Abstract
Insulin therapy in diabetes mellitus imposes burdens including limited lifestyle flexibility, difficulty achieving glycemic targets, and dissatisfaction with delivery devices. This study aimed to assess insulin-treated patient experiences using the Insulin Treatment Satisfaction Questionnaire (ITSQ) and to identify key predictors impacting patient experiences. We conducted a cross-sectional survey of 220 insulin-treated adults at primary healthcare clinics across the West Bank, Palestine. The subscale scores were 68.8% ± 26.6% for regimen inconvenience, 68.3% ± 28.1% for lifestyle flexibility, 58.0% ± 18.7% for glycemic control, 62.2% ± 21.0% for delivery-device satisfaction, and 72.3% ± 16.5% overall ITSQ score. Multiple linear regression was used to explore associations between ITSQ domains and candidate predictors. Delivery-device satisfaction was independently lower among female patients (β = − 0.18, p = 0.007) and in those with type 2 diabetes (vs. type 1; β = − 0.14, p = 0.037). Overall ITSQ total scores were on average 11.0% higher in diet-adherent patients (β = 0.31, p < 0.001). Insulin-treated patients reported suboptimal satisfaction influenced predominantly by diabetes type, dietary adherence, and delivery mode, underscoring the need for targeted interventions such as flexible meal planning, expanded pen access, and enhanced adherence support to improve experiences and reduce complications, warranting further research.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-025-15564-x.
Keywords: Diabetes mellitus, Delivery systems, Insulin, Quality of life, Satisfaction, Patient experience
Subject terms: Endocrinology, Medical research
Introduction
Diabetes mellitus is a chronic metabolic disorder characterized by persistent hyperglycemia resulting from defects in insulin secretion, insulin action, or both1,2. In 2019, over 488 million adults (aged 20–99 years) worldwide were living with diabetes mellitus3. According to the Palestinian Ministry of Health, over 270,456 individuals in Palestine are affected by the disease4. Diabetes mellitus is a leading cause of morbidity and mortality globally, responsible for approximately 4.2 million deaths annually among adults aged 20–79 years5.
Diabetes mellitus is managed by a combination of pharmacological and nonpharmacological approaches6,7. Among pharmacotherapies, insulin remains the cornerstone of treatment for all patients with type 1 diabetes and for approximately one-third of those with type 2 diabetes mellitus8. Since its discovery in 1921, insulin has been essential to achieving glycemic control. Most insulin regimens require patients to self-administer individualized doses daily, and this self-administration must be accompanied by dietary restrictions and exercise, which are integral to optimal glycemic control9. Inconvenience, lifestyle flexibility, glycemic control, and overall satisfaction with insulin therapy are all intertwined in patients’ real-world experiences. Injection-site pain, needle anxiety, complex multi-daily dosing schedules, refrigeration and sharps-disposal requirements each add to the regimen’s inconvenience. These demands also erode lifestyle flexibility, forcing patients to rigidly plan meals, exercise, and social activities around their injections9. Fear of hypoglycemia—both daytime and nocturnal—along with frequent glucose monitoring, further undermines confidence in glycemic control. Together, these burdens feed into lower overall treatment satisfaction, amplified by the emotional distress and social stigma of administering insulin in public. Consequently, insulin-treated patients often report poorer satisfaction than those managed with oral agents or lifestyle modification alone10.
It has been argued that patients who perceive their individualized therapeutic regimens as less burdensome and easy to integrate into the daily life activities would report higher satisfaction, adherence to therapy, and are more likely to achieve optimal glycemic control and reduce the short- and long-term complications of diabetes mellitus11–14. On the other hand, patients who perceive their therapeutic regimens as burdensome are more likely to report poor self-management. Poor adherence to the recommended treatment would lead to serious and disabling complications of diabetes mellitus15–17.
Today, advances in insulin formulation have yielded analogues with diverse pharmacokinetic profiles—rapid-, short-, intermediate-, mixed-, and long-acting—allowing precise tailoring of glycemic management18,19. Furthermore, these preparations can be administered via multiple delivery systems, including traditional syringes, insulin pens, and continuous subcutaneous insulin pumps18. Each delivery modality offers distinct advantages—for example, enhanced dosing accuracy and portability with pens or steady basal infusion with pumps—but also carries challenges, such as increased device cost, technical complexity, need for patient training, and potential for mechanical failure. In eight European countries (Belgium, France, Germany, Ireland, Italy, Sweden, the Netherlands and the UK), patients were more satisfied with insulin therapy when they received structured diabetes education, had macrovascular complications, and better self-rated their health status10. In contrast, lower satisfaction correlated with more frequent perceived hyperglycemia and higher glycated hemoglobin. In Jordan, a large cross-sectional study of 1002 adults with diabetes reported that higher treatment satisfaction and well-being were predicted by male sex, older age, adherence to dietary recommendations, good glycemic control, absence of neuropathy, and use of insulin therapy20. Another study evaluated proper insulin injection techniques and their relationship to glycemic control21. The study reported that lipohypertrophy affected more than 55% of the patients who used insulin.
