, C B Dumatar2
1
Second Year Resident, Department of Pharmacology, B.J. Medical College, Ahmedabad,Gujarat
2
Associate Professor, Department of Pharmacology, B.J. Medical College, Ahmedabad,Gujarat

ABSTRACT
BACKGROUND AND OBJECTIVES: The study was conducted to assess knowledge, attitude, and practice
regarding insulin use among diabetic patients in tertiary care hospitals. METHODS: Diabetic patients, aged 18
years and above, attending the Medicine out-patient department were enrolled. A pretested structured questionnaire
comprising of 36 items was administered through face-to-face interview. RESULTS: Responses from 240 subjects
were analyzed. Mean age of patient was 62.51 ± 10 years. Mean duration of diabetes was 9.4 ± 7.6 years. Longer
duration of diabetes and its treatment (oral anti-diabetic drugs and insulin) were associated with better knowledge of
some parameters. 35% subjects were not aware of HbA1c as a monitoring tool. Nearly 73% knew the complication
of Diabetes. Among current insulin users, 78 % had never used a Glucometer; only 22 % carried simple
carbohydrates for use in Hypoglycemic attacks; and 41 % failed to rotate sites for insulin injection.
CONCLUSION: Knowledge and attitude were good in majority of patients but practice regarding use of insulin
was poor, which can be removed through appropriate counselling.
Keywords: Knowledge, attitude practice, diabetes mellitus

INTRODUCTION Diabetes currently affects more than 62

According to the latest 2016 data from the million Indians, which is more than 7.1%
World Health Organization (WHO).1 of the adult population. The average age
Diabetes mellitus occurs throughout the on onset is 42.5 years. Nearly 1 million
world, Globally, an estimated 422 million Indians die due to diabetes every
adults are living with diabetes mellitus, but year.5According to the Indian Heart
is more common (especially type 2) in the Association, India is projected to be home
developed countries.2 The greatest increase to 109 million individuals with diabetes by
in prevalence is, however, occurring in 2035.5-6 A study by the American Diabetes
low- and middle-income countries in Asia Association reports that India will see the
and Africa, where most patients will greatest increase in people diagnosed with
probably be found by 2030.3 The risk of diabetes by 2030.6-8 The high incidence is
getting type 2 diabetes has been widely attributed to a combination of genetic
found to be associated with lower socio- susceptibility plus adoption of a high-
economic position across countries4 calorie, low-activity lifestyle by India's
growing middle class.8-10 Inadequate
knowledge regarding insulin is likely to
influence its acceptance and adherence.
*Corresponding Author:
Studies related to knowledge-attitude-
Dr. Kinjal Ninama
practice (KAP) survey in diabetics are
2nd year Resident,
limited in India.11-13 A large proportion of
Department of Pharmacology
type 2 diabetics eventually require insulin
B. J. Medical College Ahmedabad.
for blood sugar control and the assessment
Contact No:
of their knowledge and attitude towards
Email: [email protected]
insulin, even if not using this drug, was
considered important to evaluate the gaps
that need to be addressed. Therefore we

