Knowledge, Attitude and Practice of Insulin Use of Diabetic Patients in India

Diabetes mellitus (DM) is a group of common metabolic disorders that share the phenotype of hyperglycemia. India is emerging as the world diabetic capital.Insulin is a therapeutic option to treat either type 1 and type 2 DM. Inadequate awareness about the use of insulin is likely to influence its acceptance and adherence. The present study was done to assess the knowledge, attitude, and practice regarding insulin use among diabetic patients at Victoria Hospital, Bangalore, India. Knowledge, attitude, and practice of sixty diabetic patients (either inpatients or outpatients) were assessed by using a validated questionnaire consisting of 24 items. Scores were allotted to each question and evaluated after applying appropriate statistical tests.The mean age of the patients was 53.51±6.48 years (58.33% males). The mean knowledge score was 9.06±1.88 out of 22, attitude score was 4.78±1.37 out of 12 and practice score was 7.75±1.24 out of 11. The mean score of attitude was better in females compared to male patients (5.32±1.34 vs. 4.4±1.28). Male patients scored 38.57% compared to female patients (41.33%) for question regarding symptoms of hypoglycemia. 57.14% of male patients and 72% of female patients carried simple carbohydrates when going out. Despite good practice score, the knowledge and attitude scores regarding insulin use were inadequate. Potential adverse effects of insulin can be avoided and better knowledge, attitude and practice can be achieved by providing proper education to patients.


Introduction
Diabetes mellitus (DM) is a group of common metabolic disorders that share the phenotype of hyperglycemia. 1 Pathogenesis of DM is contributed by both genetic and environmental factors which involve insufficient insulin secretion, insulin resistance, increased glucose production and/or fat and protein metabolism abnormalities. 2 Patients with diabetes are in a high risk of cardiovascular, peripheral vascular and cerebrovascular disease. 3,4 These complications can be prevented with appropriate and judicious medical care. 5,6 India is emerging as the world diabetic capital. An estimated 72 million cases were reported in 2017 and expected to almost double by 2025. 7 The prevalence of DM in Karnataka is 7.7% in 2017. 8 Type 1 DM is the result of complete or near-total insulin deficiency. Type 2 DM is a heterogeneous group of doi: 10.15416/pcpr.v4i3.26564 disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production. Type 2 diabetics frequently end up in need of insulin as the disease progresses. 1 Thirty percent of all diabetic patients use insulin either alone or in combination with oral anti-diabetic drugs (OADs) in developed countries though this figure may be lower for India. 9 Inadequate awareness regarding insulin use is likely to influence its acceptance & adherence. One third of patients fail to take their insulin as prescribed, and 20% of adults intentionally skip their doses. It's imperative that all the diabetic patients who use insulin should be educated about its use. 10 Many studies have been published in India on diabetes epidemiology. However, knowledge, attitude and practice (KAP) survey of insulin use in diabetic patients is limited. Thus, the present study was conducted to assess the knowledge, attitude, and practice regarding insulin use among diabetic patients at Victoria Hospital, Banglore, India.

Study Population
This cross sectional, observational, KAP study was conducted in Bangalore Medical College and Research Institute, Department of Medicine. Inclusion criteria were patients: 1. Aged above 18 years old (both female and male) 2. Suffered type 1 and or type 2 DM under insulin therapy 3. Willing to participate in the study Whereas, patients with extremes of age, pregnant, and lactating mother were excluded from the study.

Data Collection
The study was conducted from June 2018 to September 2018. The sample size was calculated using the previous studies. Prior to the enrollment, an informed consent was obtained from the patient in a language which they can best understand. A validated questionnaire was used to assess the KAP of any type of insulin use and its adverse effects. 15 The questionnaire contained 24 questions (8 questions for knowledge, 6 questions for attitude, and 10 questions of practice). The data collected through questionnaire were tabulated and evaluated. Results were analyzed based on categorization of the responses and expressed as percentage. All data were analyzed using Microsoft Excel software.
The responses were scored: 1. Yes: 1 2. No: 0 3. Partially: 0.5 (in attitude and practice), whereas each correct answer in knowledge was scored 1 The responses for the first 2 questions in the attitude were scored: 1. Strongly Agree: -2 2. Agree: -1 3. Unsure: 0 4. Disagree: +1 5.Strongly Disagree: +2 The score was reversed for the next 4 questions. Each correct answer in the practice was scored: 1.Yes: 1 2.No: 0 3. Sometimes/partial response: 0.5 The maximum and minimum scores were: 1. Knowledge: maximum 22, minimum 4 2. Attitude: ranged from -12 to +12 3. Practice: ranged from 2 to 11 The questionnaire used to evaluate the KAP of insulin use and its adverse effects are shown in Supplementary Table 1, Table 2 and  Table 3 respectively.

Results and Discussion
Diabetes continues to be a pandemic worldwide caused by a sedentary lifestyle and food habits. Genetic predisposition along with the fore mentioned factors have led to early onset of diabetes in the Indian population. 11 Patients with diabetes needs to be continuously educated along with lifestyle modification, dietary adjustment, and insulin or oral-antidiabetic drug use, to prevent complications and adverse effects. The education is very essential in diabetics patients, especially for patients under insulin treatment. This KAP study was conducted to evaluate insulin use and its adverse effects.
KAP study was conducted in 60 diabetic patients based on inclusion and exclusion criteria (25 females and 35 males). In this study, we found the number of male patients was higher than females. The previous study showed that male patients are predominance in the prevalence of diabetes 12 due to central obesity that more common in men. 13 It shows that there are lifestyle differences between men and women in India, where men spend more time having meal outside. The mean age of the study population was 53.51 (6.48) years. A study in north India revealed that the prevalence of diabetes is higher in an age group ranging from 45 to 69 years, which is consistent with our study. 14 The rising number of type 2 diabetic cases can be caused by urbanization and sedentary lifestyle.
Present study showed the mean scores of each parameter: knowledge was 9.06/22 (1.88), attitude score was 4.78/12 (1.37), and practice score was 7.75/11 (1.24). Our study showed a comparable knowledge score, whereas the attitude and practice score were better than in previous study that conducted in Tamil Nadu. 15 This difference may be because of better health facility and its accessibility in Bangalore, India. The majority of the patients (90%) know the action of insulin to reduce the glucose levels in the blood and this result was consistent with a study done by Jagadeesh et al in Andhra Pradesh, India. 16  The major finding in our study was the lack of awareness about diabetes and sub-optimal KAP about insulin use and its adverse effects, which can be ascribed to many factors. The limitation of our study is a small study population. Since India is the diabetic capital of the world, so it's imperative to raise the awareness about diabetes and insulin use. The integral part of comprehensive diabetes care is the information and education which leads to improvements in knowledge, attitude and practice. This can be achieved by many Regular awareness programmes are also must to be held. The need of the hour is to have a separate course on diabetes in allied health sciences (AHS) which will provide surplus manpower to assist the diabetologist. All these measures will help to manage diabetes in an effective way.

Conclusion
This study showed that despite good practice score, the knowledge and attitude scores regarding insulin use were inadequate. The results are based on the patient's decisions which reflect about self-management of DM. All the diabetic patients should receive the much-needed education about the knowledge, attitude and practice of insulin use.