Previous studies in the Middle East have overlooked critical aspects of the insulin experience that directly impact patients’ daily lives—specifically, the inconvenience of complex regimens, restrictions on lifestyle flexibility, challenges in achieving consistent glycemic control, and overall treatment satisfaction. None employed an insulin-specific satisfaction instrument capable of dissecting these domains12,20–22. The interplay of these burdens and facilitators—and their influence on adherence and satisfaction—among Palestinian adults with type 1 and type 2 diabetes remains unexplored. To address this gap, we conducted a cross-sectional study in Palestine using the 22-item Insulin Treatment Satisfaction Questionnaire (ITSQ) alongside validated adherence measures to quantify perceived regimen inconvenience, impacts on lifestyle flexibility, confidence in glycemic control, and overall satisfaction with insulin therapy. We then analyzed how sociodemographic, clinical, and therapy-related variables correlate with these four key domains. By capturing patients’ perceptions and preferences across inconvenience, flexibility, glycemic control, and satisfaction, our findings aim to inform targeted interventions and policy initiatives that reduce treatment burden, optimize device selection, strengthen glycemic outcomes, and improve the overall insulin-therapy experience in resource-limited settings.
Methods
Study design and settings
This cross-sectional study was carried out from November 2022 to February 2023 at primary healthcare clinics in Nablus, Jenin, Tukaram, and Qalqilya in the West Bank, Palestine. Trained field researchers approached eligible insulin-treated patients during their routine visits, obtained written informed consent, and then administered a structured questionnaire to assess their perceived regimen inconvenience, impacts on lifestyle flexibility, confidence in glycemic control, and overall satisfaction with insulin therapy.
Study population, sample size, inclusion, and exclusion criteria
The study enrolled adults (≥ 18 years) with a confirmed diagnosis of type 1 or type 2 diabetes mellitus who had been on insulin therapy for at least six months and were able to read, write, and provide informed consent. We calculated a target sample size of 385 using Raosoft’s online calculator (www.raosoft.com), which implements Daniel’s formula for prevalence studies at a 95% confidence level, 5% margin of error, and 50% response distribution.
We deliberately included patients both with and without diabetic complications to reflect the real-world spectrum of insulin users in Palestine. Those excluded were individuals who could not read or write in Arabic, had active psychiatric illnesses that would compromise reliable questionnaire responses, or declined to provide written consent.
Study tool, validity, and reliability
We used a structured questionnaire to collect patients’ sociodemographic details (age, sex, weight, height, place of residence, exercise and dietary habits) alongside clinical variables (diabetes type, time since diagnosis, use of antidiabetic and other chronic medications, insulin delivery mode, duration of insulin therapy, and usual glycosylated hemoglobin [HbA1c] level). The instrument also incorporated the 22-item Insulin Treatment Satisfaction Questionnaire (ITSQ)11.
Patients were asked to reflect on their insulin treatment experiences over the previous four weeks, taking into account all insulin types, dosing regimens, and administration schedules. Through 22 items, the ITSQ prompts insulin users to describe how their therapy affects daily life and to share their perceptions of its burden.
For each item, patients rated the degree of burden or interference on a five-point Likert scale (1 = no burden/interference; 5 = extreme burden/tremendous interference). The ITSQ covers four domains: regimen inconvenience, lifestyle flexibility, glycemic control, and delivery-device satisfaction. The questionnaire is provided as Supplementary Table S1.
To establish face validity, the draft questionnaire was reviewed by a panel of five physicians and researchers. Each panelist evaluated the clarity, relevance, and suitability of every item using a 5-point Likert scale (1 = not relevant; 5 = highly relevant).
To ensure reliability and clarity before the main survey, we conducted a pilot study with 20 insulin-treated patients (distinct from the primary sample). Each participant completed the full ITSQ twice, one week apart. Test–retest reliability was evaluated by calculating Pearson’s correlation coefficient between time-1 and time-2 total scores (r = 0.93), indicating excellent score stability. Internal consistency was assessed on the first-round responses using Cronbach’s alpha, yielding α = 0.79 for the 22 items—demonstrating good item relatedness.
Data collection
The questionnaire was administered in person during face-to-face interviews. Two final-year medical students—each trained in proper patient-interviewing techniques—conducted all interviews.
Statistical analysis
The data were entered into IBM SPSS for Windows v.22.0. Descriptive statistics are presented as mean ± standard deviation (SD) or frequency (n) and percentage, as appropriate. Normality of distribution was ensured by skewness values between − 2.0 and + 2.0 and kurtosis values between − 7.0 and + 7.0.