1 Int J Res Med. 2018; 7(4); 1-5 e ISSN:2320-2742 p ISSN: 2320-2734

 Survey of knowledge-attitude-practice (KAP) concerning insulin

undertook this KAP study with two Dislike injections

objectives – to assess the extent of insulin in general
literacy in all adult diabetics irrespective 4%
of whether they are using insulin and to 5% 2% 18% Financial
assess, in actual insulin users, the extent to problem
which they follow accepted practice.
Fear of
hypoglycemia
MATERIALS AND METHODS
A single centric, cross-sectional, KAP Insulin is the
survey was carried out between July 2017 last resort in
71%
to December 2017 among patients diabetes
attending the Medicine out-patient
departments (OPD) in Civil Hospital,
Ahmadabad. The study subjects comprised
of adult (>18 years) diabetic patients who Figure1. Reasons for not using
were willing to respond to the study insulin, currently
questionnaire. Written informed consent were males (203; 84.5%).majority were
was obtained prior to interview. The Hindus (230; 95.8%).In Non- Insulin users
questionnaire used for the survey was 29 and Insulin users, 36 Subjects had a
designed by the authors and underwent good understanding of the role of insulin
content and construct validation by and 76 and 56 believed that it cures
pharmacologist of our institute. It was pre- diabetes. A substantial proportion in Non-
tested on a group of 10 ambulatory Insulin users, 77 and Insulin users, 88
diabetic patients currently using insulin believed that bitter condiments (like bitter
and educated at least up to the primary gourd or Neem) could be used to control
level to remove any ambiguity in blood sugar. Among Non- Insulin users 90
interpretation of the responses. The and Insulin users 52 subjects felt insulin
finalized questionnaire had 35 items of was harmful and hypoglycemia was the
which the first 20 pertained to knowledge most common fear.(Table-2) There were
and attitude. The remainder focused on 120 current insulin users of whom 78 self
practice and this section was administered administered insulin and 78 missed insulin
only to current insulin users. Data captured doses. However, 78 had never used a
during the pilot survey was not reused for glucometer and only 9 used a glucometer
the actual survey. On each day of survey, regularly for home blood glucose
the first five consecutive adult patients monitoring. It was of concern to note that
reporting to the diabetes OPD were 9 subjects reported a significant number of
selected, explained about the survey and if meals skipped following insulin injection.
willing, interviewed in a separate While 52 Non insulin users and 60 Insulin
room.Duration of study was 6 months. Users patients could enumerate the
essential symptoms of hypoglycemia, only
RESULTS 29 and 22 patients respectively made it a
Total 240 subjects were interviewed & practice to carry simple carbohydrates (e.g.
their data analysed. Mean age of the study glucose sachets, sugar cubes) for use
subjects was 62.5 ± 10 years range, 43-89 during such attacks. There was no
years (95% CI 61.2 – 63.8) with a mean association with education status in this
duration of diabetes of 9.4 ± 7.6 years regard. Table 3 lists the findings related to
(95% CI: 8.6-10.1). Majority (45.4%) were practice of insulin use in the study subjects
under 60 years of age with 40-49 years age (n= 120).
group being the major contributor (11.6%)
Table -1. More than half of the subjects

2 Int J Res Med. 2018; 7(4); 1-5 e ISSN:2320-2742 p ISSN: 2320-2734

 Survey of knowledge-attitude-practice (KAP) concerning insulin

Table : 1 Demographic Detail of Patients

Non-Insulin user(N=120) Insulin users (N=120)
Age (Mean ± SD) 58.7 ± 10 year 61.7 ± 9.7 year
Male: Female 7:1 13:1
Duration of DM (Mean ± SD) 6.8 ± 1.5 year 6.5 ± 1.4 year
Table : 2 Questions regarding knowledge and attitude
Non-Insulin Users Insulin Users
(N-120)(%) (N-120)(%)
No Question Not No Yes Not No
Yes Sure Sure

1 Do you know why insulin is prescribed for

diabetes? 29(24%) 36(30%) 55(46%) 51(42%) 43(36%) 26(22%)
2 Do you think insulin can cure diabetes? 76(63%) 21(18%) 23(19%) 56(47%) 41(34%) 23(19%)
3 Do you think insulin is habit forming? 54(45%) 42(35%) 24(20%) 62(52%) 24(20%) 34(28%)
4 Do you believe insulin is the last resort for
treatment of diabetes? 63(53%) 42(37%) 12(10%) 58(49%) 29(23%) 33(28%)
5 Do you think insulin can cause harm? 90(75%) 10(8%) 20(17%) 52(43%) 26(22%) 42(35%)
6 Do you believe bitter condiments can be used
to control blood sugar? 77(64%) 19(15%) 25(21%) 88(73%) 17(14%) 15(13%)
7 Do you think insulin can be stopped once blood
sugar levels normalize? 15(13%) 49(41%) 56(46%) 62(52%) 38(32%) 20(16%)
8 Do you feel that once insulin is started diet and
exercise become less important? 66(55%) 7(6%) 47(39%) 10(9%) 18(15%) 91(76%)
9 Are you aware that there are different types of
insulin? 62(52%) 21(18%) 36(30%) 56(47%) 56(46%) 8(6%)
10 Are you aware that there are different types of
insulin Device? 84(70%) 12(10%) 24(20%) 60(50%) 12(10%) 48(40%)
11 Are you aware that even if insulin is not
mandatory in a diabetes patient, it may still be 58(48%) 42(35%) 20(17%) 62(52%) 37(30%) 21(18%)
required during certain stressful conditions?
12 Are you aware of HbA1c
48(40%) 40(33%) 32(27%) 42(35%) 37(31%) 41(34%)
13 Do you believe insulin use could be against
your religious practice at any point? 28(23%) 65(54%) 27(23%) 36(30%) 46(39%) 38(31%)
14 Can you mention some symptoms of
36(30%)
Hypoglycemia ? 52(43%) 30(25%) 38(32%) 60(50%) 24(20%)
Do you visit an eye specialist in relation to Infreque
15 your diabetes? Regular No Regular Infrequent No
nt
42(34%) 33(31%) 45(35%) 75(63%) 21(17%) 24(20%)
16 Do you carry simple carbohydrates with you Sometim
while travelling? Usually No Usually Sometime No
e
29 45 46 22 64 34
(24%) (38%) (38%) (18%) (54%) (28%)
17 Do you carry a tag identifying yourself as a
diabetes patient?
31 37 52 42 44 34
(26%) (31%) (43%) (35%) (37%) (28%)
18 What do you understand by diabetes?
Good Moderate Moderate
Poor Idea: Good Idea: Poor Idea
Idea Idea: Idea:
29(24%) 36(30%) 55(46%) 46 (38%) 36(30%) 38(32%)
19 What are the complications of diabetes?
31 27 62 42 45 33
(26%) (22%) (52%) (35%) (38%) (27%)
20 Have you ever been hospitalized for insulin
More More than
related hypoglycemia? Often No Often No
than one one
59 42 19 68 44 8
(49%) (35%) (16%) (56%) (36%) (8%)

