INTRODUCTION:

“It is not enough to take good decisions and make good choices. It is necessary to take heed and comply with whatever you plan and that can only happen by the influence of the Lord God, the giver of your dreams.”

Israelmore Ayivor

Diabetes is a serious public health problem that threatens the quality of life of patients. The success of long-term maintenance therapy for diabetes depends largely on the patients compliance with a therapeutic plan. According to Diabetes Atlas published by the International Diabetes Federation (IDF), globally there were an estimated 366 million people having diabetes in 2011. By 2030 this will have risen to 552 million.¹According to Indian Council of Medical research –Indian Diabetes Study (ICMR-INDIAB), India currently has 62.4 million people with diabetes; this is set to increase to over 100 million by 2030². Kerala is the diabetes capital of India with a prevalence of diabetes as high as 20%, double the national average of 8%.³Insulin treatment remains the most longstanding blood-glucose-lowering therapies for people with type 2 diabetes. Patient’s non-compliance to treatment is a serious healthcare concern that poses a great challenge to the successful delivery of healthcare and it can also lead to diabetic complications.⁴

From the perspective of healthcare providers, therapeutic non-compliance is a major clinical issue as non-compliance could have a major effect on treatment outcomes and direct clinical consequences.⁶Besides undesirable impact on clinical outcomes, non-compliance would also cause an increased financial burden for society. For example, therapeutic non-compliance has been associated with frequent emergency health care consultations, hospitalizations and higher treatment costs .⁸

Information and Education gives consequent improvements in knowledge, practice and skills which lead to better control of the disease and is widely accepted to be an integral part of comprehensive diabetes care. So in the present study more emphasis is given in teaching correct technique of self administration of insulin. So the people will become more aware of their responsibility and makes no mistakes during self administration of insulin. ¹⁰

Research Studies conducted in different parts of the world showed the evidence of inadequate knowledge and poor practice on self administration of insulin among diabetes patients. It was proved that there is an increasing amount of evidence that the patient education is the most effective way to lessen the complications of diabetes and its better management.¹¹

NEED FOR THE STUDY:

As a major epidemic of the 21^st century, diabetes poses a threat to public health and is associated with increased physical, psychological and social morbidity, if left untreated. In order to compensate the above mentioned ill effects of diabetes, these patients need to obtain adequate knowledge and favorable attitude towards the management of the condition.¹²

Kerala is the diabetes capital of India. High literacy rate in Kerala state does not seem to translate to health literacy. The high prevalence of diabetes is accompanied by poor detection and poor compliance to insulin therapy. ¹³

The ultimate aim of any prescribed medical therapy is to achieve certain desired outcomes in the patients concerned. These desired outcomes are part and parcel of the objectives in the management of the diseases or conditions. However, despite all the best intention and efforts on the part of the healthcare professionals, those outcomes might not be achievable if the patients are non-compliant.

Diabetes is one of the incurable but early controllable diseases. It is a chronic disease due to the impaired balance between glucose and insulin in the body. Improper handling or administration of insulin is one of the common reasons for uncontrolled diabetes and occurrence of complications. These complications can cause major morbidity and mortality in patients with insulin dependent diabetes mellitus. So assessment and re-instruction on self administration of insulin is important to improve glycemic control, not only for those with erroneous injection skill, but also for those with proper technique.¹⁷

The investigator during her clinical experience has come in contact with insulin requiring diabetes patients. The major problem experienced by them was inadequate skill and technique in the area of “self administration of insulin” and they expressed their desire to learn it correctly. During her two weeks posting in selected community health centre, researcher identified 19 diabetes patients, out of seven having lip dystrophy. Hence the investigator felt the need to provide awareness programme on insulin therapy among diabetes patients in order to improve their knowledge and compliance.

REVIEW OF LITERATURE:

A survey was conducted in 2009 at Islam ad to evaluate the base line level of knowledge and awareness of diabetic patients about their disease and self administration of insulin techniques. The study results showed that the awareness about the disease and self administration of insulin in majority (88.3%) of diabetes patients was inadequate. This study suggested that routine individual teaching and counseling are suggested as an effective educational model to reduce diabetic related complications.³⁸

A literature search was performed by Joyce A. Cramer in the year 2012 in US to identify reports with quantitative data on compliance with oral hypoglycemic agents (OHAs) and insulin and correlations between compliance rates and glycemic control. Results showed that insulin adherence among patients with type 2 diabetes were 40–45%. This review confirms that many patients for whom diabetes medication was prescribed were poor compliers with treatment, including both OHAs and insulin. This study concluded that awareness programme is necessity for improving therapeutic compliance.³⁹

A randomized control study was conducted in India in the year of 2011, to find out the effect of an education programme on self administration of insulin among 186 type 2 diabetes patients. Results showed that educational programme was effective in lowering glycated hemoglobin and findings also revealed that education will also helps to improve the therapeutic compliance to insulin therapy and thereby reducing diabetes related complications.⁵⁰

STATEMENT OF THE PROBLEM:

“A study to assess the effect of awareness programme on compliance to insulin therapy among patients with diabetes mellitus (DM) in a selected community health centre, Thrissur district”.