Bivariate comparisons between patient subgroups (e.g., age, sex, residence) and ITSQ subscale scores (inconvenience, lifestyle flexibility, glycemic control, device satisfaction) or total ITSQ score were conducted with independent-samples t‐tests.
To control potentially confounding variables and to identify significant predictors for each ITSQ domain and for the overall ITSQ total score, we constructed a separate multiple linear regression model. In each model, the dependent variable was the ITSQ subscale or total score (continuous, expressed as percentage). Each model included the candidate independent variables included, age, sex, place of residence, body mass index, adherence to diet, exercise status, exercising ≥ 150 min/week, type of diabetes, duration of diabetes, use of other antidiabetic medications, use of other chronic medications, and insulin delivery mode. We entered all candidate predictors into an initial “enter” model, then applied backward elimination (remove p > 0.10) to arrive at a final parsimonious model for each outcome. Multicollinearity was assessed using variance inflation factors (VIF < 5 and tolerance > 0.2 indicating acceptable collinearity). The final models had adjusted R² of > 0.4 and F-statistic values with a p < 0.05. This indicated that the models could explain more than 40% of the variance. All statistical tests were two-tailed, and significance was set at α = 0.05.
Ethical approval
The study adhered to the local and international ethical principles of scientific and medical research involving human subjects, including those in the Helsinki Declaration. All methods were performed in accordance with the relevant guidelines and regulations. The study was approved by the Institutional Review Board (IRB) of An-Najah National University and the Office of Health Education of the Palestinian Ministry of Health. All patients provided written informed consent.
Results
Demographic variables of the participants
Of the 385 patients with diabetes mellitus who were invited to this study, 227 met the inclusion criteria and completed the questionnaire, giving a response rate of (59.0%). Of the patients, 145 (63.9%) were 40 years and older, 117 (51.5%) were male, 138 (60.8%) resided in rural areas, 148 (65.2%) were overweight or obese, 155 (68.3%) were adherents to recommended diet, 50 (22.0%) exercised for at least 150 min per week, 143 (63.0%) had type 2 diabetes mellitus, 119 (52.4%) were diagnosed with diabetes mellitus for 12 or more years, 129 (56.8%) used other antidiabetic medications, 134 (59.0%) were on other chronic medications, 115 (50.7%) used insulin injections/vials, and 120 (52.9%) used insulin for 7 or more years. The detailed sociodemographic and disease characteristics of the patients are shown in Table 1.
Table 1.
Sociodemographic and disease characteristics of the patients.
| Variable | n (%) |
|---|---|
| Age (years), ≥ 40 | 145 (63.9) |
| Sex, male | 117 (51.5) |
| Place of residence, rural | 138 (60.8) |
| Body mass index, overweight/obese | 148 (65.2) |
| Adherence to recommended diet, yes | 72 (31.7) |
| Exercising for at least 150 min per week, yes | 50 (22.0) |
| Type of diabetes, type 2 | 143 (63.0) |
| Time elapsed since diagnosis with diabetes mellitus (years), ≥ 12 | 119 (52.4) |
| Other anti-diabetic medications, yes | 129 (56.8) |
| Other chronic medications, yes | 134 (59.0) |
| Insulin delivery, pen | 112 (49.3) |
| Time elapsed since using insulin (years), ≥ 7 | 120 (52.9) |
Responses of the patients on the ITSQ items
Table 2 presents patient responses to the 22 ITSQ items, grouped into four domains with mean subscale scores of 68.8% ± 26.6% for regimen inconvenience, 68.3% ± 28.1% for lifestyle flexibility, 58.0% ± 18.7% for glycemic control, and 62.2% ± 21.0% for delivery-device satisfaction (overall ITSQ = 72.3% ± 16.5%). In the regimen‐inconvenience domain, 97 (42.7%) patients rated taking all daily insulin doses as an “extreme burden,” 123 (54.2%) reported “tremendous interference” with social or leisure activities, and 113 (49.8%) indicated “tremendous interference” with work or school obligations. Within lifestyle flexibility, the greatest constraint was planning physical activities around insulin, with 119 (52.4%) of participants responding “extremely,” while 89 (39.2%) “extremely” had to schedule meal timing and 84 (37.0%) “extremely” planned food choices to fit their regimen. The glycemic‐control domain scored lowest overall: although 109 (48.0%) felt “extremely confident” avoiding severe hypoglycemia, only 34 (15.0%) were “extremely pleased” with their overall blood‐sugar control and 66 (29.1%) were “extremely worried” about nocturnal hypoglycemia. Finally, in delivery‐device satisfaction, 131 (57.7%) found dosing “extremely easy,” 134 (59.0%) experienced “no pain or discomfort,” and 114 (50.2%) reported “no emotional distress” when injecting insulin.