3 Int J Res Med. 2018; 7(4); 1-5 e ISSN:2320-2742 p ISSN: 2320-2734

 Survey of knowledge-attitude-practice (KAP) concerning insulin

Table : 3 Questions regarding Practice of insulin (N-120 Insulin users) (%)

No Question
1 Upper arm Abdomen Thigh
Where do you inject insulin?
89(74%) 14(12%) 17(14%)
2 Usually Sometime No
Do you rotate sites?
24(20%) 55(46%) 41(34%)
3 31 21 68
Do you clean the injection site with spirit beforehand?
(26%) (17%) (57%)
4 After introducing the syringe, do you withdraw it 21 29 70
partly to look for presence of blood? (18%) (24%) (58%)
5
Do you take any other medicines for diabetes without 30 89
0
informing the physician who Prescribes your insulin? (25%) (75%)
6 Before meals After meals Not Fixed
When do you take insulin in relation to your meals?
96(80%) 0 24(20%)
7 Refrigerator At room temperature Not fixed
Where do you keep your insulin?
82(68%) 30(25%) 8(7%)
8 Regularly Infrequently: No
Do you use a glucometer?
9(8%) 33(27%) 78(65%)
9
Usually Sometime No
Do you skip food after taking insulin?
9(8%) 55(46%) 56(46%)
10 Book Internet Television Other sources:
How else do you gather information regarding the
7 70 21 21
insulin that you use?
(6%) (58%) (18%) (18%)
11 Yes Not Sure No
Are you confident about self-administering insulin?
78(63%) 31(26%) 15(11%)
12 Did your family members encourage you regarding
75(63%) 17(14%) 28(23%)
insulin use?
13 Regularly Infrequently: No
Would you ask your physician/healthcare provider in
62 39 19
case you have any queries regarding insulin use?
(52%) (32%) (16%)
14 Do you miss insulin doses? 78(65%) 8(6%) 34(29%)
15 Dislike injections in general 22(18%)
Financial problem 84(71%)
If you have been advised insulin but currently not
Fear of hypoglycaemia 6(5%)
using it, why is that so?
Insulin is the last resort in diabetes 3(2%)
Insulin is habit-forming 5(4%)

DISCUSSION knowledge and attitude are considered, the

Aided by increasing urbanization, rural to study population showed satisfactory
urban migration, adoption of sedentary trends comparable to earlier KAP studies
lifestyle, and unhealthy food habits, the conducted in other parts of India.9-12
diabetes pandemic continues to snowball However, there are some points of
worldwide. These adverse factors interact difference in our study. Approximately 60
with the already heightened genetic % of our subjects had a satisfactory idea
predisposition for diabetes among Indians, about diabetes and its signs and symptom.
leading to onset of diabetes at a younger Only 24.1% Non-Insulin and 18.3%
age.12 In addition to modification of diet Insulin users were carrying simple sugars
and lifestyle and institution of insulin or while traveling as precaution against
other anti-diabetic drugs, the management serious hypoglycemia Overall, in our
of this complex metabolic disease needs study, awareness regarding insulin as a
continuous educational and counseling therapeutic option was satisfactory and the
efforts. The need is all the more acute belief that insulin could cure diabetes or
among diabetics on insulin to ensure its that it could be substituted was minimal.
effective and safe use. Our KAP study was On the negative side, some were not using
conceived in this context to capture data insulin in spite of medical advice, 71.1%
regarding insulin use and its perceived due to financial Problem (Figure 1).
advantages and disadvantages. As far as Knowledge regarding the necessity for

