A Descriptive Study To “Assess The Knowledge And Attitude

A Descriptive Study To “Assess The Knowledge And Attitude

Regarding Self-Administration Of Insulin Injection Among Diabetes

Mellitus Patients In Kempa Cheluvamba General Hospital At

Malleswaram, Bangalore”

By

Namita Singha

Dissertation submitted to the

Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore

In partial fulfillment

Of the requirement for the degree of

Master of Science

In

Medical-Surgical Nursing

Under the guidance of

Asso. Prof. Victorial Selva Kumari C.


Sarvodaya College of Nursing

Vijayanagar, Bangalore-40

November 2005

II

Rajiv Gandhi University of Health Sciences

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation / thesis entitled “A Descriptive Study To

Assess The Knowledge And Attitude Regarding Self-administration of Insulin

Injection Among Diabetes Mellitus Patients In Kempa Cheluvamba General

Hospital At Malleswaram, Bangalore” is a bonafide and genuine research work

carried out by me under the guidance of Mrs. Victorial Selva Kumari C,

Asso. Professor and HOD, Department of Medical-Surgical Nursing.

Date: Signature of the Candidate

Place: Bangalore Ms. Namita Singha

III

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A Descriptive Study To Assess The

Knowledge And Attitude Regarding Self-administration of Insulin Injection

Among Diabetes Mellitus Patients In Kempa Cheluvamba General Hospital At

Malleswaram, Bangalore” is a bonafide research work done by Namita Singha in

partial fulfillment of the requirement for the degree of Master of Science in Nursing.

Date: Signature of the Guide

Place: Bangalore Mrs.Victorial Selva Kumari C.

Asso. Professor and HOD


IV

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION

This is to certify that the dissertation entitled “A Descriptive Study To Assess

The Knowledge And Attitude Regarding Self-Administration Of Insulin

Injection Among Diabetes Mellitus Patients In Kempa Cheluvamba General

Hospital At Malleswaram, Bangalore” is a bonafide research work done by

Namita Singha under the guidance of Mrs.Victorial Selva Kumari C,

Asso. Professor, Medical-Surgical Nursing.

Seal and Signature of the Seal and Signature of the

HOD Principal

Asso. Prof. Victorial Selva Kumari C. Prof. T. Bheemappa

Date: Date:

Place: Bangalore Place: Bangalore

V

COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University Of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation/thesis in print or

electronic format for academic/research purpose.


Place: Bangalore Namita Singha

© Rajiv Gandhi University Of Health Sciences, Karnataka

VI

ACKNOWLEDGEMENT

No one can lead a life apart

Untouched by others lives

My life is not just my own design but

Part of all the rest that pass my way

And each of them is part of mine

It is my pleasure and pride to record my gratitude and thanks to those who have

contributed to the successful completion of this endeavor.

A sincere gratitude to Sri. V. Narayanaswamy, Chairman, Sarvodaya College of

Nursing for providing me an opportunity to advance my education in this institution.

I express my heartfelt thanks to Prof. T Bheemappa, Principal, Sarvodaya College of

Nursing for all the timely guidance and help given in completing this study.

The present study was undertaken and completed under the inspiring and valuable

guidance of Mrs. Victorial Selva Kumari, Asso. Professor and HOD, Medical

surgical Nursing and (my) Co-Guide Mr. Amal Einstein Xavier, Principal, Oriental

College of Nursing. I express my deep sense of gratitude to both of them for their

expert guidance, valuable suggestions, constant encouragement and keen interest in

planning and execution of my study.

I am highly obliged to Prof. Hemalatha, Head of the Department, Pediatric Nursing

and Research Methodologist for her expert guidance and help throughout the study.

I am indebted to Prof. Shridhar, Associate Professor, Medical Surgical Nursing

Kempegowda Institute of Nursing for his guidance and expert suggestions.

I express my gratitude to Mrs. Fermina, Lecturer Medical Surgical Nursing and

Ms. Ramya, Lecturer OBG Department for their guidance and support.

VII

I convey my thanks to the Medical Superintendent, Kempa Cheluvamba General

Hospital, Malleswaram for granting me permission to conduct the research study at

K.C.General Hospital.

Heartfelt thanks to Dr.Gangaboraiah, Biostatistician for guiding me in statistical

analysis and interpretation of data.

I express my gratitude to the entire teaching and non-teaching faculty of Sarvodaya

College of Nursing for their support extended during the course of my study.

My sincere thanks and appreciation to all the experts who validated the tool and

provided constructive and valuable opinion.

A note of thanks to Librarians, Sarvodaya College of Nursing and Chief Librarian,

National Institute of Mental Health and Neuro Sciences, Bangalore for their assistance

in library reviews.

A special thanks to the Diabetic Patients, who participated in my study.

Sincere thanks to Ms. Surekha for Kannada translation and to my beloved

classmates and friends.

I extend my thanks to Mr. B. Suraj Shetty for his excellent computer assistance.

I owe depth of gratitude to my loving parents Mr. Harendra Singha and

Mrs. Dipali Singha and my brother Pranjal for their inspiration and encouragement

throughout the study.

My sincere thanks and gratitude to all whose names are not mentioned but who have

directly or indirectly helped in the completion of this thesis.

Above all, I bow my head with profound gratitude in front of 'God Almighty' for the

blessings showered on me throughout.


Place: Namita Singha

VIII

LISTS OF ABBREVIATIONS USED

(In alphabetical order)

1. χ² - Chi-square

2. = - Equal to

3. > - Greater Than

4. < - Lesser Than

5. % - Percent

6. BC - Before Christ

7. DCCT - Diabetes control and complications Trial

8. DM - Diabetes Mellitus

9. E.g. - For example

10. HBA,C - Glycosylated Haemoglobin

11. IDDM - Insulin Dependant Diabetes Mellitus

12. IDF - International Diabetes Federation

13. i.e - That is

14. NIDDM - Non- Insulin Dependant Diabetes Mellitus

15. OHA - Oral Hypoglycemic Agent

16. SD -Standard Deviation

17. WHO - World Health Organization

IX

ABSTRACT

Statement of The Problem

A Descriptive Study To “Assess The Knowledge And Attitude Regarding Self-

administration of Insulin Injection Among Diabetes Mellitus Patients In Kempa

Cheluvamba General Hospital At Malleswaram, Bangalore”.

Objectives of The Study

1. To assess the knowledge of patients regarding the Self-administration of

Insulin Injection.

2. To assess the attitude of patients regarding Self-administration of Insulin

Injection

3. To correlate the knowledge and attitude of diabetic patients regarding self-

administration of insulin injection.

4. To associate the knowledge with selected demographic variables.

5. To associate the attitude with selected demographic variables.

6. To develop an information booklet on self-administration of insulin injection

for diabetes mellitus patients.

Research Approach

A descriptive survey approach was used for assessing the knowledge and attitude of

Diabetes Mellitus patients regarding Self-Administration of insulin injection.

Population

The target population consisted of 60 Diabetic patients who were on Insulin Therapy

within the age group of 40-70 years. Half of the patients were admitted and a few

were attending the OPD services in Kempa Cheluvamba General Hospital at

Malleswaram, Bangalore.

X

Sample And Sampling Technique

A sample of 60 Diabetic patients, were selected according to the availability and

convenience of the researcher. Non-probability Convenient sampling technique was

used.

Tool

A Structured Self-Administered Questionnaire and a Likert type of Attitude Scale was

used for the data collection.

The tool consisted of three parts.

Part I : Demographic Data (11questions)

Part II : Knowledge Questionnaire (30 questions)

Part III : Attitude Scale (20 statements)

An information booklet on self-administration of insulin injection was prepared and

distributed among the insulin dependent patients

Data Collection

After obtaining an informed consent from the respondents, the investigator collected

the data from 60 Diabetic patients by means of self administered questionnaire.

Major Findings Of The Study

1. Out of 60 diabetic patients 81.7% had average knowledge, 13.3% had poor

knowledge and only 5% had good knowledge regarding self administration of

insulin injection. The overall mean value of the diabetic patients knowledge

regarding self administration of insulin injection was 14.45 with a standard

deviation of 3.326.

2. Out of 60 diabetic patients, only 18.3% had most favourable and 81.7% had a

favourable attitude towards self administration of insulin injection. It revealed

XI

the mean percentage of the positive attitude, which was 69.05 with a standard

deviation of 5.585.

3. There is no significant association between the level of knowledge and

selected demographic variables.

4. Age, gender, education, religion, occupation, marital status, duration of

diagnosis of diabetes mellitus, number of years on insulin therapy and family

history of diabetes mellitus are not significantly associated with the level of

attitude of diabetic patients.

5. There is a highly significant association between the level of attitude and the

family income of diabetic patients.

In view of the nature of the present study and to accomplish the objectives of the

study, an informational booklet was prepared on self administration of insulin

injection.

Interpretation and Conclusion

The study showed that the theoretical knowledge of diabetic patients regarding self

administration of insulin injection were average and the attitude towards self

administration of insulin injections were favourable.

Key Words

Diabetes Mellitus; Insulin Therapy; Self Administration; Diabetic Patients; Insulin

Injection

XII

TABLE OF CONTENTS

Sl. No Contents Page No

1 Introduction 1 - 13

2 Objectives 14

3 Review of Literature 15 - 26

4 Methodology 27 – 36

5 Results 37 – 65

6 Discussion 66 – 70

7 Conclusion 71 – 74

8 Summary 75 – 78

9 Bibliography 79 – 84

10 Annexure 85 – 137

XIII

LIST OF TABLES Sl. No. Tables Page No.

1. The frequency and percentage distribution of diabetic patients according to their age group (in years)

39

2. The frequency and percentage distribution of the diabetic patients according to gender.

40

3 Frequency and percentage distribution of the diabetic patients according to education.

41

4 Frequency and percentage distribution of the diabetic patient according to occupation

42

5 The frequency and percentage distribution of the diabetic patient according to religion.

43

6 Frequency and percentage distribution of diabetic patients according to Marital Status

44

7 Frequency and percentage of the diabetic patients according to Family Income per month.

45

8 The frequency and percentage distribution of the diabetic patients according to duration since diagnosis of Diabetes Mellitus

46

9 The Frequency and percentage distribution of the diabetic patients according to number of years on insulin therapy

47

10 The frequency and percentage distribution of the diabetic patients according to family history of diabetes mellitus

48

11 Distribution of Knowledge Related to General Information on Insulin Therapy.

49

12 Distribution of Knowledge Related to Self-Administration of Insulin Injection.

50-51

13 Mean, Mean percentage and the standard deviation of the diabetic patients knowledge as per areas of self administration of insulin injection

53

14 Overall knowledge of the diabetic patients on self-administration of insulin injection

54

15 Overall attitude of the diabetic patients regarding self-administration of insulin injection

55

16 Association between the selected demographic variables of Diabetic Patients and their level of knowledge regarding self administration of Insulin Injection

56-57

17 Association between selected demographic variables of diabetic patients and their level of attitude regarding self-administration of insulin injection.

60-61

18 Correlation of the Diabetic patients knowledge and the attitude on the self-administration of Insulin Injection.

65

XIV

LIST OF FIGURES Sl. No. Figures Page No.

1. Conceptual Framework 13

2. Schematic Representation of Research Design 28

3. Distribution of diabetic patients according to their Age 39

4. Pie chart representing percentage distribution of the diabetic patient according to gender

40

5. Bar Diagram representing Percentage Distribution of the Diabetic Patients according to Education.

41

6. Bar Diagram Representing Percentage Distribution of the Diabetic Patients according to Occupation

42

7. Bar diagram representing Percentage Distribution of the Diabetic patient according to Religion.

43

8. Bar Diagram representing Percentage Distribution of Diabetic Patient according to Marital Status

44

9. Pie diagram Representing Percentage Distribution of the Diabetic Patients according to Family Income per month.

45

10 Bar Diagram representing Percentage Distribution of the Diabetic Patients according to duration since diagnosis of diabetes Mellitus

46

11 Bar diagram representing Percentage Distribution of the Diabetic Patients according to Numbers of years on Insulin Therapy

47

12 Bar Diagram representing Percentage Distribution of the Diabetic Patients according to Family History of Diabetes Mellitus

48

13 Cone Diagram representing Mean Percentage of Diabetic Patients in both the areas of Self - administration of Insulin Injection

53

1 4 Pie diagram representing overall knowledge of the Diabetic patients regarding Self-administration of Insulin Injection

54

15 Pie Diagram Representing overall attitude level of the diabetic patients regarding self-administration of insulin injection

55

16 Scattered diagram representing relationship between knowledge and attitude 65

1

1. INTRODUCTION

"A wonderful affection not very frequent among men, being a melting down of

the flesh and limbs into urine… life is short, disgusting and painful, thirst

unquenchable, death is inevitable." Areatus, the Greek physician thus described the

clinical features of Diabetes Mellitus, almost 4000 years ago.

Diabetes Mellitus is an endocrine disorder, characterized by hyperglycemia that is,

high blood sugar levels. This is caused due to a relative or absolute insulin deficiency,

a hormone produced by the pancreas. Lack of insulin, either relative or absolute

affects metabolism or breaking down of carbohydrates, proteins, fat, water and

electrolytes leading to an accumulation of glucose in the blood.1 Till the earlier part of

this century, it was believed that there was no effective treatment for this condition,

until the discovery of insulin, in 1922, by Fredrick Banting and his student, John

McCleod 2

PREVALENCE OF DIABETES MELLITUS:

Global Scenario:- The International Diabetes Federation estimated that the

worldwide prevalence of diabetes mellitus in the year 2003 is 194 million.3 The

World Health Organization (WHO) has projected that this number would increase

to 300 million by the year 2025.4

Indian Scenario:- Prevalence of Diabetes Mellitus in India has been growing by

leaps and bounds. In the last 20 years there has been a three fold increase in the

prevalence of Diabetes and today it is estimated that there are over 20 million diabetic

patients in India. India’s diabetic population now ranks first in the world5.

2

A recent national population based study conducted by Ramachandran A,

Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK et al in six urban cities

revealed astonishing results. This study suggested that the prevalence of diabetes

among Chennai residents to be 13.5%, Bangalore – 12.4%, Hyderabad – 16.6%,

Calcutta –11.7%, New Delhi – 11.6% and Mumbai - 9.3%. Thus it is clear that in the

last two decades, there has been a marked increase in the prevalence of diabetes

among urban Indians.6 Ramaiya KL, Kodali VRR, Alberti KGMM had mentioned

that there is a wide urban – rural difference, the prevalence being 2.4% in rural and

11.6% in the urban population.7

Diabetes Mellitus is commonly divided into two main categories namely Type I

diabetes earlier referred as Insulin – Dependent diabetes, and Type II diabetes also

known as Non-Insulin Dependent diabetes. Although both are characterised by

abnormalities in glucose metabolism, there are significant differences in etiology,

pathology and treatment of the two conditions.8

Type II diabetes or Non-Insulin dependent diabetes occurs at a later age, usually after

age of 40, and has a large hereditary component. It is caused by a combination of beta

cell (of the islets of Langerhans) dysfunction and insulin resistance. Management of

Type II diabetes in the majority of patients is with diet, exercise with or without Oral

Hypoglycemic Agents. Even though the disease is prolonged and in the process

certain diabetes complications are associated with the illness requiring insulin, Non-

Insulin Dependent diabetes is often asymptomatic and ketoacidosis is rare.9

Type I diabetes is typically diagnosed at childhood, with peak incidence at puberty. It

is characterized by complete Beta cell failure, requiring exogenous insulin

3

replacement by injection for survival.10 There is evidence to suggest that Type I

diabetes is a slow auto-immune disease, in which insulin producing beta cells of the

pancreas are destroyed by the body’s fight against infection. As in type II the resulting

insulin deficiency leads to the accumulation of glucose in the blood stream,

accompanied by the classical symptoms of polyuria (excessive urination), polydypsia

(excessive thirst), weight loss, fatigue and tiredness. In addition, compensatory fat

metabolism produces ketone bodies, leading to ketoacidosis and coma. The treatment

of Type I diabetes is often complex. In addition to daily injection, it involves many

other life style adjustments such as timing and nature of food consumption, regular

exercise and blood glucose monitoring.11 These life style changes place unique

demands on the individuals as well as the family, as failure to follow any of these

could lead to serious short term and long term consequences (hypoglycemia,

ketoacidosis, heart disease, neuropathy, retinopathy, nephropathy). Both Type I and

Type II diabetes could lead to macro and micro vascular complications, if not

controlled adequately. The long term prognosis of Type I diabetes is said to improve

with a complex demanding and often intensive regimen and maintenance of lower

blood glucose levels is said to reduce the risk of long term complications by as much

as 60%12.