Table 2.
Responses of the patients on the ITSQ items.
| # | Item | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | n (%) | ||
| Inconvenience of regimen (score = 68.8% ± 26.6%) | ||||||
| 1 | How much of a bother is it for you to take all your daily insulin doses as prescribed? | 25 (11.0) | 30 (13.2) | 29 (12.8) | 46 (20.3) | 97 (42.7) |
| 2 | How much does your current insulin treatment interfere with your ability to enjoy social or leisure activities? | 20 (8.8) | 27 (11.9) | 31 (13.7) | 26 (11.5) | 123 (54.2) |
| 3 | How much does your current insulin treatment interfere with your work or school activities? (If you do not work or attend school) | 26 (11.5) | 24 (10.6) | 31 (13.7) | 33 (14.5) | 113 (49.8) |
| 4 | In general, how stressful is it for you to manage your current insulin treatment? | 25 (11.0) | 23 (10.1) | 38 (16.7) | 61 (26.9) | 80 (35.2) |
| 5 | How burdensome is it for you to manage your current insulin treatment? | 20 (8.8) | 20 (8.8) | 46 (20.3) | 65 (28.6) | 76 (33.5) |
| Lifestyle flexibility (score = 68.3% ± 28.1%) | ||||||
| 6 | How much do you have to plan the timing of your meals or snacks around the insulin you currently use? | 29 (12.8) | 28 (12.3) | 37 (16.3) | 44 (19.4) | 89 (39.2) |
| 7 | How much do you have to plan what you eat with your current insulin treatment? | 33 (14.5) | 26 (11.5) | 45 (19.8) | 39 (17.2) | 84 (37.0) |
| 8 | How much do you have to plan your physical activities (such as exercise or strenuous household chores) around your current insulin treatment? | 12 (5.3) | 14 (6.2) | 34 (15.0) | 48 (21.1) | 119 (52.4) |
| Glycemic control (score = 58.0% ± 18.7%) | ||||||
| 9 | How confident are you that you can avoid symptoms of low blood sugar (such as sweating, trembling, dizziness, blurred vision) with your current insulin treatment? | 21 (9.3) | 29 (12.8) | 35 (15.4) | 53 (23.3) | 89 (39.2) |
| 10 | How confident are you that you can avoid severe episodes of low blood sugar that result in loss of consciousness (fainting or passing out) with the insulin you currently use? | 20 (8.8) | 15 (6.6) | 38 (16.7) | 45 (19.8) | 109 (48.0) |
| 11 | In general, how bothered are you by symptoms of low blood sugar (such as sweating, trembling, dizziness, blurred vision) with the insulin you currently use? | 80 (35.2) | 40 (17.6) | 38 (16.7) | 24 (10.6) | 45 (19.8) |
| 12 | How much do you feel that the insulin you are currently using increases the chances that you will experience low blood sugar? | 32 (14.1) | 29 (12.8) | 38 (16.7) | 41 (18.1) | 87 (38.3) |
| 13 | How worried are you about experiencing low blood sugar during the night with the insulin you currently use? | 53 (23.3) | 42 (18.5) | 31 (13.7) | 35 (15.4) | 66 (29.1) |
| 14 | How confident are you that you can avoid symptoms of high blood sugar (such as dry mouth, thirst, frequent urination, fatigue, increased appetite) with your current insulin treatment? | 23 (10.1) | 23 (10.1) | 51 (22.5) | 38 (16.7) | 92 (40.5) |
| 15 | How satisfied are you with the stability of your blood sugar levels with your current insulin treatment? | 49 (21.6) | 31 (13.7) | 46 (20.3) | 53 (23.3) | 48 (21.1) |
| 16 | Overall, how pleased are you with the blood sugar control you achieve with your current insulin treatment? | 54 (23.8) | 34 (15.0) | 46 (20.3) | 59 (26.0) | 34 (15.0) |
| Insulin delivery device satisfaction (score = 62.2% ± 21.0%) | ||||||
| 17 | How easy is it for you to take the correct amount of insulin each time with your current method of taking insulin? | 14 (6.2) | 15 (6.6) | 38 (16.7) | 29 (12.8) | 131 (57.7) |
| 18 | How convenient is your current method of taking insulin when you are away from home? | 77 (33.9) | 28 (12.3) | 38 (16.7) | 30 (13.2) | 54 (23.8) |