OBJECTIVES OF THE STUDY:

1. To assess the knowledge on insulin therapy among patients with diabetes mellitus.

2. To assess the compliance to insulin therapy among patients with diabetes mellitus.

3. To evaluate the effect of awareness programme on insulin therapy among patients with diabetes mellitus.

4. To correlate the pre-test knowledge score and pre-test compliance score on insulin therapy.

OPERATIONAL DEFINITIONS:

1.Effect: It refers to the extent to which the awareness programme achieved the desired result in terms of gain in knowledge and compliance to insulin therapy.

2.Awareness programme: It refers to planned group teaching with demonstration on self administration of insulin which designed to educate insulin requiring diabetes patients.

3.Compliance: It refers to the extent to which a person follows standard steps in administration of insulin as assessed by a checklist.

4.Insulin therapy: It refers to self administration of exogenous insulin subcutaneously by patients with diabetes mellitus according to standard procedure of insulin administration.

5.Patients with Diabetic mellitus: It refers to individual who are diagnosed to have diabetes mellitus and on insulin therapy for a minimum period of 6 months.

HYPOTHESIS :

H₁: There will be significant difference between mean pre-test knowledge score and mean post-test knowledge score on insulin therapy among patients with diabetes mellitus

H_2: There will be significant difference between mean pre-test compliance score and mean post-test compliance score on insulin therapy among patients with diabetes mellitus.

H₃: There will be significant relationship between mean pre-test knowledge score and mean pre-test compliance score on insulin therapy among patients with diabetes mellitus.

CONCEPTUAL FRAME WORK:

The conceptual frame work of the present study is based on modified general system theory by Ludwing Von Bertalanffy.

METHODOLOGY:

Research Design: Quasi-experimental design with one group pre-test post-test design research design.

Setting of the Study: Non Communicable Disease (NCD) clinic of Community Health Centre, Mala. Observation of self administration of insulin was done at home setting.

Population: Patients with diabetes mellitus who are on insulin therapy for a minimum period of 6 months

Sample and sampling technique:

Sample: 60 diabetes patients who are on insulin therapy.

Sampling Technique: Consecutive sampling technique.

Sampling criteria:

Inclusion Criteria:

1. Patients with diabetes mellitus and who is on insulin therapy for a minimum period of 6 months.

2. Patients with diabetes mellitus whose age between 20-60 years.

Exclusion criteria:

1. Diabetes mellitus patients those who have severe medical illness or mental illness.

2. Patients with diabetes mellitus who are medical professionals.

Variables:

1. Independent variables: In this study independent variable are awareness programme on compliance to insulin therapy.

2. Dependent variable.: In this study dependent variable is the level of knowledge and practice of diabetic patients regarding the insulin therapy.

Tools and Technique:

Tool 1: Structured interview schedule: A structured interview schedule was used to collect the demographic proforma and knowledge on diabetes and insulin therapy

Tool 2: Observation checklist: Here the investigator used a observation checklist for exploring the compliance regarding insulin therapy.

RESULTS:

Presentation of data: The data collected were organized, analyzed and presented under the following headings.

Section 1: Baseline characteristics of the subjects.

· It was observed that equal percentages (36.7%) of the subjects were in the age group of 51- 65 years.

· More than half (51.7%) of the subjects were males and 48.3 % were females.

· With regard to education, most (38.3 %) of the subjects had primary level education.

· With reference to occupational status 33% of the subjects were unemployed.

· Most of diabetic patients (46.7%) had family history of diabetes mellitus.

· Majority of subjects (78.3%) followed only allopathic treatment for diabetes.

· Most of the subjects (45.0%) had more than 3 years of duration of diabetes.

· Duration of insulin therapy for most of the subjects (38.3%) was below one year.

Section 2: Effect of awareness programme on knowledge score on insulin therapy.

Figure 1: Grading of pre-test and post-test knowledge score of subjects on insulin therapy.