The maintenance of lower blood glucose level is dependent on many factors,

including compliance or adherence to treatment. Insulin has become cornerstone of

diabetes treatment since its initial discovery.13

Insulin therapy in any form is effective in restoring normoglycemia, suppressing

ketogenesis, and delaying or arresting diabetes complications in all patients with

diabetes.13

4

Regular Insulin Therapy is life saving in Type I diabetes. Non-obese, early onset

patients with Type II diabetes respond poorly to Oral Hypoglycemic Agents (OHA)

due to hypoinsulinaemia and low insulin reserve (latent autoimmune diabetes in

adults) hence require Insulin Therapy. The commonest indication of regular Insulin

Therapy in Type II diabetes is OHA failure, which can be primary in 30% or

secondary in 5% - 10% Patients on OHA per year. Regular Insulin Therapy is also

indicated in patients of diabetes associated with renal or hepatic disease, where OHA

is contraindicated.14

Different type and species of insulin have different pharmacological properties.

Human insulin is preferred, for use in pregnant women considering pregnancy,

individuals with allergies or immune resistance to animal derived insulin, those

initiating insulin therapy, and those expected to use insulin only intermittently.14

Conventional insulin administration involves subcutaneous injections with syringes

marked in insulin units. These syringes must be matched with concentration of insulin

in vials.15

Several alternative methods of insulin administration are available like jet injectors

that inject insulin as a fine stream into the skin. Several pen-like devices and insulin

containing cartridge are available, which are easy to operate, improve accuracy and

more convenient. Several new insulin delivery systems are under development that

may eliminate the need for needle-based introduction. This includes insulin pumps,

insulin inhalers. Preliminary studies have shown very promising results but they are

not yet available in India.16

5

Even after discovery of so many alternative devices and newer technologies,

conventional Insulin Therapy with a needle and syringe is still one of the most

popular, convenient, and cost effective method for insulin administration.

Subcutaneous insulin administration is the only insulin administration technique,

which can be done at home environment and can be done by patients themselves.

NEED FOR THE STUDY

Diabetes is widely recognized as one of the leading causes of death and disability

worldwide. Diabetes is not new to the medical world as it is known since antiquity

(1500BC), but now Diabetes has become a major health threat to the whole world.17

The explosion of diabetes in India and other developing countries has been viewed

with serious concern by the World Health Organization (WHO) and the International

Diabetes Federation (IDF) 5.

Increasing prevalence of Diabetes will put a heavy burden not only on health system

but a health worker also have to spend a lot of his professional time on Diabetes care.

Majority of Diabetes population in India belong to Type II (NIDDM) group. Strict

long-term glycemic control reduces the complications associated with Diabetes

Mellitus. This has been established in the recent Diabetes Control and Complications

Trial (DCCT).

Maia FFR, Araujo LR in their study “ Insulin pen injector for the treatment of

Type I Diabetes Mellitus” has mentioned that the treatment of Type I Diabetes

mellitus (DM) has had some breakthroughs over the last few decades. The exogenous

administration of insulin has been the only available treatment for millions of

Diabetics all over the world. After Banting and Best discovered insulin in 1921, the

6

possibility of obtaining an ideal sugar control was more likely, offering Diabetics a

better survival rate and quality of life.18

Mollema ED, Snock FJ, Pouwer F in their study “Diabetes; fear of injecting and self

testing questionnaire” has found that extreme fear of self injecting insulin (Injection

Phobia) is likely to compromise glycemic control as well as emotional well being.19

Cramer JA, Pugh MJ in their study “The influence of Insulin use on glycemic

control” has described numerous barriers to use of insulin e.g., fear of self-injections,

and hypoglycemic events, burden of injections and timings in relation to meals etc.20

According to Diabetes Control and Complication Trial (DCCT) the strict control of

blood sugar level reduces the risks of microangiopathy, retinopathy, and nephropathy

in Diabetic patients. The treatment should be conducted on an individual basis and

requires participation of a multiprofessional team, commitment of the patient and help

from family members.21

It is obvious that in a country like India, the rising prevalence of diabetes with its

attendant complications is likely to produce severe constraints on health care budgets

in the future.5

Considering all the above factors and had having witnessed while posting in clinical

areas the investigator felt that there is a need for assessing the knowledge and attitude

regarding self-administration of insulin injection among Diabetes Mellitus patients.

The Diabetic patients who are on Insulin need to be knowledgeable regarding the

disease and Insulin Therapy and also they must have a positive attitude towards self-

administration of insulin injection to overcome the barriers of insulin injection.

7

Therefore, the researcher is keenly interested to undertake this study. This will help

in avoiding complications besides improving quality of life of the patients.

STATEMENT OF THE PROBLEM

A Descriptive Study To Assess The Knowledge And Attitude Regarding

Self-Administration Of Insulin Injection Among Diabetes Mellitus Patients In Kempa

Cheluvamba General Hospital At Malleswaram, Bangalore.

OBJECTIVES OF THE STUDY

1. To assess the knowledge of patients regarding self-administration of insulin

injection.

2. To assess the attitude of patients regarding self-administration of insulin

injection.

3. To correlate the knowledge and attitude of Diabetic patients regarding self-




6. To develop an information booklet on self-administration of insulin for

Diabetes Mellitus patients.

OPERATIONAL DEFINITIONS

1. Knowledge: It refers to the level of understanding of Diabetic Patients

regarding self-administration of insulin injection as measured by the correct

responses to the items.

8

2. Attitude: These are feelings and beliefs expressed by patients towards

self-administration and are evident from scores obtained by their response in a

validated rating scale.

3. Self-Administration: The injection expected to be administered by the

patients at home without assistance. This includes preparation of article,

withdrawal of injection, administration and after care.

ASSUMPTIONS

Patients who are on Insulin Therapy of Kempa Cheluvamba General Hospital

will posses some knowledge regarding self-administration of insulin injection.

The increased knowledge of the Diabetes Mellitus patients will show a

positive attitude towards self-administration of Insulin injection.

HYPOTHESIS

H1 : There is a significant relationship between knowledge and attitude of

Diabetes Mellitus patients regarding self-administration of insulin injection.

H2 : There is a significant association between levels of knowledge with


H3 : There is a significant association between the attitudes of diabetes

mellitus patients with selected demographic variables.

SAMPLING CRITERIA

Inclusion Criteria

1. Patients who are diagnosed with diabetes mellitus in K. C. General Hospital

2. Those who are in the age of 40 to 70 years

3. Patients who are on Insulin Therapy.

4. Both male and female are included.

9

Exclusion criteria

1. Diabetic patients who are on Oral Hypoglycemic Agents.

2. Diabetic patients who are on Intravenous Insulin Therapy.

Conceptual Frame Work

A concept is a thought, idea or mental image formed in the mind in response to

learning something new. A framework is a basic structure supporting anything. 22

Conceptual framework deals with the interrelated concepts that assembled together in

some rational scheme by virtue of their relevance to a common theme. 23

One of the important purposes of conceptual framework is to communicate clearly the

interrelationship of various concepts. It guides an investigator to know what data

needs to be collected and gives direction to entire research process.24

The conceptual framework for this study was based on Orem’s self-care model as

cited in Potter and Perry.25 This conceptual framework identifies and defines the

factor or phenomena of work in a nursing situation and describes their relationships.

Each individual has an innate ability to care for oneself. It is a theoretical model

which values individual responsibility and belives in health education as key aspect of

nursing intervention.(Dorothea E.Orem)

This study is aimed at assessing the knowledge and attitude on self-administration of

insulin injection among diabetes Mellitus patients. This study will focus on to find the

association if any, between knowledge and attitude with selected demographic

10

variables and so also will find association if any between the knowledge and attitudes

of Diabetic patients regarding self-administration of insulin injection.

The main concepts that are enumerated in this study are Self-care requisites and self-

care agency. Self-care is the practice of the activities that individuals perform in their

own behalf in maintaining life, health and well-being. In this study self-care

comprises all the activities related to self-administration of insulin injection which in

turn contribute to healthy practices and general health maintenance.

Self-care requisites are the demands of Diabetic patient’s specific of their needs. The

self-care requisites arise from a variety of conditions, which pose as a threat to the life

of an individual .In this study this refers to those conditions where Diabetic patients

need assistance due to wrong self-administration practices, which are detrimental to

their life.

The nurse posses the ability to identify the self-care requisites so as to render

comprehensive nursing care. Self-care agency refers to the human ability for engaging

in self-care. Normally adults voluntarily care for themselves. In this study self-care

agency refers to nursing activities (Nursing Agency) when assessing and determining

client’s needs, one should identify which are the areas where self-care deficits exists.

At the same time, one must gather sufficient information why there is self-care deficit.

The ability of Diabetic patients to meet the self-care demands depends partly on their

knowledge, beliefs, tradition, education, religion, socio-economic background,

making use of skills and available resources. Once the nurses are able to identify the

reasons for the client’s self-care deficits it is possible to plan for intervention.

11

Orem identifies three basic types of nursing systems to meet the client’s needs for

nursing assistance.

1. Wholly compensatory system

2. Partly compensatory system

3. Supportive educative system

The above first two systems plays a vital role in maintaining health of Diabetic

patients. In supportive educative system the client has the resources to meet their

demands, but needs nursing assistance in decision making, behavior control and

acquisition of knowledge and skill.

The investigator assumes that some demographic variables could affect knowledge

and attitude of diabetic patients and further knowledge about self-administration of

insulin injection will have clear association with their behaviors. Based on their

knowledge and background the diabetic patients will possess a positive attitude

towards self-administration of insulin injection. After assessment the findings will

focus on the extent of the problem in these areas.

In this study supportive–educative system is selected for developing framework of the

study. So, in order to educate the diabetic patients, their existing knowledge and

attitude is assessed and guidelines for health teaching is developed according to the

unified unhealthy attitudes (not contributing to healthful living) which are the main

objectives of the study.

In this conceptual model, the self-care agents are the diabetic patients who are on

insulin therapy in K. C. General Hospital at Malleswaram, Bangalore. The identified

Diabetic patient’s attitudes are taken into account and a guide for health teaching will

12

enable them for healthful living. Based on the Orem’s Self-care model the supportive-

educative system is within a client-centered system, where health teaching material is

considered to be an appropriate teaching strategy. The following model represents the

conceptual framework, which the investigator constructed before attempting the

study.

14

2. OBJECTIVES

STATEMENT OF THE PROBLEM

A descriptive study to assess the knowledge and attitude regarding self-administration

of insulin injection among Diabetes Mellitus patients in Kempa Cheluvamba General

Hospital at Malleswaram, Bangalore.

OBJECTIVES OF THE STUDY


injection.


injection.







15

3. REVIEW OF LITERATURE

Review of literature is an integral component of any study or research project. It

equips the investigator to be familiar with the existing studies, provides basis for

future investigation and also helps in development of methodology, tool and research

design.

Review of literature involves the systematic identification, location, scrutiny and

summary of written materials that contain information on a research problem.23

Abdellah, Levine states that the review of literature provides basis for future

investigation, justifies the need for replication, throws light upon the feasibility of the

study, indicates constraints of data collection and help to relate findings of one to

another.26

The literature review was based on an extensive survey of books, journals,

international nursing studies and Medline search. A review of research and non-

research literature relevant to the study was taken, which helped the investigator to

develop deeper insight into the problem and gain information on what has been done

in the past. The review of literature related to the purpose of the present study has

been organized and presented under the following headings

Part A: Literature related to Insulin Therapy

Part B: Literature related to insulin administration devices and patient’s preferences

Part C: Literature related to complications of insulin therapy

Part D: Literature related to the knowledge and attitude regarding Insulin Therapy and

patient’s compliance

16

Part A: Literature related to Insulin Therapy

Insulin injections are given to replace endogenous insulin in patients with absolute or

relative deficiencies in insulin secretion.

The aims of insulin therapy are-

Abolish hyperglycemic symptoms

Maintain ideal body weight

Optimize glucose control

Avoid hypoglycemia

Maintain as near normal a blood glucose as practical and safe for the

individual.27

Cramer JA, Pugh MJ conducted a study on ‘‘The influence of Insulin Use on

Glycemic Control’’ to determine the relationship between the self-management and

glycemic control and to identify patient characteristics associated with better control.

In their study they found that adults prescribed a specific insulin regimen averaged

using 77% of prescribed doses, demonstrating good intention to follow the

prescription. However, glycosylated hemoglobin (HbA1C) higher than the

recommended level suggested that the rate of insulin use, the prescribed regimen, or

both were inadequate to achieve good glycemic control in patients with long-term

insulin use.20

Franeine RK in the article ‘‘Intensive Management of Type 1 diabetes in young

children” had mentioned that many pediatric diabetes specialists do not place their

very young patients on continuous subcutaneous insulin injection or flexible bolus

therapy with multiple daily injections. It was shown that very young children with

supportive knowledgeable families can lower glycosylated hemoglobin (HbA1C) to

17

under 80% with multiple injections without increasing episodes of hypoglycemia.

This will enable these very young children to survive into adulthood with minimum

risk for the devastating long-term complications of this disease.28

Another article published by Dewitt DE, Dugedale DC ‘‘Using New Insulin

Strategies in the out patient treatment of Diabetes’’ had commented that when to use

insulin and how to apply the principles of physiologic insulin replacement, using

existing and new insulin is a key step for improving diabetes care. Insulin analogues

and premixed insulin increase physician’s and patient’s ability to lower glycosylated

hemoglobin (HbA1C) levels with fewer episodes of hypoglycemia. Earlier use of

insulin and more aggressive dose escalation are important steps in achieving treatment

goals.29

Garg MK in the article ‘‘Current perspective in Insulin Therapy in the management

of Diabetes Mellitus’’ had mentioned about the effectiveness of Insulin Therapy

among Diabetes Mellitus patients. In the article it was concluded that the efficacy of

human insulin has been proved beyond doubt by two large long term trials in both

Type I and Type II diabetes in controlling hyperglycemia, maintaining

normoglycemia and delaying onset and progression of diabetes complications.24

The Diabetes Control and Complications Trial/ Epidemiology of Diabetes

Interventions and Complications Research Group conducted a study on

‘‘Retinopathy and Neuropathy in patients with type I diabetes four years after a trial

of Insulin Therapy’’ and concluded that among patients with type I diabetes mellitus,

intensive therapy markedly reduces the risk of micro vascular complications as

compared with Conventional Therapy and reduction in the risk of progressive

18

retinopathy and nephropathy persists for at least four years despite increasing

hyperglycemia.30

Hayward RA, Manning WG, Kaplan SH, Wagner EH, Greenfield S did a study

on ‘‘Starting Insulin Therapy in Patients with Type II Diabetes’’ to determine the

effectiveness, complication rates and resource utilization of Insulin Therapy in

clinical practice. They conducted an extensive survey and found that for patients with

Type II Diabetes who were cared for by generalist physicians, starting Insulin

Therapy was generally safe and effective in achieving moderate glycemic control.