| 19 | How much pain or other physical discomfort do you experience with your current method of taking insulin? | 15 (6.6) | 18 (7.9) | 29 (12.8) | 31 (13.7) | 134 (59.0) |
| 20 | How comfortable are you taking insulin in a public place (where people might see you) with your current method of taking insulin? | 87 (38.3) | 48 (21.1) | 21 (9.3) | 19 (8.4) | 52 (22.9) |
| 21 | How much emotional distress or anxiety do you experience from your method of taking insulin? | 11 (4.8) | 23 (10.1) | 40 (17.6) | 39 (17.2) | 114 (50.2) |
| 22 | Overall, how satisfied are you with your current method of taking insulin? | 37 (16.3) | 36 (15.9) | 37 (16.3) | 40 (17.6) | 77 (33.9) |
| ITSQ (score = 72.3% ± 16.5%) | ||||||
Association between the sociodemographic and disease variables of the patients with inconvenience, lifestyle flexibility, glycemic control, satisfaction with insulin delivery device, and overall ITSQ total score
As assessed by independent-samples t‐tests, patients aged ≥ 40 years reported greater lifestyle inflexibility (71.4% ± 26.7% vs. 62.9% ± 29.7%, p = 0.029) while those < 40 years achieved higher glycemic‐control scores (61.7% ± 16.7% vs. 55.9% ± 19.4%, p = 0.023). Urban residents outperformed rural patients on glycemic control (63.1% ± 15.5% vs. 54.7% ± 19.9%, p = 0.001) but reported fewer lifestyle constraints (63.4% ± 28.1% vs. 71.5% ± 27.7%, p = 0.033). Non‐adherence to dietary recommendations was linked to markedly higher inflexibility (79.4% ± 22.0% vs. 44.6% ± 24.9%, p < 0.001) and higher overall ITSQ total scores (75.4% ± 14.7% vs. 65.6% ± 18.0%, p < 0.001). Patients exercising < 150 min/week also reported significantly greater lifestyle inflexibility (74.0% ± 24.8% vs. 48.3% ± 29.9%, p < 0.001). Type 2 diabetes and use of other chronic medications were both associated with higher inflexibility (72.3% ± 26.6% vs. 61.5% ± 29.3% in type 1, p = 0.005) and 72.3% ± 25.6% vs. 62.6% ± 30.5% in non‐users of other drugs, p = 0.011). Injection/vial users experienced more inflexibility than pen users (77.5% ± 24.3% vs. 58.9% ± 28.6%, p < 0.001). Participants not using other antidiabetic drugs had superior glycemic‐control scores (61.4% ± 16.7% vs. 55.5% ± 19.7%, p = 0.018). Finally, delivery‐device satisfaction was higher among males (65.7% ± 20.1% vs. 58.3% ± 21.5% in females, p = 0.008) and patients with type 1 diabetes (65.9% ± 19.4% vs. 60.0% ± 21.7% in type 2, p = 0.041). Differences in inconvenience, lifestyle flexibility, glycemic control, satisfaction with insulin delivery device, and ITSQ total scores are shown in Table 3.
Table 3.
Differences in inconvenience, lifestyle flexibility, glycemic control, satisfaction with insulin delivery device, and ITSQ total score.
| Variable | N | % | Inconvenience of regimen (%) | Lifestyle flexibility (%) | Glycemic control (%) | ||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | p | Mean | SD | p | Mean | |||
| Age (years) | |||||||||
| < 40 | 82 | 36.1 | 72.1 | 25.3 | 0.155 | 62.9 | 29.7 | 0.029 | 61.7 |
| ≥ 40 | 145 | 63.9 | 66.9 | 27.2 | 71.4 | 26.7 | 55.9 | ||
| Sex | |||||||||
| Male | 117 | 51.5 | 69.3 | 28.3 | 0.778 | 68.7 | 29.9 | 0.850 | 58.7 |
| Female | 110 | 48.5 | 68.3 | 24.8 | 68.0 | 26.2 | 57.2 | ||
| Place of residence | |||||||||
| Urban | 89 | 39.2 | 72.1 | 23.5 | 0.135 | 63.4 | 28.1 | 0.033 | 63.1 |
| Rural | 138 | 60.8 | 66.7 | 28.3 | 71.5 | 27.7 | 54.7 | ||
| Body mass index | |||||||||
| Normal weight | 79 | 34.8 | 72.0 | 26.1 | 0.190 | 66.0 | 30.3 | 0.371 | 61.0 |
| Overweight/obese | 148 | 65.2 | 67.1 | 26.9 | 69.5 | 26.8 | 56.4 | ||
| Adherence to recommended diet | |||||||||