4 Int J Res Med. 2018; 7(4); 1-5 e ISSN:2320-2742 p ISSN: 2320-2734

 Survey of knowledge-attitude-practice (KAP) concerning insulin

continuity of insulin administration and Millions Who Escape Poverty".

pronounced inhibition to discuss insulin Bloomberg. Retrieved 8 June 2012.
treatment with the physician were other 5. Indian Heart Association Why South
notable findings. Majority were getting Asians Facts Web. 30 April 2015.
their blood glucose checked regularly. 6. Wild, Sarah, Gojka Roglic, Anders
Only a handful used glucometer regularly, Green, Richard Sicree, and Hilary King.
majority had never used once. Despite "Global Prevalence of Diabetes."
knowledge of hypoglycemia symptoms, Diabetes Care. American Diabetes
only a quarter of insulin users carried Association, 26 Jan. 2004. Web. 22
simple carbohydrates with them while Apr. 2014.
travelling and a small number had even 7. Kleinfield, N. R. (September 13, 2006).
carried a tag for identification as a diabetic "Modern Ways Open India’s Doors to
on insulin in both group of Patients. Diabetes". New York Times. Retrieved
Despite these limitations, Our study results 8 June 2012.
have identified some points by which we 8. Mishra A, Pandey RM, Devi JR,
can improved diabetes care by earlier Sharma R, Vikram NK, Khanna N.
detection, effective management and High prevalence of diabetes, obesity
effective reduction in diabetes co- and dyslipidemia in urban slum
morbidities and complications through population in northern India. Int J Obes
insulin-based improved diabetes care. Relat Metab Disord 2001;25:1722-9.
Some monitoring and practice aspects 9. Madhu SV, Rao PV. Epidemiology of
need urgent attention. Diabetes clinics in diabetes mellitus in India. In: Tripathi
tertiary care hospitals are probably in the BB, Chandalia HB, editors. RSSDI
best position to launch interventional and Textbook of Diabetes Mellitus. 2nd ed.
educational programs with the help of Hyderabad: Research Society for study
local physicians, healthcare workers, of diabetes in India; 2008. p. 209-26.
community leaders and mass media. The 10. Ramachandran A, Snehalatha C, Kapur
practice aspect needs improvement A, Vijay V, Mohan V, Das AK, et al.;
through careful initial counselling and Diabetes Epidemiology Study Group in
repetition at each follow-up visit. India (DESI). High prevalence of
CONCLUSION diabetes and impaired glucose tolerance
Knowledge and attitude were satisfactory in India: National Urban Diabetes
on the whole but deficiencies in practice Survey. Diabetologia 2001;44:1094-
were pronounced, which can potentially be 101.
removed through appropriate counseling. 11. Shah VN, Kamdar PK, Shah N.
Assessing the knowledge, attitudes and
REFERENCES practice of type 2 diabetes among
1. World Health Organization, Global patients of Saurashtra region, Gujarat.
Report on Diabetes. Geneva, 2016. Int J Diabetes Dev Ctries 2009;29: 118-
Accessed 30 August 2016. 22.
2. Wild S, Roglic G, Green A, Sicree R, 12. Priyanka Raj CK, Angadi MM.
King H (2004). "Global prevalence of Hospital-based KAP study on diabetes
diabetes: Estimates for the year 2000 in Bijapur, Karnataka. Indian J Med
and projections for 2030". Diabetes Spec 2010;1:80-3.
Care. 27 (5): 1047–53. 13. Malathy R, Narmadha M, Ramesh S,
3. "China faces 'diabetes epidemic', Alvin JM, Dinesh BN. Effect of a
research suggests". BBC. March 25, diabetes counseling programme on
2010. Retrieved 8 June 2012. knowledge, attitude and practice among
4. Gale, Jason (November 7, 2010). diabetic patients in Erode district of
"India’s Diabetes Epidemic Cuts Down South India. J Young Pharm 2011;3:65-
72.
5 Int J Res Med. 2018; 7(4); 1-5 e ISSN:2320-2742 p ISSN: 2320-2734