However Insulin Therapy was associated with increases in resource use and was

rarely effective in achieving tight glycemic control, even for those with moderate

control.31

Saudek CD, Duckworth WC, Giobbie-Hurder A, Henderson WG, Henry RR,

Kelly DE et al conducted a study on ‘‘Implantable Insulin Pump vs. Multiple-Dose

Insulin for Non Insulin Dependent Diabetes Mellitus’’ to determine whether

Implantable Insulin Pump (IIP) Therapy and Multiple Daily Insulin (MDI) injections

could equally attain improved blood glucose control, and to compare the 2 treatments

with respect to reducing daily blood glucose fluctuations, reducing severe

hypoglycemic insulin reactions and improving patient’s quality of life. After

analyzing the results they concluded that Intensive Insulin Therapy with Implant able

Insulin Pump and Multiple Daily Injection is effective in controlling Non-Insulin

Dependent Diabetes Mellitus.32

19

Part B: Literature related to Insulin administration devices and patient’s

preferences

Summers KH, Szeinbach SL, Lenox BM conducted a study on “Preference for

Insulin Delivery by systems among current Insulin users and non-users” to examine

the respondent preferences for the vial and syringe and the insulin injection pen

device between current insulin users and non-users. Based on this survey, they

concluded that the overall preference for the insulin injection pen device appeared to

be higher compared with the vial and syringe among both insulin users and non-users

Social acceptability was the strongest predictor of preferences for insulin injection

pen devices for current insulin users. Social acceptability and ease of use were

significant predictors of preference for the vial and syringes. For insulin non –users,

these results suggested that patient discussions about vial and syringe should

emphasize activity interference and ease of use.33

Hill J in the review article “Devices for Insulin Administration” has commented that

the drive to improve blood glucose control to prevent diabetic complications has

resulted in many patient’s with Type II as well as those with type I requiring Insulin

Therapy. Jillian Hill describes the devices now available to deliver insulin, which

enable more people to manage their insulin administration independently.34

Sucic M, Galic E, Cabrijan T, Ivandic A, Petrusic A, Wyatt J et al did a study on

“Patient acceptance and reliability of new Humalin / Humalog 3.0 ml prefilled insulin

pen in ten Croatian diabetes centers’’ to assess preferences patient acceptance

reliability and safety of the new Lilly Humalin / Humalog 3.0 ml prefilled insulin pen

in a clinical setting. Results of the study were majority of patient rated the new

prefilled pen as being more convenient and easier to use and indicated that it

20

represented a significant or modest an improvement over their previous insulin

injection method (i.e., either reusable devices or traditional syringe and vial)35

Another study was conducted by de Sauza CR, Zanetti ML on "The use of

disposable syringes in administration of insulin at home’’ to observe the behavior of

113 people with diabetes mellitus in relation to the utilization and reutilization of

disposable syringes for the administration of insulin at home. The obtained results

showed that 98.2% used a disposable syringe for insulin application and only 5.3%

actually disposed of it. Among these 94.6% re-used the disposable syringe after

application by means of various procedures.36

Robertson KE, Glazer NB, Campabell RK in their article “Latest developments in

Insulin injection devices” had mentioned about the dramatic changes in the treatment

of diabetes. Today patients with diabetes have ready access to more information about

the disease and its treatment options. As a result insulin treated patients have become

more autonomous in the management of their diabetes and may be better prepared to

participate in making informed choices regarding insulin delivery devices.37

Part C: Literature related to complications of Insulin Therapy

Messad D, Outtas O, Demoly P in their article “Hypersensitivity to Insulin” had

commented that the use of purified insulin obtained by genetics has dramatically

lowered the frequency of insulin hypersensitivity, In the case of localized cutaneous

reactions spontaneous regression is generally observed, the association of an oral

antihistamine and / or fractioning of the dose and its injections on several different

sites often leads to disappearance of these reactions.38

21

Saudan B, Gipardot C, Fermon C in their case report ‘‘Extreme subcutaneous

insulin resistance a misunderstood syndrome’’ had mentioned that extreme

subcutaneous insulin resistance (SIR) is a rare syndrome characterized by severe

resistance to subcutaneous insulin with normal intravenous insulin sensitivity.39

Richardson T, Kerr D in their review article ‘‘Skin related complications of Insulin

Therapy-epidemiology and emerging management strategies’’ had reported that

Insulin Therapy is associated with important cutaneous adverse effects which can

affect insulin absorption kinetics causing glycemic excursions above and below target

levels for blood glucose. Common complications of subcutaneous insulin injection

include lipoatrophy and lipohypertrophy. The likelihood of lipoatrophy can be

reduced by regular rotation of injection sites. Local allergic reactions to insulin are

usually erythema, pruritus and indurations. These allergic reactions are usually short-

lived and resolve spontaneously within a few weeks.40

Yokoyama H, Fukumoto S, Koyama H in their case report Insulin Allergy

desensitization with crystalline zinc insulin and steroid tapering had recommended

that the insulin analogues Aspart and Lispro, have been safe alternatives for patients

with insulin allergy, because of their decreased immunogenecity.41

Sola -Grzagnes A, Pecquet C, Radermeker R, Pietri L, Elgrably F, Slama G

et al. did a study on successful treatment of insulin allergy in a type 1 diabetic patient

by means of constant subcutaneous pump infusion of insulin.42

Log win S, Conget I, Jansa M, Vidal M, Nicolan C, Gomis R et al. conducted a

study on “Human Insulin Induced Lipoatrophy; successful treatment using a jet

22

injector device’’ to evaluate the efficacy of the administration of insulin by a jet

injector device in stopping and reversing severe human insulin–induced lipoatrophy.

The results of the study were total loss of subcutaneous tissue in the injection areas

were demonstrated and measured by high frequency ultrasound. Dermatologic exam

demonstrated a severe reduction of fat tissue. So they concluded that jet-injector

devices might constitute a helpful method to treat those patients affected by severe

human insulin induced lipoatrophy. 43

Part D: Literature related to the knowledge and attitude regarding Insulin

Therapy and patient’s compliance.

Reach G, Zerrouki A, Leclereq D, d’Ivernois JF did a study on “Adjusting Insulin

doses from knowledge to decision” to analyze the adjustment of insulin doses in type

1 diabetic patients with poorly controlled diabetes. After analysis they had found that

the fear of hypoglycemia was the most frequently given reason for not adjusting the

insulin doses, when the question asked to the patients with an open answer. This study

illustrates the difference between the thinking and doing. It also shows that the

degree of confidence in one’s own knowledge, the health beliefs, and the fear of

hypoglycemia differently influences the preparation that the patients have of their

behavior and what they really do.44

According to Bergenstal RM one key physician barrier to start insulin is either not

understanding or accepting that over time insulin will be a necessary part of therapy

for most patients with type II diabetes. Diabetes experts feel so strongly that

overcoming barriers to insulin initiation is critical to improve glycemic control and

quality of life outcomes for patients with diabetes. A study conducted by Diabetes

Attitudes, Wishes and Needs (DAWN) shows health care provider should focus as

23

much on patient’s attitudes and environment as on medicine when trying to improve

health.45

Skinner TC in the article “Psychological barriers” had mentioned that type II

diabetes treatment outcomes ultimately depend on patients and their ability to make

long term behavioral changes that support good self care and metabolic control.

Patient’s perception about diabetes and diabetes related complications can have a

strong influence on their emotional well being and quality of metabolic control.

Negative emotions and preconceptions about treatment can also discourage adherence

to treatment plans. “Psychological insulin resistance” caused by fear and concerns

about insulin and daily injections can discourage many patients from starting Insulin

Therapy. Depression, stress and anxiety represent further obstacles to optimum self-

care and the attainment of glucose goals.46

Asakura T did a study on “Research regarding proper use of insulin in diabetic

patients” to determine education and the degree of understanding of insulin self

injection. After analysis it became clear that older patients ability to understand

diminished and that patient’s life style, including psychological factors, exerts a large

influence on continuing the correct treatment. So the researcher recommended giving

guidance about treatment, which fits the patient’s lifestyles.47

Maureen IH conducted a study on “A National sample patients with type 2 diabetes”

in Bethesda, Maryland. Study revealed that 29% Patients were treated with insulin,

65% treated with oral agents, 80% treated with diet alone had never monitored their

blood glucose level. At least once per day blood glucose monitoring was predicted by

39% of those taking insulin.48

24

Mollema ED, Snock FJ, Heine RJ, Vander Ploeg HM conducted a study on

“Phobia of self injecting and self –testing in insulin treated diabetic patient’s

opportunity for screening’’ and found that severe fear of self injection and self-testing

characterized by emotional distress and avoidance behavior seems to occur in a small

group of insulin treated patients with diabetes.49

Pawar BK, Walfard S, Sigh BM conducted a study on ‘‘Type I diabetes mellitus in

a routine diabetes clinic the association of psycho-social factors, diabetes knowledge

and glycemic control to insulin regime’’ and concluded that in routine clinical

practice the use of intensive insulin regimes are associated with worse glycemic

control, despite patients being marginally more knowledgeable and self-directed.50

Almeida HG, Campus JJ, Kfouri C, Tanita MT, Dias AE, Souza MM conducted a

study on ‘‘Profile of patients with diabetes type I: insulin therapy and self-

monitoring’’ to know the insulin treatment and the plan for glycemic self-monitoring

used by these patients, to verify their knowledge as for what they consider the

optimization of these parameters and limitations for use They concluded that although

human insulin is already adopted as the use of choice, the outline of insulin treatment

plan is still traditional and the monitoring is for behind the ideal.51

Lombardo F, Salzano G, Messina MF, Deluka F in their article ‘‘How self

management therapy can improve quality of life for diabetic patients’’ has mentioned

that self control led therapy is vital in the treatment of insulin dependent diabetes

mellitus, allowing as it does, correct insulin therapy, a reduction in hospitalization and

modification of therapy for individual needs in relation to various factors. The

diabetes team (doctors, nurse,5 dietician, psychologist and social assistant) must set

25

objectives making the patient aware of his condition, giving him the knowledge of

what to do and how to do it. In this way quality of life can be improved for the

patients affected by this chronic illness and they can understand how to face the future

with realistic optimism.52

Coates VF, Boore JR conducted a study on ‘‘The influence of psychological factors

on the self management of insulin dependent diabetes mellitus’’ to investigate the

influence of a number of psychological factors upon the practice and outcome of

diabetes self-management among young adults with IDDM health beliefs, perception

of control and knowledge were assessed by scales, questionnaire and glycosylated

hemoglobin values The results demonstrated that the subjects perceived that they

were responsible for the control of their diabetes, that the benefits of following the

treatment is greater than any barriers and that they were knowledgeable about their

diabetes.53

Saunders SA, Wallymahmed M, Macfarlane IA in their study “glycemic control in

a type I diabetes clinic for younger adult’’ had concluded that despite regular

specialist physician, specialist diabetic nurse, and dietician input, encouragement of

multiple daily injection and rapidly following up failed appointments (including home

visits) tight glycemic control is rare in a routine clinic setting.54

Kapoor A conducted a study on ‘‘Diabetes care in India’’ and revealed that among

824 diabetes 69% were on oral agents, 15% were on combination of insulin and oral

hypoglycemic agents, 15% were on insulin alone 1% were on diet exercise and others

on herbal precautions. 58% of insulin users visit doctor monthly compared to 58%

tablet users, 43% self-administer insulin, 33% were given insulin by family members,

26

while 25% depend on health care professional to administer insulin. Only 109 patients

answered to the question “who taught you injection technique?’’ 78% learnt the

technique by themselves, 9%were taught by family members and 13% learnt from

qualified source.55

De Weerdt I, Visser AP, Kok G, Vander Veen KA in their study “Determinants of

active self care behavior of insulin treated patients with diabetes; implications for

diabetes education’’ revealed that most important aim of diabetes education is to alter

the self care behavior of patients with diabetes. In order to change their behavior its

determinants must be known. The attitude was found to be the most important

determinant of active self care, while a sufficient level of knowledge was a

prerequisite for a positive attitude. According to the results of this study diabetes

education should first aim at improving the level the knowledge and the health focus

of control of the patients and second at a positive attitude to active self care. It is

necessary to educate the social environment to create a more supportive atmosphere

for the patients with diabetes.56

An extensive review of related literature both research and non research was carried

out and presented in this chapter. The literature review helped the investigator to

establish the need for the study, state the problem clearly, develop a conceptual

framework, develop the tool, to adopt research methodology, select techniques of data

collection and decide on the plans of statistical analysis in order to achieve the

objectives of the study.

27

4. METHODOLOGY

Research methodology is the systematic way to solve the research problem.

Research methodology aims at helping the researcher to answer the research questions

effectively, accurately and economically, studying how research is done

scientifically.57

This chapter deals with the description of methodology and different steps, which

were undertaken for gathering and organizing date for the investigation. This includes

Research Approach, Research Design, Variables under Study, Settings of the Study,

Population of the Study, Sample, Sample Size, Sampling Technique, Criteria for

selection of Sample, Development and Description of the Tool, Content Validity,

Pilot Study, Method for Data Collection and Data Analysis.

RESEARCH APPROACH

The approach to research is the umbrella that covers the basic procedure for

conducting research.24 The study was intended to assess the knowledge and attitude

of Diabetes Mellitus patients regarding self-administration of insulin injection.

Descriptive survey approach, which is exploratory in nature, was found to be the most

suitable approach for the attainment of the objectives of the study

RESEARCH DESIGN

The research design is concerned with the overall framework for conducting the

study. A research design incorporates the most important methodological decision

that a researcher makes in conducting a research study23. The research design used

for this study is descriptive and exploratory.

The schematic representation of the design used in this study is given in figure (2)

28

K. C. General Hospital

Background Variables

• Age • Sex • Education • Occupation • Religion • Martial

Status • Family

Income • Duration

since diagnosis of Diabetes Mellitus

• Actual number of years on insulin therapy

• Family history of Diabetes M llit

Target

Population

Diabetic Patient who are on Insulin therapy and who are admitted in K.C. G Hospital are also those attending the OPD services in K. C. General Hospital

Samples 60 Diabetic Patients between age of 40 to 70 years and who are on Subcutaneous Insulin Injection Sampling: Convenient Sampling

Tool

Structured Knowledge Questionnaire

Structured

Likert type Attitude Scale

Assessment

Knowledge and Attitude of Diabetic Patients regarding self administration of Insulin Injection

Plan for Intervention

Development of an Information Booklet

K. C. General Hospital

Fig. 2 : Schematic Representation of Research Design

29

VARIABLES UNDER STUDY

Variables are qualities, properties or characteristics of persons things or situation that

change or vary.58

Research Variables

Knowledge and attitude of Diabetic patients regarding self-administration of Insulin

Injection.

Demographic Variables

Age, Gender, Education, Occupation, Religion, Marital Status, Family income per

month, Duration since diagnosis of Diabetes Mellitus, Actual number of years on

Insulin therapy, Family History of Diabetes Mellitus.

SETTING OF THE STUDY

Setting is the physical location and condition in which data collection takes place 23

Setting of this particular study was the ward and OPD of Kempa Cheluvamba General

Hospital, at Malleswaram, Bangalore.

The Kempa Cheluvamba General Hospital is situated in the heart of the city with bed

strength of 450 with daily average of 250 inpatients. The outpatient department

functions daily and average of 80 patients avail the clinical facilities

POPULATION FOR THE STUDY

Population is the entire aggregation of cases that meet a designed set of criteria 23

The target population for the present study includes the diabetic patients who are on

Insulin Therapy and who are aged between 40 to 70 years and those who are admitted

30

in the wards and attending OPD services in Kempa Cheluvamba General Hospital at

Malleswaram, Bangalore.

SAMPLE

Sample is a subset of population selected to participate in a research study.23

SAMPLE SIZE

The sample was arbitrarily decided to be 60 diabetic patients who are on Insulin

Therapy keeping in mind the availability of subjects

SAMPLING TECHNIQUE

Sampling is a process of selecting a portion of the population to represent the entire

population. Non-probability sampling technique was considered appropriate for this

study. According to Kerlinger FN “Non probability samples are selected based on

the judgments of researcher to achieve particular objectives of the research at hand” 59

The convenience sampling technique is a type of non-probability sampling, which

was found to be appropriate for the study

CRITERIA FOR SELECTION OF SAMPLE

Inclusion Criteria

1. Patients who are diagnosed with diabetes mellitus

2. Those who are in the age of 40 to 70 years

3. Patients who are on insulin therapy

4. Both male and female are included

31

Exclusion Criteria

1. Diabetic patients who are on Oral Hypoglycemic Agents

2. Diabetic patients who are on Intravenous Insulin Therapy.

DATA COLLECTION INSTRUMENT

An instrument is a written device that a researcher uses to collect data

Based on the objectives of study a structured questionnaire and an attitude scale were

developed to assess the knowledge and attitude of the diabetes mellitus patients

regarding self-administration of insulin injection.

DEVELOPMENT OF TOOL

The tool was developed based on the following

o Review of related literature

o Preparation of blue print

o Consultation with subject experts

o Researcher’s personal experience in Clinical Setting

The tool was initially prepared in English and was then translated to Kannada

(annexure H and J)

THE BLUE PRINT

The blue print was prepared to construct the tool. There was 30 knowledge

questionnaire featuring to the three domains of learning i.e., knowledge, application

and comprehension were formed. According to the content area, the item were spread

in three domains. There were 11 items on knowledge domain, 10 items on application

and 09 items in comprehension domain.

32

DESCRIPTION OF THE TOOL

The instrument consists of 3 sections

Section I Socio-Demographic Data

The first items of the tool consists of items seeking information about age, sex,

occupation, education, income, religion, duration of years on insulin therapy and

family history of Diabetes Mellitus.

Section II Knowledge Questionnaire

This section comprises of 30 statements regarding self-administration of insulin

injection and is divided into 2 main areas

Part –A : Statement related to general information regarding Insulin Therapy.

Part-B : Statement related to self –administration of insulin injection

The items were of multiple-choice type. Total score is 30. Each correct response will

carry a score of‘ “one’’ and “zero” score for incorrect response.

The knowledge of the respondents was arbitrarily categorized as follows:

Poor : 0-10

Average : 11-20

Good : 21-30

Section III Attitude sale

This section contains 20 statements framed into a Likert type Attitude Scale that gives

the attitude of diabetes mellitus patient regarding self-administration of insulin

injection. Each attitude items are having 5 options i.e., Strongly Agree (SA), Agree

(A), Uncertain (U), Disagree (D) and Strongly Disagree (SD). There were 15

positively stated and 5 negatively stated items

33

The response for each item was measured as a five-point scale as follows

Options Positive statements Negative statements

Strongly agree 5 1

Agree 4 2

Uncertain 3 3

Disagree 2 4

Strongly 1 5

The maximum score is 100 and minimum score is 20

The attitudes of the respondents were arbitrarily categorized as follows:

Unfavorable : Below 50

Favorable : 50-75

Most Favorable : Above 75

TESTING OF THE INSTRUMENT

A. Content Validity:

Validity refers to a complex concept, which broadly concerns the soundness of the

study’s evidence that is, whether the findings are cogent, convincing and well

grounded.23

Content validity represents the universe of contents or the domain of the given

construct. The universe of the content provides the framework and basis of

formulating the items.