| Yes | 72 | 31.7 | 67.8 | 26.9 | 0.717 | 44.6 | 24.9 | < 0.001 | 58.7 |
| No | 155 | 68.3 | 69.2 | 26.6 | 79.4 | 22.0 | 57.7 | ||
| Exercising for at least 150 min per week | |||||||||
| No | 177 | 78.0 | 67.8 | 26.6 | 0.278 | 74.0 | 24.8 | < 0.001 | 57.0 |
| Yes | 50 | 22.0 | 72.4 | 26.5 | 48.3 | 29.9 | 61.6 | ||
| Type of diabetes | |||||||||
| Type 1 | 84 | 37.0 | 71.0 | 25.6 | 0.349 | 61.5 | 29.3 | 0.005 | 60.9 |
| Type 2 | 143 | 63.0 | 67.5 | 27.2 | 72.3 | 26.6 | 56.3 | ||
| Time elapsed since diagnosis with diabetes mellitus (years) | |||||||||
| < 12 | 108 | 47.6 | 68.2 | 26.9 | 0.750 | 65.2 | 28.6 | 0.111 | 58.0 |
| ≥ 12 | 119 | 52.4 | 69.3 | 26.5 | 71.1 | 27.4 | 58.0 | ||
| Other anti-diabetic medications | |||||||||
| Yes | 129 | 56.8 | 66.6 | 26.9 | 0.154 | 71.3 | 27.3 | 0.071 | 55.5 |
| No | 98 | 43.2 | 71.7 | 26.1 | 64.5 | 28.7 | 61.4 | ||
| Other chronic medications | |||||||||
| Yes | 134 | 59.0 | 67.2 | 27.4 | 0.271 | 72.3 | 25.6 | 0.011 | 55.6 |
| No | 93 | 41.0 | 71.1 | 25.4 | 62.6 | 30.5 | 61.5 | ||
| Insulin delivery | |||||||||
| Injection/vial | 115 | 50.7 | 68.3 | 27.3 | 0.782 | 77.5 | 24.3 | < 0.001 | 57.1 |
| Pen | 112 | 49.3 | 69.3 | 26.0 | 58.9 | 28.6 | 59.0 | ||
| Time elapsed since using insulin (years) | |||||||||
| < 7 | 107 | 47.1 | 67.3 | 27.1 | 0.439 | 67.7 | 27.1 | 0.747 | 58.2 |
| ≥ 7 | 120 | 52.9 | 70.1 | 26.2 | 68.9 | 29.0 | 57.8 | ||
| Glycemic control (%) | Insulin delivery device satisfaction (%) | ITSQ total (%) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Variable | SD | p | Mean | SD | p | Mean | SD | p | |
| Age (years) | |||||||||
| < 40 | 16.7 | 0.023 | 65.5 | 19.6 | 0.072 | 73.9 | 13.8 | 0.285 | |
| ≥ 40 | 19.4 | 60.3 | 21.7 | 71.4 | 17.8 | ||||
| Sex | |||||||||
| Male | 18.7 | 0.557 | 65.7 | 20.1 | 0.008 | 73.7 | 17.4 | 0.174 | |
| Female | 18.7 | 58.3 | 21.5 | 70.8 | 15.4 | ||||
| Place of residence | |||||||||
| Urban | 15.5 | 0.001 | 63.9 | 19.2 | 0.315 | 74.0 | 15.4 | 0.202 | |
| Rural | 19.9 | 61.0 | 22.2 | 71.2 | 17.0 | ||||
| Body mass index | |||||||||
| Normal weight | 18.4 | 0.073 | 64.5 | 16.9 | 0.219 | 74.2 | 14.3 | 0.218 | |
| Overweight/obese | 18.7 | 60.9 | 22.9 | 71.3 | 17.5 | ||||
| Adherence to recommended diet | |||||||||
| Yes | 19.8 | 0.709 | 61.3 | 23.5 | 0.673 | 65.6 | 18.0 | < 0.001 | |
| No | 18.2 | 62.6 | 19.9 | 75.4 | 14.7 | ||||
| Exercising for at least 150 min per week | |||||||||
| No | 19.3 | 0.127 | 61.5 | 21.4 | 0.390 | 73.1 | 16.7 | 0.187 | |
| Yes | 16.0 | 64.4 | 19.8 | 69.6 | 15.6 | ||||
| Type of diabetes | |||||||||
| Type 1 | 17.9 | 0.077 | 65.9 | 19.4 | 0.041 | 73.0 | 14.0 | 0.629 | |
| Type 2 | 19.0 | 60.0 | 21.7 | 71.9 | 17.8 | ||||
| Time elapsed since diagnosis with diabetes mellitus (years) | |||||||||
| < 12 | 19.2 | 0.990 | 60.8 | 20.2 | 0.373 | 71.0 | 16.9 | 0.244 | |
| ≥ 12 | 18.3 | 63.3 | 21.8 | 73.5 | 16.0 | ||||
| Other anti-diabetic medications | |||||||||
| Yes | 19.7 | 0.018 | 60.4 | 21.7 | 0.143 | 71.2 | 17.6 | 0.243 | |
| No | 16.7 | 64.5 | 20.0 | 73.8 | 14.8 | ||||
| Other chronic medications | |||||||||
| Yes | 19.9 | 0.018 | 60.9 | 21.0 | 0.289 | 71.8 | 16.4 | 0.568 | |
| No | 16.3 | 63.9 | 21.1 | 73.1 | 16.6 | ||||
| Insulin delivery | |||||||||
| Injection/vial | 18.9 | 0.447 | 61.2 | 22.5 | 0.489 | 74.1 | 17.3 | 0.098 | |
| Pen | 18.5 | 63.1 | 19.4 | 70.5 | 15.4 | ||||
| Time elapsed since using insulin (years) | |||||||||
| < 7 | 18.9 | 0.874 | 60.2 | 21.9 | 0.197 | 71.4 | 16.9 | 0.413 | |
| ≥ 7 | 18.6 | 63.9 | 20.2 | 73.2 | 16.0 | ||||
p: p-value, all associations were assessed by independent-samples t‐tests, statistically significant values are in boldface, SD: standard deviation.