Figure 1 depicts that in pre-test most of subjects (36.7%) had poor level of knowledge, 28.3% of subjects had average level of knowledge, 20.0% had good level of knowledge, 8.3% of subjects had very poor level of knowledge and only 6.7% of subjects had very good knowledge on insulin therapy. Where as in post test 51.7% had good knowledge, 28.3% had very good knowledge, 20% had average knowledge and no one had poor and very poor knowledge on insulin therapy.

Table 1: Effect of awareness programme on knowledge score on insulin therapy. N=60

Knowledge Score	Mean	SD	Mean Difference	Paired ‘t’ value	df	Table Value
Pre-Test	14.62	5.74	7.68	19.99*	59	2.00
Post-Test	22.30	3.99	7.68	19.99*	59	2.00

*Significant at 0.05 level

The data presented in the table 1 shows that the mean pre-test knowledge score of the subjects is 14.62 and the mean post -test knowledge score is 22.30. Here the calculated value (19.990) is greater than the table value (2.00) at degree of freedom 59 and 0.05 level of significance. Hence null hypothesis (H0₁) is rejected and the research hypothesis ( H₁) is accepted. Therefore it can be concluded that the difference of mean scores observed was true difference and the awareness programme on insulin therapy is effective in terms of knowledge gain among diabetes mellitus patients.

Section 3: Effect of awareness programme on compliance score on insulin therapy.

Figure 2: Grading of Pre-Test and Post-Test Compliance Score of Subjects on Insulin Therapy.

Figure2 shows that in pre-test equal number of subjects (35.0%) had poor and average level of compliance, least number (17%) of subjects had good level of compliance, 10.0% of subjects had very poor compliance level and only 3.0% of subjects had very good compliance level on insulin therapy among patients with diabetes mellitus. Where as in post test most of subjects (45.0%) had good level of practice, 38.3% of subjects had average level of compliance, 16.7% of subjects belonged to very good level of compliance and no one had poor and very poor level of compliance on insulin therapy among patients with diabetes mellitus.

Table 2: Effect of Awareness Programme on Compliance Score on Insulin Therapy. N=60

Compliance Score	Mean	SD	Mean Difference	‘t’ value	df	Table Value
Pre-Test	18.80	6.62	7.73	14.611*	59	2.00
Post-Test	26.53	5.30	7.73	14.611*	59	2.00

*Significant at 0.05 level

The data presented in the table 2 shows that the mean pre-test compliance score of the subjects is 18.80 and the mean post-test compliance score is 26.53. Here the calculated value (14.611) is greater than the table value (2.00) at degree of freedom 59 and 0.05 level of significance. Hence null hypothesis (H0₂) is rejected and the research hypothesis (H₂) is accepted. Therefore it can be concluded that the difference of mean observed was true difference and the awareness programme on insulin therapy is effective in terms of compliance gain among diabetes mellitus patients.

Section 4: Correlation between pre-test knowledge and pre-test compliance score of patients with diabetes mellitus.

Table 3: Correlation between pre-test knowledge score and pre-test compliance score of patients with diabetes mellitus. N=60

Variables	Mean	SD	‘r’ value
Knowledge	14.62	5.737	0.838*
Compliance	18.80	6.625	0.838*

*0.05 level of significance

Table 3 shows that correlation between pre-test knowledge score and pre-test compliance score was 0.838. Thus the null hypothesis (H0₃) is rejected indicating that there was positive high correlation between pre-test knowledge scores and pre-test compliance scores of diabetes patients on insulin therapy. Above table says that when the knowledge increases compliance also increases.

Section 5: Association between pre-test knowledge and pre-test compliance score with selected baseline variables.

Table 3: Association between pre-test knowledge scores of diabetes patients with selected baseline variables. N=60

Demographic Variables	Pre-Test Knowledge
Demographic Variables	Fisher’s Value	‘P’ Value
Age	10.20	0.56^NS
Sex	1.92	0.79^NS
Educational qualification	16.33	0.09^NS
Occupational status	9.69	0.64^NS
Family History of Diabetes Mellitus	12.24	0.31^NS
Medication of Diabetes	13.24	0.30^NS
Duration of Diabetes	15.48	0.17^NS
Duration of Insulin Therapy	9.93	0.61^NS

NS = Not Significant

Table 3 depicts that the ‘p’ value of each baseline variable is higher than the 0.05 level of significance. Hence there is no association between pre-test knowledge score and baseline variables.

Table 4: Association between pre-test compliance score of diabetes patients and selected baseline variables N=60

Demographic Variables	Pre-Test Knowledge
Demographic Variables	Fisher’s Value	‘P’ Value
Age	8.27	0.79^NS
Sex	2.19	0.78^NS
Educational Qualification	15.02	0.16^NS
Occupational Status	12.56	0.32^NS
Family History of Diabetes Mellitus	7.61	0.89^NS
Medication of Diabetes	15.16	0.20^NS
Duration of Diabetes	16.03	0.15^NS
Duration of Insulin Therapy	12.57	0.32^NS

NS = Not Significant.