The prepared tool was sent to eleven experts for content validity (Annexure D) who

were requested to render their opinion about relevance the items of the study - nine

34

experts in the field of Medical Surgical Nursing, one expert from General Medicine

and one expert from department of Bio-statistics

There were 100% agreements on all items, but suggestions were given to modify

contain questions and the modifications were then made in the tool.

CRITERIA CHECKLIST

A criteria checklist was prepared for content validity. Each criteria has 1-3 response

columns for rating

1) Completely meets the criteria

2) Partially meets the criteria

3) Does not meet the criteria

B. Reliability of the Tool

Reliability is the degree of consistency that the instrument or procedure demonstrates

whatever it is measuring it does so consistently.22

In order to establish the reliability of the tool, split-half method was used. The tool

was administered to 6 diabetic patients and the test was first divided into two

equivalent halves and correlation of the half test was found by using Karl Pearson

Correlation Coefficient formula and the significance of the correlation was tested by

using probable error. The reliability coefficient of the whole test was then estimated

by Spearman’s Brown Prophecy formula. The reliability of the knowledge

questionnaire was 0.94 and reliability of the Likert type Attitude Scale was 0.84. So

the tool was found to be highly feasible and reliable for data collection

35

PILOT STUDY

The pilot study is the trial run study, conducted before actual study in different

population with similar characteristics.

A pilot study was conducted to test the reliability of the tool. The data for the pilot

study was collected from six diabetic patients in K.C.General hospital at

Malleswaram, Bangalore from 02-09-05 to 10-09-05.Administrative approval was

obtained from the hospital administrator.

The pilot study confirmed that the final study was feasible.

METHOD OF DATA COLLECTION

A formal permission for conducting the study was obtained from the Medical

Superintendent and Nursing Superintendent of K.C. General Hospital at

Malleswaram, Bangalore. The method adopted for data collection was Self

Administered Questionnaire method by the investigator. The investigator introduced

herself to the Diabetic patients and explained the purpose of the study. The subjects

were assured confidentiality. They were requested to reply frankly and truly. The

investigator took consent from the Diabetic patients before administering the

questionnaire. Approximately 45-50 minutes were spent with each patient to collect

the complete data. No significant problem was faced by the investigator.

PLAN FOR DATA ANALYSIS

The data will be analyzed on the basis of objectives and hypothesis of the study. The

data obtained will be analyzed by using descriptive and inferential statistics.

36

The planned analysis of raw data is as follows:

Section I Socio Demographic Data

Demographic data would be analyzed in terms of frequency and percentage

distribution.

Section II Knowledge Questionnaire

The knowledge will be analyzed in terms of frequency, percentage, mean, mean

percentage and standard deviation.

Section III Attitude Scale

The attitude of the diabetic patients will be analyzed in terms of frequency,

percentage, mean, mean percentage and standard deviation.

Section IV Relationship between the knowledge and attitude of Diabetes Mellitus

patients with selected demographic variables.

χ² test will be used to find out the association between the knowledge and attitude

with selected demographic variables.

Section V relationship between knowledge and attitude

The relationship between knowledge and attitude of Diabetes Mellitus patients will be

tested by using Product Moment Correlation Co-Efficient.

The level of significance would be set at 0.05 levels to test the significance of

difference. This level is often used as a standard for testing the difference.

SUMMARY

This chapter has dealt with the methodology undertaken for the study. It includes

research approach, research design, description of setting; population, sample and

sampling technique used, development and description of tool, pilot study, procedure

for data collection and plan for data analysis.

37

5. RESULTS

Analysis refers to a number of closely related operations, which are performed with

the purpose of summarizing the collecting data and organizing the data in such a

manner that they answer the research questions.

Descriptive study design with survey approach was used in the present study. The

data was collected from Diabetic patients

Objectives of the study were:


injection.


injection.







The data collected were organized, tabulated, analyzed and interpreted by using

descriptive and inferential statistics and described with the help of tables and graphs.

38

The data presented under the following sections

Section I:

In this section the description of socio-demographic characteristics of the subjects are

drawn.

Section II:

The descriptive statistics such as mean, SD, calculated to average out the knowledge

scores.

Section III:

The descriptive statistics such as mean and SD calculated to average out the attitude

scores

Section IV

Data on association between the selected Demographic variables of the diabetic

patients and knowledge regarding self administration of insulin injection

Section V

Data on association between selected demographic variables of the diabetic patients

and their attitude regarding self administration of insulin injection.

Section VI

This section is to examine the relationship between knowledge and attitude by using

inferential statistical method, the Karl Pearson’s Correlation Co-efficient method.

39

Section - I

Data on Demographic variables of the Diabetic Patients Table - I

The Frequency and Percentage Distribution of Diabetic Patients according to their Age Group (in years)

Age (yrs) No. of subjects Percent

≤ 40 5 8.3

41-50 12 20.0

51-60 20 33.3

61-70 23 38.3

Total 60 100.0

Fig. 3 Distribution of diabetic patients according to their Age

Maximum number of diabetic patients, 38.3% were in the age group of 61 – 70 years,

33.3% were of 51 – 60 years. 20% fell under the age group of 41 – 50 years and 8.3%

were of below 40 years of age. Thus it shows that the maximum number of diabetic

patients participated in the study were between the age group of 61 – 70 years.

38.3

33.3

20

8.3

05

10152025303540

Perc

enta

ge

61-70 51-60 41-50 ? 40

Age

61-7051-6041-50? 40

<

<

40

Table – II

The Frequency and Percentage Distribution of the Diabetic patients according to Gender.

Gender No. of Subjects Percent

Male 44 73.3

Female 16 26.7

Total 60 100.0

26.7

73.3

MaleFemale

Fig. 4 Pie chart representing Percentage Distribution of the Diabetic Patients

according to Gender.

The percentage distribution of the diabetic patient according to gender reveals that

majority of the subjects, 73.3% were male and 26.7% were female.

41

Table - III

The Frequency and Percentage Distribution of the Diabetic Patients according to Education.

Educational status No. of subjects Percent

Primary 44 73.3

Secondary 13 21.7

Higher secondary 2 3.3

Graduate and above 1 1.7

Total 60 100.0

73.3

21.7

3.3 1.7

0

10

20

30

40

50

60

70

80

Perc

enta

ge

Primary Secondary Higher secondary Graduate andabove

Education

Primary

Secondary

Higher secondary

Graduate and above

Fig. 5 Bar Diagram representing Percentage Distribution of the Diabetic Patients according to Education.

The result indicate that only 1.7% of the diabetic patient had completed graduation,

3.3% had completed higher secondary, 21.7% completed secondary education and

73.3 % had completed only primary education. It shows that maximum number of the

diabetic patient who participated in the study had completed their primary education.

42

Table - IV

The Frequency and Percentage Distribution of the Diabetic Patients according to

Occupation

Occupation No. of

Subjects Percent

Unemployed 32 53.3

Private 9 15.0

Government 5 8.3

Self-employed 14 23.3

Total 60 100.0

53.3

158.3

23.3

0

10

20

30

40

50

60

Perc

enta

ge

Unemployed Private Government Self-employed

Occupation

Unemployed

Private

Government

Self-employed

Fig. 6 Bar Diagram Representing Percentage Distribution of the Diabetic

Patients according to Occupation

Table IV (Figure 6) depicts that 53.3% diabetic patients were unemployed, 23% were

self employed, 15% were private employee and only 8.3% were Government

employee.

43

Table - V

The Frequency and Percentage Distribution of the Diabetic Patients according to

Religion.

Religion No. of

Subjects Percent

Hindu 47 78.3

Muslim 11 18.3

Christian 2 3.3

Total 60 100.0

78.3

18.3 3.30

10

20

30

40

50

60

70

80

Perc

enta

ge

Hindu Muslim Christian

Religion

HinduMuslimChristian

Fig. 7 Bar diagram representing Percentage Distribution of the Diabetic patient

according to Religion.

Table V (Figure 7) reveals that 78.3% of the diabetic patients were Hindus, 18.3%

were Muslims and 3.3% of diabetic patient were Christians. Thus it shows that

Maximum number of Diabetic patients who participated in the study were Hindus.

44

Table - VI

The Frequency and Percentage Distribution of Diabetic Patients according to Marital Status

Marital status No. of subjects Percent

Married 52 86.7

Unmarried 1 1.7

Widow(er) 7 11.7

Divorced 0 0

Total 60 100.0

86.7

1.711.7

0

0

10

20

30

40

50

60

70

80

90

Perc

enta

ge

Married Unmarried Widow(er) Divorced

Marital Status

Married

Unmarried

Widow(er)

Divorced

Fig. 8 Bar Diagram representing Percentage Distribution of Diabetic Patient according to Marital Status

Data presented shows that maximum number of the diabetic patients, 86.7% were

married, 11.7% were widow or widower and only 1.7% were unmarried. None of the

subjects were divorced.

45

Table - VII

The Frequency and percentage Distribution of the Diabetic Patient according to

Family Income per month.

Income (Rs) No. of subjects Percent

≤2000 38 63.3

2001-3000 11 18.3

3001-4000 5 8.3

>4001 6 10.0

Total 60 100.0

Fig. 9 Pie diagram Representing Percentage Distribution of the Diabetic Patients according to Family Income per month.

The results indicate that 63.3% of the diabetic patient had a family income less than or

equal to 2,000 per month, 18.3% had between 2001 to 3000, 10.%.were having family

income more than 4001 or above and 8.3% had a family income of 3001 – 4000.

63.318.3

8.310

? 20002001-30003001-4000> 4001

≤

46

Table – VIII

The Frequency and Percentage Distribution of the diabetic patients according to

Duration since diagnosis of Diabetes Mellitus

Distribution of duration

diabetes mellitus

No. of subjects Percent

<3 24 40.0

4-6 13 21.7

7-9 9 15.0

>9 14 23.4

Total 60 100.0

40

21.7

15

23.4

0

5

10

15

20

25

30

35

40

Perc

enta

ge

< 3 4 ~ 6 7 ~ 8 > 9

Duration of Diabetes Mellitus

< 34 ~ 67 ~ 8> 9

Fig 10 Bar Diagram representing Percentage Distribution of the Diabetic Patients according to duration since diagnosis of diabetes Mellitus

The table VIII and Figure 10 reveals that in 40% diabetic patient duration of diagnosis

of Diabetes Mellitus were lesser than or equal to 3 years, 23.4% duration of diagnosis

were greater than or equal to 9 years, 21.7% were within 4 – 6 years and in 15%

duration of diabetes Mellitus were 7 – 9 years.

47

Table - IX

The Frequency and Percentage Distribution of the Diabetic Patients according to Numbers of years on Insulin Therapy

Number of years

of insulin

Number of subjects Percent

<2 49 81.7

3-4 6 10.0

5-6 3 5.0

>6 2 3.3

Total 60 100.0

81.7

10 5 3.3

0102030405060708090

Perc

enta

ge

< 2 3 ~ 4 5 ~ 6 > 7

Number of Years on Insulin

< 23 ~ 45 ~ 6> 7

Fig. 11 Bar diagram representing Percentage Distribution of the Diabetic Patients according to Numbers of years on Insulin Therapy

The data presented reveals that maximum number of diabetic patients, 81.7% were on

Insulin Therapy for lesser than 2 years, 10% were for 3 – 4 years, 5% were 5 – 6 years

and only 3.3% were on Insulin Therapy for more than 7 years.

48

Table - X

The Frequency and Percentage Distribution of the Diabetic Patients according to Family History of Diabetes Mellitus

Family history

No. of Subjects Percent

Yes 22 36.7

No 38 63.3

Total 60 100.0

Fig. 12 Bar Diagram representing Percentage Distribution of the Diabetic Patients according to Family History of Diabetes Mellitus

Table X and Figure 12 shows that maximum number of Diabetic patients, 63.3% had

no family history of Diabetes Mellitus and 36.7% had family history of Diabetes

Mellitus

36.7

63.3

0

10

20

30

40

50

60

70

Perc

enta

ge

Yes No

Family History of DM YesNo

49

Section – II Data on Knowledge of the Diabetic patients regarding Self - administration of

Insulin Injection

Table XI

Distribution of Knowledge Related to General Information on Insulin Therapy.

Correct Answer

Wrong Answer

Sl No.

Items

No % No % 1. Insulin is a hormone. 15 25 45 75 2. Insulin is secreted by pancreas. 22 36.67 38 63.33 3. Action of insulin is - it lowers blood

glucose level. 50 83.33 10 16.67

4. Types of insulin are rapid acting, intermediate acting and long acting.

25 41.67 35 58.33

5. Short acting insulin has to be administrated 0-15 minutes before food.

21 35 39 65

6. Intermediate acting insulin has to be administrated 30-45 minutes before eating.

15 25 45 75

7. The effects of insulin injection when taken on empty stomach are blurred vision and dryness of mouth.

45 75 15 25

Table XI Shows the distribution of knowledge related to general information on

insulin therapy. It revealed that only 25% were aware that insulin is a hormone,

36.67% diabetic patients knew that insulin is secreted by pancreas, 83.33% were

aware that the action of insulin it lowers blood glucose levels, 41.67% knew that types

of insulin are rapid acting, intermediate acting and long acting, 35% were aware that

short acting insulin has to be administered 0-15 minutes before food, 25% of diabetic

patients knew that intermediate acting insulin has to be administrated 30-45 minutes

before food and 75% of the diabetic patients were aware of the effects of insulin

injection when taken on empty stomach are blurred vision and dryness of mouth.

50

Table XII

Distribution of Knowledge Related to Self Administration of Insulin Injection.

Correct Answer

Wrong Answer

Sl No.

Items

No % No % 8. Self administration of insulin is a cost

effective method 20 33.33 40 66.67

9. Insulin injection should be taken according to doctors advice

16 26.67 44 73.33

10. The areas suitable for self administration of insulin injection are arms, thighs, abdomen

32 53.33 28 46.67

11. Insulin injection can be administered just beneath the skin

47 78.33 13 21.67

,12. The sites for insulin injections are selected by rotating pattern.

26 43.33 34 56.67

13. The advantage of site rotation is to prevent tissue damage.

34 56.67 26 43.33

14. An open insulin vial can be preserved by keeping in a cold place

47 78.33 13 21.67

15. One of the complications of insulin injection is decreased blood sugar

52 86.67 8 13.33

16. Insulin syringes are preferred for insulin injection it is easy to calculate the dose

30 50 30 50

17. Before administering insulin injection inspect the vial for changes, like clumping, frosting

15 25 45 75

18. Insulin should be drawn from the vial by injecting a small amount of air

20 33.33 40 66.67

19. Which of the following step is correct when preparing to administer two types of insulin – the regular insulin is withdrawn first

13 21.67 47 78.33

20. An insulin vial should not be shaken vigorously to prevent clumping

15 25 45 75

21. Insulin preloaded syringes should be kept in vertical position

17 28.33 43 71.67

22. Insulin absorption rate increases with exercise

20 33.33 40 66.67

23. Insulin absorption rate decreases with smoking

16 26.67 44 73.33

24. Insulin doses are calculated in units 22 36.67 38 63.33 25. Spirit is used to wipe the insulin

injection site. 50 83.33 10 16.67

26. One should not message the site following insulin injection in order to prevent rapid absorption of insulin.

14 23.33 46 76.67

51

27. Once opened an insulin vial can be used for 30 days

16 26.67 44 73.33

28. The effectiveness of insulin can be measured by checking blood and urine glucose levels

51 85 9 15

29. Taking insulin ensures best control of diabetes

48 80 12 20

30. When experiencing hypoglycemia one should take some sugar dissolved in water.

53 88.33 7 11.67

Table XII depicts the distribution of knowledge related to self-administration of

insulin injection. It revealed that only 33.33% accepts that self-administration of

insulin injection is a cost effective method, 26.67% knew that insulin injection should

be taken according to doctor’s advice, 53.33% diabetic patients were aware that the

areas suitable for insulin injection are arms, thighs, abdomen, 78.33% of them knew

that Insulin injection can be administered just beneath the skin, 43.33% were aware

that the sites for insulin injection are selected by rotating pattern 56.67% were aware

that the advantage of site rotation is to prevent tissue damage 78.33% knew that an

open insulin vial can be preserved by keeping in a cold place, 86.67% knew that one

of the complications of insulin injection is decreased blood sugar, 50% were aware

that insulin syringes are preferred for insulin injection because it is easy to calculate

the dose, 25% knew that before administering insulin injection inspection of the vial

for changes, clumping, frosting should be done. 33.33% were aware that insulin

should be drawn from the vial by injecting a small amount of air 21.67% knew that

while preparing to administer two types of insulin the regular insulin is withdrawn

first, 25% were aware that an insulin vial should not be shaken vigorously to prevent

clumping, 28.33% knew that insulin preloaded syringes should be kept in vertical

position, 33.33% were aware that insulin absorption rate increases with exercise,

26.67% of them knew that insulin absoption rate decreases with smoking, 36.67%

52

were aware that insulin doses are calculated in units, 83.33% were having the idea

that spirit is used to wipe the insulin injection site, 23.33% knew that one should not

massage the site following insulin injection in order to prevent rapid absorption of

insulin. 26.67% were aware that once opened an insulin vial can be used for 30 days,

85% were aware that the effectiveness of insulin can be measured by checking blood

and urine sugar levels, 80% diabetic patient knew that taking insulin ensures best

control of diabetes and 88.33% of the subjects were aware that when experiencing

hypoglycemia one should take some sugar dissolved in water.