Significance values are in bold.
In the fully adjusted models (Table 4), adherence to a recommended diet emerged as the strongest independent predictor of lifestyle flexibility, with diet-adherent patients scoring 29.2% points higher on the inflexibility scale than non-adherent patients (β = 0.48, p < 0.001), whereas meeting the exercise target (≥ 150 min/week) and using an insulin pen (vs. vial) were both associated with significantly lower inflexibility scores (exercise: β = − 0.18, p = 0.001; pen use: β = − 0.16, p = 0.004). For the glycemic-control domain, rural residence predicted an 8.0% decrease in satisfaction compared to urban patients (β = − 0.21, p = 0.001), while use of non-diabetic chronic medications conferred a 5.5% increase (β = 0.14, t = 2.23, p = 0.027). Delivery-device satisfaction was independently lower among female patients (β = − 0.18, p = 0.007) and in those with type 2 diabetes (vs. type 1; β = − 0.14, p = 0.037). Finally, overall ITSQ total scores were on average 11.0% higher in diet-adherent patients (β = 0.31, p < 0.001), with nonsignificant trends toward higher total satisfaction in those with longer diabetes duration (β = 0.12, t = 1.80, p = 0.073) and users of other chronic medications (β = 0.13, p = 0.052), whereas rural residence predicted a 4.2% lower overall score (β = − 0.13, p = 0.051). All predictors demonstrated acceptable collinearity.
Table 4.
Factors predicting lifestyle flexibility, glycemic control, satisfaction with insulin delivery device, and ITSQ total scores.
| Predictor | Unstandardized coefficients | Standardized coefficients | Collinearity statistics | ||||
|---|---|---|---|---|---|---|---|
| B | SE | β | t | p | Tolerance | VIF | |
| Lifestyle flexibility score | |||||||
| Adherence to recommended diet | 29.2 | 3.3 | 0.5 | 8.8 | < 0.001 | 0.9 | 1.1 |
| Exercising for at least 150 min per week | −12.5 | 3.8 | −0.2 | −3.3 | 0.001 | 0.9 | 1.2 |
| Insulin delivery | −9.0 | 3.1 | −0.2 | −2.9 | 0.004 | 0.9 | 1.1 |
| Glycemic control score | |||||||
| Place of residence | −8.0 | 2.5 | −0.2 | −3.3 | 0.001 | 1.0 | 1.0 |
| Other chronic medications | 5.5 | 2.5 | 0.1 | 2.2 | 0.027 | 1.0 | 1.0 |
| Insulin delivery device satisfaction score | |||||||
| Sex | −7.4 | 2.7 | −0.2 | −2.7 | 0.007 | 1.0 | 1.0 |
| Type of diabetes | −5.9 | 2.8 | −0.1 | −2.1 | 0.037 | 1.0 | 1.0 |
| ITSQ overall score | |||||||
| Place of residence | −4.2 | 2.2 | −0.1 | −2.0 | 0.051 | 1.0 | 1.0 |
| Adherence to recommended diet | 11.0 | 2.3 | 0.3 | 4.8 | < 0.001 | 0.9 | 1.1 |
| Time elapsed since diagnosis with diabetes | 4.0 | 2.2 | 0.1 | 1.8 | 0.073 | 0.9 | 1.1 |
| Other chronic medications | 4.5 | 2.3 | 0.1 | 2.0 | 0.052 | 0.9 | 1.2 |
p: p-value, SE: standard error, t: t-statistic, VIF: variance inflation factor.
Significance values are in bold.