Table 4 shows that the ‘p’ values of each baseline variable is higher than the 0.05 level of significance. Hence there is no association between pre-test compliance score and the baseline variables.

DISCUSSION:

Section 1: Effect of Awareness Programme on Knowledge Score on Insulin Therapy.

In the present study it was found that most (36.7%) of the subjects scored poor level of knowledge, 20.0% of subjects had good level of knowledge,28.3% of subjects had average level of knowledge and 8.3% of subjects had very poor level of knowledge in pre-test. Where as in post-test most of the subjects (51.7%) had good level of knowledge, 28.3% had very good level of knowledge, 20% had average level of knowledge and no one had poor and very poor level of knowledge on insulin therapy. The knowledge score had increased in all the areas of insulin therapy. The mean gain in knowledge score was in the area of management of diabetes and insulin self administration. Therefore it can be concluded that in the present study the awareness programme was effective (t₅₉=19.990 >t=2.00) in increasing the knowledge of subjects regarding insulin therapy and the difference of mean observed was true difference.

A study was conducted to assess the effectiveness of structured teaching programme on knowledge and practice regarding self administration of insulin among insulin requiring diabetic patients showed a supportive result that majority (73.3%) of the insulin requiring diabetic patients had inadequate knowledge on self administration of insulin. Regarding knowledge on diabetes, most (46.7%) of the subjects had inadequate knowledge. These results showed that structured teaching programme was very effective to improve the knowledge and practice scores of subjects.⁴⁴

Section 2: Effect of Awareness Programme on Compliance Score on Insulin Therapy.

In the present study it was found that the highest percentage (35.0%) of subjects had poor and average level of compliance in pre-test. In the post-test most (45.0%) of the subjects had good level of compliance. In the area of ‘site selection for insulin’ most (68.3%) of the subjects had very poor level of compliance in the pre-test. In the post-test this area had only 18.3% of subjects with very poor compliance. The compliance score had increased in all the areas of insulin therapy. The mean gain in compliance score was highest in the area of ‘hand washing’ and ‘insulin injection site selection’.

In the present study the awareness programme was effective (t₅₉= 14.611>t=2.00) in increasing the compliance of subjects to insulin therapy and the difference of mean observed was true difference.

A study was conducted to describe the most common correct and incorrect techniques of self administration of insulin and to find the effect of structured teaching programme on insulin self administration among diabetes patients in Nigerian community. This study also revealed that diabetes patients are not following correct steps while taking insulin injection. The subjects had poor practice in the area of ‘injection site rotation’ which is true in the present study too. The conclusion of the study conducted in Nigerian community that the structured teaching programme was effective (t₄₀= 22.85>t=2.66) in increasing the compliance to insulin therapy supports the present study finding also.⁴⁹

Section 3: Correlation between Pre-Test Knowledge and Pre-Test Compliance Score of Patients with Diabetes Mellitus.

The present study showed that the correlation between knowledge and compliance on insulin therapy was 0.838, which was positive high correlation. A descriptive study conducted in Bangalore to supported the strong correlation (0.638) between the knowledge and practice of diabetes patients on insulin self administration.⁴² In contrast to the present study findings Alphonsa J in Manglore identified poor correlation (0.162) between knowledge and practice on self injection of insulin.³⁰

Section 4: Association Between Pre-Test Knowledge Scores and Practice Scores with Selected Baseline Variables.

The result of the present study showed that there was no significant association between pre-test knowledge score and pre-test compliance score with all baseline variables such as age, sex, educational qualification, occupational status, family history of diabetes, type of medication, duration of diabetes mellitus and duration of insulin therapy.

In contrast to present study findings, Mahipal S, Viji P in Rajastan in the year of 2011 in a study regarding self administration of insulin found that there was significant association between practice score and selected baseline variables such as age and educational status.⁴⁰

CONCLUSION:

Reviews and present study finding show that awareness programme is effective to improve the knowledge and compliance to insulin therapy.

AKNOWLEDGEMENT:

“In every walk of our life we need guidance”. I am deeply indebted and express heartfelt gratitude to my guide, Sr. Symphoria, Professor and HOD (Department Of Medical Surgical Nursing) for her valuable efforts and enthusiasm, which was a source of inspiration throughout the study.

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Received on 24.11.2015 Modified on 08.12.2015

Asian J. Nur. Edu. and Research.2016; 6(4): 464-470.

DOI: 10.5958/2349-2996.2016.00087.2