53

Table – XIII

Mean, Mean percentage and the Standard Deviation of the diabetic patients knowledge as per areas of self administration of Insulin Injection

Percentage of

Areas Range Max. score Mean SD Mean SD

General information 1-7 7 3.21 1.67 45.85 23.87

Self administration 6-16 23 11.23 2.61 48.82 11.34

Overall 7-23 30 14.45 3.26 48.17 10.87

Fig .13 Cone Diagram representing Mean Percentage of Diabetic Patients

in both the areas of Self - administration of Insulin Injection

The data analysed shows the mean, mean percentage, and the standard deviation of

the knowledge obtained by the diabetic patients in both the areas of self

administration of insulin injection The data reveals that the lowest mean percentage

score is 45.85% with a standard deviation of 1.67 in the area of knowledge related to

insulin therapy, where as the area of knowledge related self administration of insulin

injection the mean percentage of score is 48.82% with a standard deviation of 2.61.

The over all mean percentage was found to be 48.17% with a standard deviation of

3.26

45.85 48.82

05

101520253035404550

Perc

enta

ge

General information Self administration

Areas General informationSelf administration

54

Table - XIV Overall knowledge of the Diabetic Patients on Self-administration of Insulin

Injection

Knowledge No. of subjects Percent

Poor 8 13.3

Average 49 81.7

Good 3 5.0

Total 60 100.0

13.3

81.7

5

Poor Average Good

Fig 14 Pie diagram representing overall knowledge of the Diabetic patients

regarding Self-administration of Insulin Injection

Table XIV and Figure 14 shows the overall knowledge of the diabetic patients

regarding self-administration of insulin injection. Among them 81.7% diabetic

patients possess average knowledge, 13.3% had poor knowledge and only 5% diabetic

patients had good knowledge regarding self-administration of insulin injection

55

Section – III Data on the Attitude of the Diabetic Patients regarding Self-administration of

Insulin Injection

Table - XV Overall Attitude of the Diabetic Patients regarding Self-administration of Insulin

Injection

Attitude No. of subjects Percent

Favourable 49 81.7

Most favourable 11 18.3

Unfavourable 0 0

Total 60 100.0

Fig. 15 Pie Diagram Representing Overall Attitude level of the Diabetic patients

regarding Self-administration of Insulin Injection

The data presented shows the overall attitude level of the diabetic patients regarding

self-administration of insulin injection. This reveals that the maximum number of

diabetic patients 81.7%, has a favorable attitude, and only 18.3% Diabetic patients

had the most favorable attitude towards self-administration of insulin injection.

81.7

18.3 0

FavourableMost favourableUnfavourable

56

Section - IV Data on Association between the selected Demographic variables of the Diabetic

Patients and Knowledge regarding Self administration of Insulin Injection

Table – XVI Association between the selected demographic variables of Diabetic Patients and

their level of Knowledge regarding Self - administration of Insulin Injection

Demographic Variables Below mean

Above mean Total

Chi- Square value

Df p-value Inference

≤40 5 0 5 41-50 9 3 12 51-60 12 8 20 61-70 13 10 23

Age (yrs)

Total 39 21 60

4.166 3 >0.244 Not significant

Male 26 18 44 Female 13 3 16 Gender Total 39 21 60


Primary 30 14 44 Secondary 7 6 13

Higher secondary 2 0 2

Graduate and above 0 1 1

Education

Total 39 21 60


Unemployed 20 12 32 Private 6 3 9

Government 3 2 5 Self-

employed 10 4 14 Occupation

Total 39 21 60


Hindu 30 17 47

Muslim 9 2 11

Christian 0 2 2 Religion

Total 39 21 60


57


Above mean Total

Chi- Square value

Df p-value Inference

Married 32 20 52

Unmarried 1 0 1

Widow(er) 6 1 7 Marital Status

Total 39 21 60


<2000 24 14 38

2001-3000 9 2 11

3001-4000 3 2 5

>4001 3 3 6

Income

Total 39 21 60

2.073 3 >0.557 Not Significant

<3 17 7 24

4-6 8 5 13

7-9 8 1 9

>9 6 8 13

Duration of Diabetes Mellitus

Total 39 21 60


<2 35 14 49

3-4 1 5 6

5-6 2 1 3

>6 1 1 2

Number of years on Insulin

Therapy

Total 39 21 60


yes 14 8 22

No 25 13 38

Family History of Diabetes Mellitus Total 39 21 60


58

Table. XVI describes the association between selected demographic variables of the

diabetic patient and their level of knowledge regarding self administration of insulin

injection.

The table reveals that there is no association between the knowledge level of diabetic

patients regarding self administration of insulin injection and their age. At 0.05 level

of significance with 3 degree of freedom the calculated Chi-square value is 4.166 is

(P> 2.44). Hence there is no association between the knowledge level and age of the

diabetic patients.

A chi-square test was done to find out the association between the level of knowledge

and gender. The calculated chi-square value is 2.532 (P> 0.244). So there is no

association between the knowledge level and gender.

To find the association between the level of knowledge and educational status a Chi-

square test was done. The calculated Chi-square value is 3.841 (P>0.279). Hence

there is no significant association between the knowledge level and education.

A Chi-square test was done to find out the association between the knowledge level

and occupation of diabetic patients. The calculated chi-square value is 0.408

(P>0.939) at 3 degree of freedom. Hence there is no association between the

knowledge level and occupation of the diabetic patients.

The association between the knowledge regarding self administration of insulin

injection and their religion were tested by using a Chi-square test. The calculated

value is 5.11 (P>0.078) at 2 degree of freedom. Hence there is no significant

association between the knowledge level and religion.

59

A Chi-square test was done to find out the association between the knowledge level

and marital status. At 2 degree of freedom and 0.05 level of significance calculated

Chi-square value is 2.133 (P>0.344). So there is no significant association between

the level of knowledge and martial status.

To find out the association between the knowledge level and income a chi-square test

was done. The calculated Chi-square value is 2.073 (P>0.557) at 3 degree of freedom

and 0.05 level of significance and there is no association between the knowledge level

and income.

A Chi-square test was done to associate the knowledge and duration of diagnosis of

Diabetes Mellitus. The calculated chi-square value is 5.702 (P> 0.127) at 3 degree of

freedom. Hence the investigator could not elicit any association between the level of

knowledge and duration of diagnosis of diabetes mellitus.

To find out the association between the knowledge level with number of years on

insulin therapy, a Chi-square test was done. The calculated Chi-square value is 7.253

(P>0.064) at 3 degree of freedom. So there is no significant association between the

knowledge and numbers of years on insulin therapy

The table reveals that there is no significant association between the level of

knowledge and family history of Diabetes Mellitus. At 1 degree of freedom the

calculated Chi-square value is 0.028 (P>0.866).

Hence H2 can be rejected, there is no significant association between the level of

knowledge of Diabetic patients and selected demographic variables.

60

Section - V Data on Association between Selected Demographic Variables of the Diabetic

Patients and their Attitude regarding Self - administration of Insulin Injection.

Table - XVII

Association between Selected Demographic Variables of Diabetic Patients and

their level of Attitude regarding Self -administration of Insulin Injection.


Above mean Total

Chi- square value

df p-value Inference

≤40 4 1 5 41-50 9 3 12 51-60 13 7 20 61-70 10 13 23

Age

Total 36 24 60


Male 26 18 44 Female 10 6 16 Gender Total 36 24 60


Primary 26 18 44 Secondary 7 6 13

Higher secondary 2 - 2

Graduate and above 1 - 1

Education

Total 36 24 60


Unemployed 17 15 32 Private 5 4 9

Government 3 2 5

Self-employed 11 3 14 Occupation

Total 36 24 60


Hindu 28 19 47

Muslim 8 3 11

Christian 2 2 Religion

Total 36 24 60


61


Above mean Total

Chi- square value

df p-value Inference

Married 31 21 52

Unmarried 1 1

Widow(er) 4 3 7 Marital Status

Total 36 24 60


<2000 18 20 38

2001-3000 11 11

3001-4000 5 5 Income

>4001 2 4 6

14.917 3 <0.002 Highly significant

<3 17 7 24

4-6 9 4 13

7-9 5 4 9

>9 5 9 14

Duration of diabetes mellitus

Total 36 24 60


<2 33 16 49

3-4 2 4 6

5-6 1 2 3

>6 2 2

Number of years on insulin therapy

Total 36 24 60


yes 15 7 22

No 21 17 38

Family History of Diabetes mellitus Total 36 24 60


62

Table - XVII describe the association between the selected demographic variables of

the diabetic patients and their level of attitude regarding self administration of insulin

injection.

A Chi - square test was done to find out the association between the level of attitude

and their age. At 0.05 level of significance and 3 degree of freedom, the calculated chi

square value is 4.783 (p>0.188). Hence, there is no significant association between the

level of attitude of diabetic patient with their age.

To find out the association between the level of attitude and gender, a chi square test

was done. The findings reveal that at 0.05 level of significance, the calculated chi

square value is 0.057 (p>0.812) at 1 degree of freedom. So there is no significant

association between the level of attitude and gender.

A Chi square test was done to find out the association between the level of attitude

and educational status. The calculated chi square value is 2.220 (p>0.528) at 3 degree

of freedom. Hence, there is no association between the level of attitude and

educational status.

To find out the association between the level of attitude and occupation, a chi square

test was done. The calculated Chi - square value is 2.716 (p>0.437) at 3 degree of

freedom. So there is no association between the level of attitude and occupation of

diabetic patients.

63


and religion. Here, the calculated chi square value depicts 3.746 which is greater than

the table value (p>0.154). No association between the level of altitude and religion

was elicited.

To find out the association between the level of attitude and marital status of diabetic

patients the calculated Chi-square value is 0.694 which is greater than the table value

(P>0.707) Hence, there is no association between the level of attitude and marital

status.

The table reveals that there is a significant association between the level of attitude

and income of diabetic patients. At 0.05 level of significance and 3 degree of

freedom, the calculated value is 14.917 (p<0.002). Hence there is an association

between the level of attitude and income of diabetic patients.

To find out the association between the level of attitude and duration of diagnosis of

diabetic mellitus a chi square test was done. The calculated chi square value is 5.15

(p>0.161) at 3 degree of freedom. So, there is no significant association between the

level of attitude and duration of diagnosis of diabetic mellitus.


and number of years in insulin therapy. At 0.05 level of significance and 3 degree of

freedom the calculated chi square value is 6.769 (p>0.08). Hence, there is no

association between the level of attitude and number of years on insulin therapy.

64

To elicit the association between the level of attitude and family history of diabetic

mellitus Chi - square test was done. At 1 degree of freedom and 0.05 level of

significance, the calculated chi square value is 0.969 (p>0.325). Hereby, the

investigator could not elicit any association between the levels of attitude with family

history of diabetic mellitus.

Hence H3 is rejected, there is no significant association between attitude towards self-

administration of insulin injection and selected demographic variables, except for

income of the Diabetic patients. The analysis shows there is a significant association

between attitude of Diabetic patients and Family Income.

65

Section – VI Data on correlation between the Knowledge and Attitude scores of the Diabetic

Patients regarding self-administration of Insulin Injection.

Table - XVIII Correlation of the Diabetic patients Knowledge and the Attitude on the

self administration of Insulin Injection.

Items Mean Standard Deviation

Product moment correlation

coefficient. "r"

Knowledge 14.45 3.326

Attitude 69.05 5.586 0.315

Knowledge score

3020100

Attit

ude

scor

e

90

80

70

60

50

Fig. 16 Scattered diagram representing relationship between Knowledge and

Attitude

The mean value of overall knowledge was 14.45 with a standard deviation of 3.326,

where as mean value of attitude was 69.05 with a standard deviation of 5.586. The

knowledge and attitude correlation value was "r" = 0.315 (p<0.014)by using Karl

Pearson's Product Moment Correlation Coefficient formula . It shows a statistically

positive correlation between the diabetic patients knowledge and attitude regarding

self administration of insulin injection. Hence H1 is accepted.

66

6. DISCUSSION

A hallmark of professional behavior is the personal commitment to the ongoing

acquisition of new knowledge.

The study is focused on assessing the knowledge and attitude regarding self-

administration of insulin injection among diabetes mellitus patients. It was aimed at

the improvement of the knowledge of Diabetic patients, so that they can develop a

positive attitude towards it.

The study attempted to test the following hypothesis:

H1 : There is a significant relationship between knowledge and attitude of

Diabetes Mellitus patients regarding self-administration of insulin injection.

H2 : There is a significant association between levels of knowledge with


H3 : There is a significant association between the attitudes of diabetes

mellitus patients with selected demographic variables.

The findings of the study have been discussed with reference to the objectives and

hypothesis of the study.

Maximum number of diabetic patients, 38.3% was in the age group of 61 – 70

years, 33.3% were of 51 – 60 years. 20% fell under the age group of 41 – 50

years and 8.3% were of below 40 years of age. Thus it shows that the

maximum number of diabetic patients participated in the study were in the age

group of 61 – 70 years.

67

The percentage distribution of the diabetic patient according to gender reveals

that majority of the subjects, 73.3% were male and 26.7% were female.

The result indicate that only 1.7% of the diabetic patient had completed

graduation, 3.3% had completed higher secondary, 21.7% completed

secondary education and 73.3 % had completed only primary education. It

shows that maximum number of the diabetic patient who participated in the

study had completed their primary education.

It reveled that 53.3% diabetic patients were unemployed, 23% were self

employed, 15% were private employee and only 8.3% were Government

employee.

It depicts that 78.3% of the diabetic patients were Hindus, 18.3% were

Muslims and 3.3% of diabetic patient were Christians. Thus it shows that

maximum number of Diabetic patients who participated in the study were

Hindus.

Data presented shows that maximum number of the diabetic patients, 86.7%

were married, 11.7% were widow or widower and only 1.7% were unmarried.

None of the subjects were divorced.

The results indicate that 63.3% of the diabetic patient had a family income less

than or equal to 2,000 per month, 18.3% had between 2001 to 3000, 10 %.

were having family income more than 4001 or above and 8.3% had a family

income of 3001 – 4000.

This reveals that in 40% diabetic patient duration of diagnosis of Diabetes

Mellitus were lesser than or equal to 3 years, 23.4% duration of diagnosis

were greater than or equal to 9 years, 21.7% were within 4 – 6 years and in

15% duration of diabetes Mellitus were 7 – 9 years.

68

The data presented reveals that maximum number of diabetic patients, 81.7%

were on insulin therapy for lesser than 2 years, 10% were for 3 – 4 years, 5%

were 5 – 6 years and only 3.3% were on insulin therapy for more than 7 years.

It shows that maximum number of diabetic patients, 63.3% had no family

history of diabetes mellitus and 36.7% had family history of diabetes mellitus

The first objective was to assess the knowledge of the diabetic patients regarding

self administration of insulin injection. The level of knowledge regarding self

administration of the insulin injection were assessed and tabulated in tables XI - XIV.

Out of 60 diabetic patients 81.7% had average knowledge, 13.3% had poor

knowledge and only 5% had good knowledge regarding self administration of insulin

injection. The overall mean value of the diabetic patients knowledge regarding self

administration of insulin injection was 14.45 with a standard deviation of 3.326. This

findings showed that the most of the diabetic patients were not much aware of self


The second objective was to assess the attitude of the diabetic patients regarding

self administration of insulin injection. The level of attitude regarding self

administration of insulin injection was assessed and tabulated in table XV. Out of 60

diabetic patients, only 18.3% had most favourable and 81.7% had a favourable

attitude towards self administration of insulin injection. It revealed the mean

percentage of the positive attitude, which was 69.05 with a standard deviation of

5.585. These results showed that most of the diabetic patients were not having a most

favourable attitude towards self-administration of insulin injection.

69

Third objective was to correlate the knowledge and attitude of diabetic patients

regarding self administration of insulin injection. The relationship between the

knowledge and the attitude was tested and presented in table XVIII. The study

revealed that there was a positive correlation between the knowledge and the attitude

of diabetic patients.

Fourth objective was to find out the association between the knowledge with

selected demographic variables. The association between the diabetic patients

knowledge with the selected demographic variables were listed in table XVI. There

was no significant association between the knowledge level of diabetic patients with

selected demographic variables at 0.05 level of significance.

The fifth objective was to find out the association between the attitude with

selected demographic variables. The association of the attitudes of diabetic patients

and selected demographic variables were tested by using a chi square test and

presented in the table XVII. Statistically no significant association was found between

age, sex, education, occupation, religion, marital status, duration of diagnosis of

diabetes mellitus, number of years on insulin therapy and family history of diabetic

mellitus. There was a highly significant association between the level of attitude

among diabetic patients and their income.

The sixth objective was to prepare an information booklet based on the

knowledge of the diabetic patients. An information booklet was prepared to improve

the knowledge and attitude of diabetic patients regarding self administration of insulin

injection. The present study shows that only 5% diabetic patients had good knowledge

81.7% had average knowledge, and 13.3% had poor knowledge regarding self

70

administration of insulin injection. The study also reveals that 81.7% of the diabetic

patients possess a favourable attitude and only 18.3% diabetic patients possess most

favorable attitude towards self administration of insulin injection. And therefore it is

important to improve their knowledge regarding self administration of insulin

injection to enable them practice self administration of insulin with a more confident

and healthy way.

71

7. CONCLUSION

Education can gradually change people from their wrong unhealthy perceptions and

practices. A major goal of nursing practice is to provide health education that is

culturally sensitive, which fits into health beliefs and practices of the people. Healthy

practices should be encouraged and a positive attitude should be reinforced.

The following conclusions were drawn from the present study.

The Diabetic patients had an average knowledge regarding Self-administration

of insulin injection.

The Diabetic patients had a favourable attitude towards Self-administration of

Insulin injection.

The study findings reveal that there is a significant relationship between the

knowledge and attitude of Diabetic patients.

The study shows that there is no significant association between the

knowledge level and selected demographic variables.

The study findings indicate that there is no significant association between the

attitude level and selected demographic variables, except for the family

income. There is a significant association between the attitude of Diabetic

patients and income.

The implications were given on various aspects like Nursing Practice, Nursing

Administration, Nursing Education and Nursing Research.

72

NURSING IMPLICATIONS

Nursing Practice

The nurses play a key role in patient care. The day of admission to the day of

discharge nurse is with the patient, caring and consoling.

A nurse is expected to give nursing care as well as health teaching regarding

safe practices of insulin administration.

The present study administers an informational booklet to the Diabetic

patients, in order to impart knowledge and to prevent Insulin Therapy

complications.

The nurse needs to prepare self-instructional materials, which can be studied at

home with family members.

The nursing personnel needs to take initiative in directing, teaching and

educating the patients about self-administration practices which can be better

understood by the patients, family members, and the community at large.

Nursing administration

Nursing administrators can play a better role in planning educational

programme for Diabetic patients in order to improve patient’s knowledge and

attitude towards self-administration of insulin injection.

Nurse administrators should be necessarily involve in formulating policies for

health education in the hospital settings as well as community.

Nursing Education

Nursing education and curriculum should be planned in a way that it will

encourage the nursing students to train the diabetic patients especially for

certain tasks.( e.g. self-administration of insulin injection)

73

Along with imparting the knowledge specific attention and motivation can be

given to a specific areas.

Nursing education should emphasize on preparing prospective nurses to

impart health education by using various methods.

Nursing Research

Nursing research is the means by which nursing profession is growing.

More research should be done related to Insulin Therapy and self-

administration, in order to prevent the complications and reduce the rate of

malpractices.

LIMITATIONS

1. The sample size was limited to 60.

2. Only one hospital in Bangalore was included

3. The study was limited to the Diabetic patients who were on subcutaneous

Insulin therapy.

4. There was no experimentation in the study.

5. Generalization could not be made due to small sample size.

RECOMMENDATIONS

On the basis of the study that had been conducted, certain recommendations are

suggested for future students.

1. A similar study can be done on a larger sample

2. An experimental study can be done to assess the effectiveness of planned

teaching programme on insulin therapy.

74

3. An Exploratory study may be conducted to identify the lack of awareness,

knowledge, practices and attitude of Diabetic patients regarding insulin self-

administration.

4. A follow up study could be carried out to find the effectiveness of the study by

evaluating the knowledge in the Diabetic patients.

5. Information Booklet of the present study could be used for educating the

Diabetic patients.

75

8. SUMMARY

Education is evidence based care and handling gives nurses the opportunity to

improve their ability to use theoretical knowledge in clinical practice.

The study was conducted to assess the knowledge and attitude of diabetes mellitus

patients regarding self-administration of insulin injection. The convenience sampling

technique was used for a sample of 60 diabetic patients. The conceptual framework

was based on Orem’s Self Care model.

Objectives of the study were


injection.


injection.







Content validity of the tool was obtained on the basis of expert judgement. Reliabity

of tool was established by using Spearman’s Brown Prophecy Formula.

A structured self-administered questionnaire and a Likert type of attitude Scale was

administered to 60 diabetic patients. The collected data were statistically analyzed by

using both descriptive and inferential statistics.

76

The major findings of the study:

I. Findings regarding demographic variables of the diabetic patients

Maximum number of diabetic patients, 38.3% was in the age group of 61 – 70

years, 33.3% were of 51 – 60 years. 20% fell under the age group of 41 – 50

years and 8.3% were of below 40 years of age. Thus it shows that the

maximum number of diabetic patients participated in the study were in the age

group of 61 – 70 years.

The percentage distribution of the diabetic patient according to gender reveals

that majority of the subjects, 73.3% were male and 26.7% were female.

The result indicate that only 1.7% of the diabetic patient had completed

graduation, 3.3% had completed higher secondary, 21.7% completed

secondary education and 73.3 % had completed only primary education. It

shows that maximum number of the diabetic patient who participated in the

study had completed their primary education.

It reveled that 53.3% diabetic patients were unemployed, 23% were self

employed, 15% were private employee and only 8.3% were Government

employee.

It depicts that 78.3% of the diabetic patients were Hindus, 18.3% were

Muslims and 3.3% of diabetic patient were Christians. Thus it shows that

maximum number of Diabetic patients who participated in the study were

Hindus.

Data presented shows that maximum number of the diabetic patients, 86.7%

were married, 11.7% were widow or widower and only 1.7% were unmarried.

None of the subjects were divorced.

77

The results indicate that 63.3% of the diabetic patient had a family income less

than or equal to 2,000 per month, 18.3% had between 2001 to 3000,

10 %.were having family income more than 4001 or above and 8.3% had a

family income of 3001 – 4000.

This reveals that in 40% diabetic patient duration of diagnosis of diabetes

Mellitus were lesser than or equal to 3 years, 23.4% duration of diagnosis

were greater than or equal to 9 years, 21.7% were within 4 – 6 years and in

15% duration of diabetes Mellitus were 7 – 9 years.

The data presented reveals that maximum number of diabetic patients, 81.7%

were on insulin therapy for lesser than 2 years, 10% were for 3 – 4 years, 5%

were 5 – 6 years and only 3.3% were on insulin therapy for more than 7 years.

It shows that maximum number of diabetic patients, 63.3% had no family

history of diabetes mellitus and 36.7% had family history of diabetes mellitus

II Findings related to the level of knowledge of the diabetic patients regarding self


Out of 60 diabetic patients 81.7% had average knowledge, 13.3% had poor

knowledge and only 5% had good knowledge regarding self administration of

insulin injection.

The overall mean value of the diabetic patients knowledge regarding self

administration of insulin injection was 14.45 with a standard deviation of

3.326.

This findings showed that the most of the diabetic patients were not aware of the

self administration of insulin injection.

78

III Findings related to the level of attitude of diabetic patients towards self


Out of 60 diabetic patients, only 18.3% had most favourable and 81.7% had a

favourable attitude towards self administration of insulin injection.

The mean percentage of the positive attitude, which was 69.05 with a standard

deviation of 5.585.

These results showed that most of the diabetic patients were not having a most

favourable attitude towards self-administration of insulin injection.

IV Findings on the association between selected demographic variables and the level

of knowledge of the diabetic patients

The investigator could not elicit any significant association between the

knowledge level of diabetic patients with selected demographic variables at

0.05 level of significance.

V Findings regarding association between selected demographic variables and level

of attitude of the diabetic patients

Statistically no significant association was found between age, gender,

education, occupation, religion, marital status, duration of diagnosis of

diabetes mellitus, numbers of years on insulin therapy and family history of

diabetic mellitus.

There was a highly significant association between the level of attitude among

diabetic patients and their income.

VI Findings on the relationship between the knowledge and attitude of diabetic

patients

There was a positive correlation between the knowledge and the attitude of

diabetic patients.

79

9. BIBLIOGRAPHIC REFERENCES

1. Hanslett C, Chilvers ER, Boon NA, Colledge NR, Hunter JAA. Davidson’s

Principles and Practice of Medicine. 19th ed. Edinburgh: Churchill Livingstone;

2002.

2. Frier B. The hazardous path of diabetes management: Pilgrims’ Progress or

Paradise Lost? Proceedings of The Royal College of Physicians of Edinburgh;

1989 Oct 19; 4:Edinburgh; 1989. p. 449-458.

3. International Diabetes Federation. Diabetes Atlas. [Online]. 2005 [Cited 2005 Oct

17]; Available from: URL:http://www.eatlas.idf.org

4. Pradeepa R, Deepa R, Mohan V. Epidemiology of Diabetes in India-current

perspective and future projections. J Indian Med Assoc 2002 Mar;100(03):144-8.

5. Mohan V. Diabetes Mellitus. [Online]. 2002. [Cited 2005 May 20]: Available

from: URL:http://www.google.com

6. Ramachandran A, Snehalatha C, Kapoor A, Vijay V, Mohan V, Das AK et al.

Diabetes Epidemiology Study Group in India (DESI): high prevalence of diabetes

and impaired glucose tolerance in India -National Urban Diabetes Survey.

Diabetologia 2001; 44:1094-101

7. Ramaiya KL, Kodali VRR, Alberti KGMM. Epidemiology of diabetes in Asians

of the Indian sub-continent. Diabetes Metab Rev 1990;6:125-46.

8. Smeltzer CS, Bare GB. Brunner and Suddarth’s Text book of Medical Surgical

Nursing. 7th ed. Philadelphia: Lippincott; 1999.

9. Cox DJ, Gonder F. Major development in Behavioral Research. Journal of

Consulting and Clinical Psychology 1992;60(4):628-38

http://www.eatlas.idf.org/

http://www.google.com/

80

10. Johnson SB. Insulin Dependent Diabetes Mellitus in childhood. In Michael C,

Roberts (Ed) Handbook of Pediatric Psychology. 2nd ed. The Guildford Press;

1995.

11. La-Greca AM, Auslander WF, Spetter D. “I get by with a little help from my

family and friends”: Adolescent support for diabetes care. J Pediatr Psychology

1992; 20:4. 449- 76

12. DCCT Research Group. Effects of Intensive Diabetes treatment on the

development and progression of long-term complication in adolescent with Insulin

Dependent Diabetes Mellitus. J Pediatr 1994 August;125(2):177-1

13. Garg MK. Current Perspective in Insulin Therapy in the Management of Diabetes

Mellitus. J Indian Med Assoc 2002 Mar ;100(3):194-5,202.

14. Garg MK, Baliga KV.Management of Type-2 Diabetes (NIDDM). Med J Armed

Forces India 2002;58:53-9

15. American Diabetes Association. Insulin Administration. Diabets Care

1999;22:S83-7.

16. Dr. Mohan V. The Hindu. 2005 Nov 14;suppl. Available from:

URL:http://www.thehindu.com

17. Zimmet PZ. Diabetes Epidemiology as a tool to trigger diabetes research and care.

Diabetologia 1999;42:499-518

18. Maia FFR, Araujo LR. Insulin Pen injector for the treatment of type 1 Diabetes

Mellitus. J Paedtr (Rio J) 2002 May-Jun;78(3):189-92.

19. Mollema ED, Snoek FJ, Pouwer F. Diabetes Fear of Injecting and Self-testing

Questionnaire. Diabetes Care 2000 Jun;23(6)

20. Cramer JA, Pugh MJ. The influence of insulin use on Glycemic Control. Diabetes

Care 2005 Jan;28(1)

http://www.thehindu.com/

81

21. The Diabetes Control and Complications Trial. Effect of Intensive Insulin

Therapy on the micro vascular complications of type 1 diabetes mellitus. JAMA

2002;287:2563-9.

22. Best JW, Kahn J. Research in Education. 1st edition. New Delhi: Hall of India Pvt

Limited; 1999.

23. Polit FD, Hungler PB. Nursing Research - Principles and Methods. 6th ed.

Philadelphia: Lippincott Company; 1999.

24. Treece EW, Treece TW. Elements of research in nursing. 2nd ed. St.Louis: Mosby

Company; 1988.

25. Potter PA, Perry AG. Basic Nursing-Theory and Practice. 5th ed. USA: Mosby

Year Book Inc; 1995.

26. Abdellah FG, Levine E. Better patient Care through Nursing Research. London:

The Mac Millan Company; 1965.

27. Brennan G. The Tayside Diabetes Handbook - Treatment with Insulin. [Online]

2004. [Cited 2005 Sep 17]: Available from: URL:http://www.medline.com

28. Francine RK. Intensive Management of Type 1 diabetes in young children. Lancet

2005 Feb 26;365

29. Dewitt DE, Dugdale DC. Using New Insulin Strategies in the Outpatient

Treatment of Diabetes. JAMA 2003 May 7; 289(7)

30. The Diabetes Control and Complications Trial / Epidemiology of Diabetes

Interventions and Complications Research Group. Retinopathy and nephropathy

in patients with type 1 diabetes four years after a trial of Intensive Therapy. N

Engl J Med 2000 Feb 10;342(6)

31. Hayward RA, Manning WG, Kaplan S, Wagner EH, Greenfield S. Starting Insulin

Therapy in Patients with Type 2 Diabetes. JAMA 1997 Nov 26;278(20)

http://www.medline.com/

82

32. Saudek CD, Duckworth WC, Giobbie-Hurder A, Henderson WG, Henry RR,

Kelly DE et al. Implantable Insulin v/s Multiple Dose Insulin for Non Insulin

Dependent Diabetes Mellitus, JAMA 1996 Oct 23-30;276(16)

33. Summers KH, Szeinbach SL, Lenox BM. Preference for Insulin Delivery Systems

among current insulin users and non-users. Clin Ther 2004 Sep: 26(9):1498-505.

34. Hill J. Devices for insulin administration. Nurs Times 2003 Apr 15-21;99(15):51-2

35. Sucio M, Galic E, Cabrijan T, Ivandic A, Petrusic A, Wyatt J et al. Patient

acceptance and reliability of new Humalin / Humalog 3.0 ml prefilled insulin pen

in ten Croatian Diabetes Centers. Med. Sci Monit 2002; 8(3): 121-6

36. De Souza CR, Zanetti ML. The use of disposable syringes in the administration of

insulin at home. Rev Lat Am Enfermagem 2001 Jan;9(1):39-45

37. Robertson KE, Glazer NB, Campbell RK. The Latest Developments in Insulin

Injection Devices. Diabetes Edu 2000 Jan –Feb; 26(1)

38. Mersad D, Outtas O, Demoly P. Hypersensitivity to Insulin. Presse Med 2004

May 22;33(9 pt 1):631 – 8

39. Soudan B, Girardot C, Fermon C. Extreme Subcutaneous Insulin Resistance: a

misunderstood syndrome. Diabetes Metab 2003 Nov;29(5):539-46

40. Richardson T, Kerr D. Skin-related complications of Insulin Therapy:

epidemiology and emerging management strategies. Am J Clin Dermatol

2003;4(10):661 - 7

41. Yokoyama H, Fukumoto S, Koyama H. Insulin Allergy; desensitization with

crystalline zinc-insulin and steroid tapering. Diabetes Res Clin Pract 2003

Sep;61(3):161–6

42. Sola-Gazagnes A, Pecquet C, Radermecker R, Pietri L, Elgrably F, Slama G et al.

Successful treatment of Insulin Allergy in a type 1 diabetic patient by means of

83

constant Subcutaneous Pump Infusion of Insulin. Diabetes care 2003

Oct;26(10):2961-2

43. Logwin S, Conget J, Jansa M, Vidal M, Nicolan C, Gomis R. Human insulin

induced Lipoatrophy. Successful treatment using a jet-injector device. Diabetes

care 1997 Jan;20(1);119

44. Reach G, Zeriouki A, Leclercq D, d’Ivernois JF. Adjusting insulin doses: from

knowledge to decision. Patient Educ Cons 2005 Jan;56(1):98-103

45. Bergenstal RM. Effective Insulin Therapy. International textbook of Diabetes

Mellitus. 3rd ed. John Wiley and sons Ltd:ISBN; 2004.

46. Skinner TC. Psychological barriers. Eur J Endocrinol 2004 Oct ;151 Suppl 2 :

T13-7:T29-30

47. Asakura T. Research regarding proper use of insulin in diabetic patients.

Yakugaku Zasshi 2001 Sep;121 (9):653-61

48. Maureen IH. Frequency of blood glucose monitoring in relation to Glycemic

Control in patients in the Type 2 Diabetes. Diabetes Care 2001;24

49. Mollema ED, Snoek FJ, Heine RJ, Van der Ploeg HM. Phobia of self-injecting

and self-testing in insulin treated diabetic patients opportunity for screening.

Diabet Med [11553207] : Available from: URL: http: // www.pubmed.com 2001

Aug ; 18 (8): 671 – 4

50. Power BK, Walford S, Singh BM. Type 1 diabetes mellitus in a routine diabetes

clinic : the association of psycho-social factors, diabetes knowledge and glycemic

control to insulin regime. Diabetes Res Clin Pract 1999 Nov;46(2):151-5

51. Almeida HG, Campos JJ, Kfouri C, Tanita MT, Dias AE, Souza MM. Profile of

patients with diabetes type 1:insulinotherapy and self-monitoring. Rev Assoc Med

Bras 2002 Apr-Jun;48(2):151-5

84

52. Lombardo F, Salzano G, Messina MF, DeLuka F. How self-management therapy

can improve quality of life for diabetic patients? Acta Biomed Ateneo Parmense

2003;74 suppl 1 : 26-8

53. Coates VF, Boore JR. The influence of psychological factors on the self-

management of Insulin-Dependent Diabetes Mellitus. J Adv Nurse 1998

Mar;27(3):528-37

54. Saunders SA, Wallymahmed M, Macfarlane IA. Glycemic control in a type 1

diabetes clinic for younger adults. Q J Med 2004;97:575-80

55. Kapoor A. Diabetes care in India. International Journal of Diabetes in Developing

Countries 1997;17: 5-7.

56. De-weerdt J, Visser AP, Kok G, Vander Veen FA. Determinants of active self-

care behavior of insulin treated patients with diabetes: implications for diabetes

education. Soc Sci Med 1990;30(5):605-15.

57. Kothari CR. Research Methodology. Mumbai: Vishwa Prakashan; 1998.

58. Burns N, Grove SK. The practice of Nursing Research. 2nd ed. Philadelphia: WB

Saunder’s Company; 2002.

59. Kerlinger FN. Foundation of Behavioral Research. New York: Hold International

Edu: 1973.

85

10. ANNEXURES ANNEXURE-A

REQUESTING FOR CONDUCTING THE RESEARCH STUDY From,

Namita Singha 2nd year M.Sc. (Nursing) Sarvodaya College of Nursing Vijayanagar, Bangalore

To, The Medical Superintendent K.C. General Hospital Malleswaram Bangalore

Through

The Principal Sarvodaya College of Nursing Vijayanagar Bangalore-560040

Sub: -Seeking permission for conducting the Research Study Respected sir, I am a student of M.Sc. (Nursing) in Sarvodaya College of Nursing affiliated to Rajiv Gandhi University of Health Sciences, Bangalore with Specialization in Medical-Surgical Nursing. I have to conduct a research for the purpose of partial fulfillment of my course. The subject selected for the study is “A Descriptive Study To Assess The Knowledge And Attitude Regarding Self-Administration Of Insulin Injection Among Diabetes Mellitus Patients In K.C. General Hospital, Malleswaram At Bangalore”. Hence, I request you to kindly permit to conduct the research study in your esteemed institution. Hope you will consider my request and will do the needful. Thanking you, Date: Place: Bangalore Your’s Faithfully, Namita Singha

86

ANNEXURE-B

LETTER GRANTING PERMISSION TO CONDUCT THE STUDY

Ref. Letter No: Date:

To,

Namita Singha

IInd year M.Sc. Nursing

Sarvodaya College of Nursing

Bangalore-40

The above candidate who is undergoing M.Sc. Nursing programme in Sarvodaya

College of Nursing, Bangalore is permitted to collect data from Kempa Cheluvamba

General Hospital at Malleswaram, Bangalore in the month of September to October.

Place: Bangalore Yours sincerely

Date:

Medical Superintendent

87

ANNEXURE-C

CONSENT FORM OF THE RESPONDENTS

Dear participants,

I Miss. Namita Singha is a 2nd year M.Sc. (Nursing) student of Sarvodaya

College of Nursing. As part of the partial fulfillment of the course, I have to conduct a

research and the problem selected is A descriptive study to “assess the knowledge and

attitude regarding self administration of Insulin injection among Diabetes Mellitus

patients” in Kempa Cheluvamba General Hospital at Malleshwaram, Bangalore. I

would like get some information and your opinion regarding self administration of

Insulin injection.

This information will be kept confidential and will be only used for study

purpose. This is for your information and kind participation.

Signature of the investigator

I am willing to participate in the study and aware that the information

provided will be kept confidential and used only for the study purpose.

Signature of the participant

89

ANNEXURE - E

LETTER SEEKING EXPERT OPINION ON VALIDITY OF THE TOOL

From

Ms. Namita Singha

2nd Year M.Sc (Nursing)

Sarvodaya College Of Nursing

Bangalore

To

[Through the Principal, Sarvodaya College of Nursing, Bangalore]

Respected Madam/sir,

Sub-Requesting Expert opinion on content validation

I am a final year M.Sc (N) student (Medical-Surgical Nursing) in the above-

mentioned institution. As a part of academic requirement I am undertaking A

Descriptive Study To “Assess The Knowledge And Attitude Regarding Self-

administration of Insulin Injection Among Diabetes Mellitus Patients In Kempa

Cheluvamba General Hospital at Malleswaram, Bangalore”.

Objectives of the study

1. To assess the knowledge of patients regarding the Self-administration of Insulin

Injection.

2. To assess the attitude of patients regarding Self-administration of Insulin Injection

3. To correlate the knowledge and attitude of diabetic patients regarding self-



90


6. To develop an information booklet on self-administration of insulin injection for

diabetes mellitus patients.

Along with that I am enclosing

a) Structured questionnaire for knowledge assessment

b) Attitude scale for the assessment of attitude

c) Scoring keys

d) Criteria checklist for validation

e) Certificate of content validity

I request you to give your expert opinion and suggestion on the appropriateness

of the items, need for modification or deletion, by using the evaluation criterion

checklist enclosed. This will help me in the systematic conduction of the study.

Kindly sign the certificate of validation stating that you have validated the tool.

Thanking you,

Your’s faithfully

Place:Bangalore

Date:

Namita Singha

91

ANNEXURE - F

CRITERIA FOR VALIDATING THE TOOL

Areas Opinion Item no Suggestions

Relevant

Relevant To Some Extent

SECTION-I

DEMOGRAPHIC DATA

Not Relevant

Relevant


SECTION-II

QUESTIONNAIRE

Not Relevant

Relevant


SECTION-III

ATTITUDE

SCALE

Not Relevant

92

ANNEXURE - G

CERTIFICATE OF CONTENT VALIDITY

This is to certify that the tool for A Descriptive Study To “Assess The

Knowledge And Attitude Regarding Self-administration of Insulin Injection Among

Diabetes Mellitus Patients In Kempa Cheluvamba General Hospital at Malleswaram,

Bangalore”, prepared by Ms.Namita Singha, II nd Year M.Sc. Nursing student of

Sarvodaya College of Nursing, Bangalore is appropriate and found to be valid.

She has lot /none/few/some/of modifications required to be made in her tool.

Signature

Place:

Date: Seal

93

ANNEXURE - H

TOOL FOR DATA COLLECTION

Section-I Socio-Demographic Data.

Instructions:

The interviewer introduces herself and asks the participants to put a tick (√) mark to

the correct answer in the box given in the right side of each option. The participant is

ensured that the information would be kept confidential and will be used only for the

research purposes

1. Code no: 2. Age in years 2.1) ≤ 40 years [ ] 2.2) 41-50 years [ ] 2.3) 51-60 years [ ] 2.4) 61–70 years [ ]

3. Gender 3.1) Male [ ] 3.2) Female [ ]

4. Education of the participant 4.1) Primary level of education [ ] 4.2) Secondary level of education [ ] 4.3) Higher Secondary level of education [ ] 4.4) Graduate and above [ ]

5. Occupation of the participant 5.1) Unemployed [ ] 5.2) Private [ ]

5.3) Government [ ] 5.4) Self-employed [ ]

94

6. Religion 6.1) Hindu [ ] 6.2) Muslim [ ] 6.3) Christian [ ] 6.4) Others [ ] 7. Marital status 7.1) Married [ ] 7.2) Unmarried [ ] 7.3) Widow (er) [ ] 7.4) Divorced [ ] 8. Family income per month 8.1) Less than 2000 [ ] 8.2) 2001-3000 [ ] 8.3) 3001-4000 [ ] 8.4) 4001 and above [ ] 9. Duration since diagnosis of Diabetes Mellitus 9.1) ≤ 3 Years [ ] 9.2) 4-6 years [ ] 9.3) 7-9 years [ ] 9.4) ≥ 10 years [ ] 10. Actual number of years on Insulin therapy 10.1 ) < 2 yrs. [ ] 10.2) 3 – 4 yrs. [ ] 10.3) 5-6 yrs. [ ] 10.4) 7 yrs. and above [ ] 11. Family history of diabetes 11.1) Yes [ ] 11.2) No [ ]

95

Section-II Self-Administered Questionnaire

Instruction to the participant:

In this section there are questions relating to the knowledge of self-administration of

insulin injection. Please read the questions carefully and give your response that you

feel most relevant to you.

A. General Information regarding Insulin Therapy 1. Insulin is a/an 1.1) Hormone [ ] 1.2) Vitamin [ ] 1.3) Mineral [ ] 1.4) Enzyme [ ]

2. Insulin is secreted by 2.1) Liver [ ] 2.2) Pancreas [ ] 2.3) Kidney [ ] 2.4) Spleen [ ]

3. Action of Insulin is 3.1) It has no action on glucose [ ]

3.2) It increases the blood glucose level [ ] 3.3) It lowers blood glucose level [ ] 3.4) It completely removes glucose from the blood [ ] 4. Types of insulin are

4.1) Rapid acting [ ] 4.2) Intermediate acting [ ] 4.3) Long acting [ ] 4.4) All of the above [ ]

5. Short acting insulin has to be administered 5.1) 0-15 minutes before food [ ] 5.2) 0-30 minutes before food [ ] 5.3) 0-45 minutes before food [ ] 5.4) 15-30 minutes after food [ ]

96

6. Intermediate acting insulin has to be administered 6.1) Along with food [ ] 6.2) 0-15 minutes before eating [ ] 6.3) 30-45 minutes before eating [ ] 6.4) 45-60 minutes before eating [ ]

7. The effects of insulin injection when taken on empty stomach are 7.1) Increased pulse and respiration [ ] 7.2) High fever and rigor [ ] 7.3) High blood pressure [ ]

7.4) Blurred vision and dryness of mouth [ ] B. Regarding Self-Administration of Insulin Injection 8. Self-administration of insulin is

8.1) Dangerous [ ] 8.2) Less painful [ ] 8.3) Time consuming [ ] 8.4) A cost-effective method [ ]

9. Insulin injections should be taken 9.1) Once daily [ ]

Twice a day [ ] 9.2) Three times a day [ ] 9.3) According to doctors advice [ ] 10. The areas suitable for self-administration of insulin injection are 10.1) Arms [ ] 10.2) Thighs [ ] 10.3) Abdomen [ ] 10.4) All of the above [ ]

11. Insulin injection can be administered 11.1) Just beneath the skin [ ] 11.2) Into the vein [ ] 11.3) Into the muscle [ ] 11.4) Into the nerves [ ]

97

12. The site for the insulin injections are selected by 12.1) Rotating pattern [ ] 12.2) Using the different sites haphazardly [ ] 12.3) Using same injection sites daily [ ] 12.4) Using two injection sites [ ]

13. The advantage of site rotation is 13.1) To promote circulation [ ] 13.2) To prevent tissue damage [ ] 13.3) To prevent absorption of insulin [ ] 13.4) To promote lymph flow [ ]

14. An open insulin vial can be preserved by 14.1) Keeping in a cold place [ ] 14.2) Keeping in direct sunlight [ ] 14.3) Keeping in a hot place [ ] 14.4) Keeping in deep freezer [ ]

15. One of the complications of insulin injection is 15.1) Increased blood sugar [ ] 15.2) Decreased blood sugar [ ] 15.3) Increased blood pressure [ ] 15.4) Decreased blood pressure [ ]

16. Insulin syringes are preferred for insulin injection because it is 16.1) Less painful [ ] 16.2) Handy [ ] 16.3) Less expensive [ ] 16.4) Easy to calculate the dose [ ] 17. Before administering insulin injection inspect the vial for changes, like 17.1) Scratches on the vial [ ] 17.2) Size of the vial [ ] 17.3) Clumping, frosting [ ] 17.4) Design of the vial [ ]

18. Insulin should be drawn from the vial

18.1) By injecting a small amounts of air [ ] 18.2) Without injecting a small amount of air [ ] 18.3) By injecting a small amount of water [ ] 18.4) Insulin is poured into the syringe [ ]

98

19. Which of the following step is correct when preparing to administer two types of insulin?

19.1) Two separate syringes must be used [ ] 19.2) The regular insulin is withdrawn first [ ] 19.3) Air is placed in the intermediate acting insulin vial first [ ] 19.4) The intermediate acting insulin is drawn up first [ ]

20. An Insulin vial should not be shaken vigorously to 20.1) Prevent discoloration [ ] 20.2) Prevent clumping [ ] 20.3) Prevent leakage [ ] 20.4) Promote precipitation [ ]

21. Insulin preloaded syringes should be kept in

21.1) Inverted position [ ] 21.2) Horizontal position [ ] 21.3) Vertical position [ ] 21.4) Oblique position [ ]

22. Insulin absorption rate increases with

22.1) Smoking [ ] 22.2) Drinking of water [ ] 22.3) Sleeping [ ] 22.4) Exercise [ ] 23. Insulin absorption rate decreases with

23.1) Drinking of water [ ] 23.2) Smoking [ ] 23.3) Exercise [ ] 23.4) Sleeping [ ]

24. Insulin doses are calculated in

24.1) Milliliters [ ] 24.2) Deciliters [ ] 24.3) Units [ ] 24.4) Milligrams [ ]

25. The following solution is used to wipe the insulin injection site 25.1) Betadine [ ] 25.2) Water [ ] 25.3) Spirit [ ] 25.4) Acriflavine [ ]

99

26. One should not massage the site following insulin injection in order to

26.1) Maintain insulin in the subcutaneous tissue [ ] 26.2) Prevent rapid absorption of insulin [ ] 26.3) Prevent tissue damage [ ] 26.4) Prevent discomfort [ ]

27. Once opened an insulin vial can be used for 27.1) 60 days [ ] 27.2) 45 days [ ] 27.3) 30 days [ ] 27.4) 15 days [ ]

28. The effectiveness of insulin can be measured by

28.1) Checking blood and urine glucose levels [ ] 28.2) Checking blood pressure levels [ ] 28.3) Checking body temperature [ ] 28.4) Checking peripheral pulses [ ]

29. Taking insulin ensures

29.1) Best control of diabetes [ ] 29.2) Damage kidneys [ ] 29.3) Not adequate for diabetes control [ ] 29.4) Damage pancreas [ ]

30. When experiencing hypoglycemia one should

30.1) Take some water [ ] 30.2) Take some sugar dissolved in water [ ] 30.3) Take the next meal [ ] 30.4) Take some milk [ ]

100

Section-III Attitude Scale to Assess the Attitude of Diabetes Mellitus patients

towards Self-Administration of Insulin Injection Instructions: The attitude scale consists of 15 statements. Each statement is provided with a five-

point scale namely Strongly Agree (SA), Agree (A), Uncertain (U), Disagree (D), and

Strongly Disagree (DA). Please read each statement given below and indicate the

response by placing a tick mark against the one of the five points in the appropriate

column.

Sl. no

Statements Strongly Agree

Agree Uncertain Disagree Strongly Disagree

Do you feel /think/believe that

1 Self-administration of insulin is the most convenient method

2 Patients can improve the quality of their life with Diabetes mellitus by self administration of insulin

3 * Self-administration of insulin is time consuming

4 Self-administration of insulin injection does not need supervision

5 Even illiterate can learn self-administration of insulin injection technique more effectively

6 Self administration of insulin therapy will not require much time to learn

7 Patients are the most appropriate persons than others to get involved in the self-administration of insulin injection

8 The stress of frequent visit to hospital is minimized

9 Right technique and site rotation are two important aspects the patient should know regarding self-administration of insulin injection

10 Self-administration of insulin is possible at home environment

101

11 Self-administration of insulin injection is a cost-effective method

12 * Patients who are on self-administration of insulin should not travel or attend social functions

13 * Self-administration of insulin injection is dangerous

14 Health education of patients is effective in self-administration of insulin injection.

15 Self-administration of insulin injection will not affect the activities of daily life

16 Once started self-administration of insulin injection should be continued life-long.

17 Persons who are on self-administration of insulin should drive with precaution.

18 * Persons who are on self-administration of insulin injection are prone to depression

19 Persons who are on self-administration of insulin injection should carry a diabetes card where type and dose of insulin is clearly mentioned

20 * Being dependant on insulin therapy is something to be ashamed of

Scoring Key

Strongly Agree -5

Agree -4 Uncertain -3 Disagree -2 Strongly Disagree -1

*NEGATIVE STATEMENTS. THESE ITEMS ARE SCORED IN REVERSE

ORDER

Maximum score-100

Minimum score- 20

102

ANNEXURE - J CORRECT RESPONSES AND SCORING KEY

QUESTIONNAIRE TO ASSESSS THE KNOWLEDGE REGARDING SELF-ADMINISTRATION OF INSULIN INJECTION

Question No Correct Response Scores

1 1.1 1 2 2.2 1 3 3.3 1 4 4.4 1 5 5.1 1 6 6.3 1 7 7.4 1 8 8.4 1 9 9.4 1 10 10.4 1 11 11.1 1 12 12.1 1 13 13.2 1 14 14.1 1 15 15.2 1 16 16.4 1 17 17.3 1 18 18.1 1 19 19.2 1 20 20.2 1 21 21.3 1 22 22.4 1 23 23.2 1 24 24.3 1 25 25.3 1 26 26.2 1 27 27.3 1 28 28.1 1 29 29.1 1 30 30.2 1

111

ANNEXURE - K

Blue Print – Knowledge regarding Self Administration of insulin injection

Sl.No Content Knowledge Comprehension Application Total no of Questions

Percentage (%)

1. General Information 1,2,3 4,7 5,7 7 23.33%

2. Insulin Self-administration 10,12,13,15,22,23,28,30 8,9,16,19,24,26,29 11,14,17,18,20,21,25,27 23 76.67%

Total 11 9 10 30 100%

Knowledge – 36.67%

Comprehension – 30%

Application – 33.33%

111

“Successful patient discharge depends on Successful Medical Team Work”

Margaret Foster - 1883

111

Information Booklet

On

Self - Administration of Insulin

Injection

Prepared in partial fulfillment for the

DEGREE OF MASTER OF SCIENCE IN NURSING FROM

Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore.

By Ms. Namita Singha

FINAL YEAR M.SC. NURSING STUDENT

112

1. Basic Concepts 1.1. What is Insulin ?

Insulin is a hormone secreted by groups of cells within the pancreas

called Islet cells.

1.2. What is the action of Insulin?

Insulin lowers the blood glucose level by

- Promoting the transport of glucose into the cells and

- Inhibiting the conversion of glycogen and amino acids to

glucose.

1.3. What do you mean by Insulin Therapy or Insulin Treatment ?

Administration of insulin in the treatment of both type 1 and type2

diabetes

2. Treatment with Insulin

2.1. Aims of Insulin Treatment

- Abolish hyperglycemic symptoms

- Maintain ideal body weight

- Optimize glucose control

- Avoid hypoglycemia

- Maintain as near normal a blood glucose as is practical and safe

for the individual

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Starting insulin is best managed as an outpatient, with input from a

Diabetes Specialist Nurse.

- - - - - - - - - - - - - - - - - - - - - - - - - - -- - -- - - - - - - - - - - - - - - - - -

2.2. Insulin therapy in Type 1 Diabetes

Regular insulin therapy is life saving in type 1 diabetes. Patients are

usually seen urgently after the diagnosis is made and insulin

started, preferably as an out-patient, with input from one of the

Diabetes Specialist Nurses.

2.3. Insulin Therapy in type 2 Diabetes

The most common indication for insulin in these patients is

worsening glycemic control on Oral Hypoglycemic Agents.

113

2.4. Insulin in the Elderly

Chronological age is not a contraindication to insulin therapy.

3. Starting Insulin

All patients starting insulin should have the following :

Review of dietary intake, with emphasis on regular and

consistent carbohydrate intake.

An individualized regime, which must take account of life style

factors such as shift work, holidays, exercise etc.

Appropriate education on self-management of insulin

administration.

Education on avoidance of hypoglycemia

Education on “sick day rules”, including avoidance of diabetic

ketoacidosis for people with type 1 Diabetes.

4. Timing of Injections in relation to meals

Standard insulin preparations should be injected subcutaneously

usually 15-30 minutes before meals

Analogue insulins have a rapid onset of action and an early

peak response. In view of this, they should be injected

immediately (usually within 5-10 minutes) before eating or just

after. Delays between injection and eating with these

preparations will predispose a patient to hypoglycemia.

Examples of short-acting analogues include insulin Lispro

(Humalog) or Insulin Aspart (NOVORAPID)

Insulin analogue mixtures are also available (e.g. Human

Mixtard, Humalog Mix 25 or Novomix)

5. Insulin presentation

- Rapid acting

- Intermediate working

- Long acting

114

6. Identification of insulin preparation

Please check the carton and the vial for the name and type of

insulin prescribed to you. In the event of any doubt, always seek

clarification from your physician.

7. Clearness or Clarity of Insulin

The Human Long acting and Human Mix acting insulin preparation

should look uniformly milky after mixing. The regular insulin is

always clear.

8. Storage

Insulin should be stored in a refrigerator but never in a freezer.

Do not use insulin if it is frozen.

If it is not possible to store it in a refrigerator, it should be kept

cool as possible below 300 C while in use. At this temperature

the preparation are likely to remain stable for about a month.

Do not use a vial of insulin beyond the date of expiry mentioned

on the label..

9. Insulin Administration devices

9.1 Syringes

The dose of insulin is always expressed in International Human

Units (IHU). Please study the markings made on the insulin

syringes carefully and understand calculation of the dose in ML.

Do make sure that you use only a syringe calibrated to 40 IHU

per ML.

The volume of insulin has to be injected, depends upon the dose

required by the patient. Hence, do use a syringe marked for the

use of insulin. If proper syringe is not used, it may lead to an

error in the dosage. This may cause serious problems such as

blood glucose may become too low or high.

Syringes are suitable for

• Patients using two different insulin preparation that need to be

mixed

115

• Patients using large volumes of insulin which cannot be

accommodated in a pen

• Patients whose injections are given by a 3rd party. Eg. Carer or

Community Nurse

• Injections for use with syringes should be prescribed in vials.

9.2 Pen devices

Many patients use a pen injection device for insulin administration.

This is available in two forms, either a reusable form for use with a

cartridge or a prefilled (disposable) type. Both are available on

prescription.

Pen devices are designed for self use only.

The advantages of pen injection devices is the convenience of

carrying and administering the insulin

Disposable (pre filled) pens are particularly useful for patients

who are not so dexterous.

All cartridges for re-usable pens at present come in 3ml size.

However a few patients receiving Porkine insulin. (Hypurin

preparations) use 1.5 ml cartridges.

Pen needles are available on prescription. 8 mm, 6mm or 5 mm needles

are recommended. Needles should be changed for each injection.

Storage of Insulin pen devices.

Insulin pens that are “in use” may be kept at room temperature, but

spare cartridges or disposable pens should be kept in a fridge.

10. Injection sites

Assess each patient individually for suitable areas to inject.

This include :

• Arms - upper, outer parts of arms

• Abdomen - lower abdomen below umbilicus

• Thighs - upper outer thighs

• Buttocks - upper outer buttocks

Recommend sites that are easiest to reach

Rotate sites at each injection.

116

Injection sites.

Injection Site Rotation

• Do not mix site and time, each side has a different absorption

pattern

• Advise patients to keep a consistence side for each time a day,

which helps to reliably predict the effect of a dose of insulin

• It is important however to rotate injections within the same site

each day

11. Injection Technique

11.1. Preparing the Dose and injection

1. Wash your hands with soap and water

2. Insert the plunger into the syringe, fix the needle with a slight

twist. Push the plunger in and out several times to remove all the

water that might have remained inside. Now, the syringe is ready

for use. However, this step is not necessary while using a sterile

disposable syringe and a needle.

3. Thoroughly but gently mix the insulin by upending the bottle and

rolling it between the palms (fig A). Shaking the bottle creates

bubbles. This step is particularly important for long acting and Mix

117

Fig. A

type of insulin. Do not use the insulin if anything unusual is

detected in the appearance of the vial.

• Begin by turning the bottle of

insulin upside down and rolling it

between the plans. The purpose of

this step is to mix the insulin

thoroughly.

(When using a new vial, remove the plastic protective cap on the stopper.

However do not remove the stopper)

4. Wipe the insulin bottle top with 70% alcohol immediately before

drawing insulin into the syringe and allow it to dry.

5. Draw air into the insulin syringe in the same amount as the insulin

to be withdrawn (fig B). If 10 units are to be removed, leave 10

units of air in the syringe.

• Carefully wipe off the top of the bottle with alcohol-soaked

cotton

• The next step is vital

• Draw air into the syringe in the

same amount as the insulin dose to

be taken.

• In other words, if you need 20 units

of insulin, you fill the syringe with

20 units of air, which is left in the

syringe temporarily,

• The reason for this is that a vacuum

exists in the insulin bottle, and in order to remove insulin you

must first inject same amount of air.

6. Insert the needle in the bottle, and push

the plunger down (fig C)

Fig. B

Fig. C

118

• With the air still in the syringe, carefully insert the needle

through the diaphragm top into the bottle

• Push the plunger down

7. Invert the bottle and draw more insulin into the syringe than

needed. Push the plunger up, expelling the insulin and air bubbles.

Do this several times to get rid of all air bubbles in the syringe (fig

D)

• Turn the bottle upside down and pull

back the plunger to a point

considerably past the amount of

insulin needed

• Push the insulin and air back into

bottle several times.

• The purpose of this step is to push all

of the air bubbles back into the bottle of insulin.

8. Pull the plunger down slowly to the right amount of insulin (fig E)

• Now that all the air bubbles are out of

the syringe, carefully pull the plunger

down to the correct amount of insulin

9. Holding the syringe at an angle to the skin (15 to 20 degrees

straight up-and-down), plunge the needle into the site that has

been prepared by cleaning with alcohol (fig F). Push the plunger

down all the way.

• The syringe now has the precise

amount of insulin required.

• Wipe the spot to be injected with

cotton and alcohol, and pinch the

skin

Fig. D

Fig E

Fig F

119

• Holding the syringe like a pencil, push the needle straight into

the skin and push the plunger down.

• Release the pinched skin, press the cotton ball next to the

needle, and pull out

10. Quickly withdraw the needle apply gentle pressure over the

injection site with an alcohol swab. Do not rub the area.

If you doctor advised you to mix different types of insulin, ensure to

follow the same sequence for drawing insulin from the vials. The rapid

acting is always drawn first.

1. Inject an amount of air equal to the dose of intermediate insulin

into the NPH or Lente insulin bottle. Withdraw the empty syringe at

this time without removing any insulin.

2.Ignore the previous bottle for a moment, inject an amount of air

equal to the desired dose of regular insulin in to the bottle and

remove the proper amount of regular insulin getting out the

bubbles as usual

3. Return to the intermediate insulin bottle but do not inject any air

this time. Simply insert the needle and withdraw the correct

amount of NPH or Lente insulin.

4.This final amount in the syringe is the sum of the regular

(crystalline) insulin plus the intermediate insulin for the total

measured dose.

Patients become very adapt it this procedure and have very little

trouble with the technique

The insulin mixture should be prepared just prior to injection

12. Sterilization of insulin syringes:

Do not share your syringe or needles with anyone else. Reusable syringes

and needles must be sterilized before each injection. Separate the

syringe, plunger (piston) and the needle. Place them in water in a covered

120

container. Bring the water to boiling and continue to boil it at least for 5

minutes. Allow it to cool completely. Follow all the instructions mentioned

on the package of the syringe.

Whenever disposable syringes and needles are used, use them only once

and then discard.

13. Dosage:

The insulin requirement of every patient is different and your doctor will

decide the dose considering your blood glucose values, age, daily

activities etc.

Insulin dose may be affected by various factors. Hence, it is necessary to

anticipate change in the dose of insulin required and seek your doctor’s

advice well on time.

Some of such factors are as follows:

13.1 Illness:

During an illness your requirement may actually go up, even if you are not

eating well.

13.2 Pregnancy:

During pregnancy it is important that your diabetes is controlled for you

as well as your baby.

13.3 Exercise:

Exercise may lower body’s need for insulin during and for some time after

activity. Exercise may also speed up the effect of an insulin dose,

especially if it involves the area of injection site.

13.4 Medication:

Insulin requirements may be modified by the effect of a number of

medications you may require to take during illness.

121

13.5 Travel:

When traveling across two or more time zones, consult your doctor well in

advance and seek his advice about dosage adjustments and schedule.

14. Common problems associated with Insulin:

14.1 Hypoglycemia:

Excessive lowering of blood glucose is called as hypoglycemia. This

problem is most frequent and can occur due to the following reasons:

• Taking higher doses of insulin than is required

• Missing or delaying meals

• Exercising or working more than usual

• An infection or illness (especially with diarrhoea or vomiting)

• A change in body’s need for insulin

• Consumption of alcoholic beverages.

The symptoms of mild to moderate hypoglycemia may include - sweating,

dizziness, palpitation, tremors, hunger, restlessness, tingling in the hands,

feet, lip or tongue, light headedness, inability to concentrate, headache,

drowsiness, sleep disturbance, anxiety, blurred vision, slurred speech,

depressive mood, abnormal behavior, unsteady movements and

personality changes

Signs and symptoms of severe hypoglycemia can include disorientation,

seizures, unconsciousness and death.

Mild to moderate hypoglycemia may be treated by -

- Consuming food or drinks that contain sugar. Patients should always

carry a quick source of sugar, such as sugar candies or glucose tablets.

More severe hypoglycemia may require assistance of another person and /

or hospitalization.

If you have frequent episodes of hypoglycemia or experience difficulty in

recognizing the symptoms, you should consult you doctor to discuss the

possible changes in therapy, meal plans and /or exercise program to help

you avoid hypoglycemia.

122

14.2 Hyperglycemia and Diabetic Acidosis: Hyperglycemia or high glucose levels in the blood may develop if your

body has too little insulin

Hyperglycemia can be brought about by:

• Omitting your insulin or taking less than the doctor has prescribed

• Eating significantly more than your meal plan suggests

• Developing a fever or infection

In patients with type I diabetes prolonged hyperglycemia can result in

diabetes acidosis usually come on gradually, over a period of hours or

days and include a drowsy feeling, flushed face, thirst, loss of appetite

and breath smelling of fruity odor. Urine tests would show large amounts

of glucose and acetone. Heavy breathing and rapid pulse are more severe

symptoms. It uncorrected, prolonged, hyperglycemia or diabetic acidosis

can result in loss of consciousness or death. Therefore it is important that

you obtain medical assistance immediately.

14.3 Lipodystophy:

Administration of insulin subcutaneonsly may result in lipotrophy

(depression in the skin) or lipohypertrophy (enlargement of thickening of

tissue). If you notice either of these conditions, consult your doctor. A

change in your injection technique may help alleviate the problem.

14.4 Allergy to insulin:

Local allergy: patients occasionally experience redness, swelling and

itching at the site of injection of insulin. If you have local reactions contact

your doctor.

Systemic Allergy: Less common, but potentially more serious is

generalized allergy to insulin which may cause rash over the whole body,

shortness of breath, wheezing, reduction in blood pressure, fast pulse or

sweating. Severe case of generalized allergy may be life threatening, if

you think you are having a generalized allergic reaction to insulin, seek

medical help immediately.

123

In conclusion each person is unique. The insulin requirement of every

patient is different considering the blood glucose values, age, daily

activities etc. Knowing how to inject and calculate the insulin dose is very

important. If you do your injections will be more comfortable. So, this

booklet is designed and given to diabetes mellitus patients who are on

insulin injection to increase their knowledge regarding self-administration

of insulin injection and to develop a positive attitude towards it and to

practice the insulin administration accurately.

135

ANNEXURE - N

Lists of Experts

1. Dr. B.A.Pataliah

Professor of Medical Surgical Nursing

The Oxford College of Nursing

J.P Nagar

Bangalore-75

2. Dr. K.P. Neeraja

Professor

Navodaya College of Nursing

Raichur

3. Mrs. Mosphea Khanam

Professor of Medical – Surgical Nursing

Regional College of Nursing

Guwahati, Assam

4. Mr. Amal Einstein Xavier

Principal

Oriental College of Nursing

Rajajinagar

5. Prof. S. Chitra

Principal

East-west College of Nursing

Rajajinagar

6. Mrs. Unmona Borgohain

Joint Director Nursing cum

Vice-Principal

Asian Institute of Nursing Education

G.N.R.C. Campus

Dispur, Guwahati – 06

137

7. Prof. N.N. Yalayyaswamy

Professor, Medical surgical Nursing

Kempa gowda Institute of Nursing

Bangalore – 4

8. Dr. Gangaboraih

Associate Professor of Statistics

Department of Community Medicine

Kempe gowda Institute of Medical Sciences

Bangalore – 4

9. Mr. Shridhar K.V

Associate Professor, Medical Surgical Nursing

Kempe gowda Institute of Nursing

Bangalore – 4

10. Dr. Dayanant.

Consultant Physician

Geetha Nursing Home

Bangalore.

11. Mr. S.N. Nanjunde Gowda

Associate Professor, Medical Surgical Nursing

Icon College of Nursing

Bangalore.

A Descriptive Study To “Assess The Knowledge And Attitude

Documents

Transcript of A Descriptive Study To “Assess The Knowledge And Attitude