Discussion
Recently, attention has shifted toward enhancing the real-world experiences of patients using therapeutic options23,24. In this study, we set out to evaluate, for the first time in Palestine, four key domains of insulin-therapy experience—perceived regimen inconvenience, lifestyle flexibility, confidence in glycemic control, and overall treatment satisfaction—and to identify the sociodemographic, clinical, and therapy-related factors that shape them. Our most striking findings were that adherence to a recommended diet emerged as the strongest predictor of both regimen flexibility and overall satisfaction; that regular exercise (≥ 150 min per week) and use of modern insulin pens significantly reduced perceived treatment burden; and that rural residence, female sex, and type 2 diabetes each independently influenced satisfaction in specific domains. These insights will be particularly valuable to diabetologists, endocrinologists, internists, family physicians, diabetes educators, and health-policy makers seeking to tailor patient-centered interventions and device choices in resource-limited settings.
In this study, lifestyle flexibility among insulin-treated patients was profoundly influenced by adherence to recommended dietary regimens. Patients mandated to adhere to fixed carbohydrate proportions described increased treatment burden, mirroring previous findings that who reported similar associations between strict meal plans and reduced perceived regimen freedom16,20. Conversely, engagement in regular moderate‐to‐vigorous physical activity and preference for pen devices emerged as facilitators of regimen integration, consistent with what was previously reported that both exercise and user‐friendly delivery formats enhance daily insulin management7,10,25. These results underscore the need for flexible nutrition planning and broader access to pen devices to mitigate the lifestyle constraints inherent to insulin therapy.
Rural residence was consistently associated with lower confidence in glycemic control, reinforcing urban–rural disparities documented in diverse settings such as the United States and Mexico26,27. Surprisingly, regular use of multiple non-diabetic medications, correlated with increased self‐efficacy in insulin handling—a phenomenon hinted at in preliminary analyses, but not extensively explored in earlier work17. Notably, traditional risk factors such as age and body mass index lost significance in multivariable models, diverging from previous observations linking older age and obesity to diminished glycemic confidence28–30. This suggests that structured support and education may attenuate the impact of individual demographic and clinical characteristics on perceived control.
Delivery-device satisfaction varied significantly by sex and diabetes type, with women and individuals with type 2 diabetes reporting lower satisfaction levels. These findings align with literature describing greater needle-related anxiety among females and deeper device familiarity and satisfaction among type 1 patients, who often initiate insulin therapy earlier and receive more prolonged device training9,31,32. The sex-based disparity in device comfort highlights the need for targeted interventions—such as anxiety-reduction workshops and tailored device demonstrations—to improve acceptance and adherence.
Overall ITSQ scores were predominantly driven by dietary adherence and cumulative experience with diabetes management, while rural patients continued to report lower composite satisfaction. This pattern underscores the multifactorial nature of insulin-therapy experience, wherein individual behaviors, such as consistent meal-plan adherence, interact with contextual factors, including geographic access to diabetes resources, to shape overall satisfaction33–35.
Our findings have important implications for clinical practice and health-system design. Clinicians should prioritize co-creating flexible meal plans that accommodate patient preferences and lifestyles, integrate prescribed physical activity into routine care, and expand access to pen and smart-pen devices36. Telehealth platforms, mobile clinics, and community-health workers can play pivotal roles in bridging urban–rural gaps, delivering tailored education, and reinforcing self-management strategies37. Sex-sensitive interventions that address injection anxiety and individualized device consultations for type 2 patients can further enhance satisfaction and adherence32.
Future research should evaluate the efficacy of multifaceted “flexibility-enhancement” programs combining continuous glucose monitoring, adaptive nutrition guidance, and customizable device selection in randomized settings. Comparative trials of delivery technologies across sex and diabetes type cohorts will elucidate optimal device characteristics, while implementation-science studies in resource-limited contexts can assess the scalability and impact of integrated care packages on both patient-reported outcomes and clinical endpoints such as HbA₁c and complication rates.
Strengths and limitations of the study
This study offers several notable strengths. First, it is the first investigation of insulin-treatment experiences and its patient‐level correlates among adults with diabetes in Palestine, thereby filling a critical gap in regional diabetes care research. By identifying the demographic, behavioral, and contextual factors that shape treatment experiences, we provide a foundational reference for future work on patient‐centered outcomes in similar low‐resource settings. Second, we employed the ITSQ, an instrument rigorously developed, validated, and applied across diverse diabetic. Leveraging this established tool not only ensures comparability with international studies but also contributes new evidence for its cross-cultural applicability and validity within Palestinian—and more broadly, developing-country—healthcare systems. Beyond its novelty and choice of instrument, the study’s methodological rigor further strengthens its conclusions. We conducted a pilot test–retest assessment, demonstrating that ITSQ scores remained stable over a short retest interval, and calculated Cronbach’s alpha coefficients that confirmed high internal consistency across all domains. These psychometric reassessments attest to the tool’s reliability in our cohort. Finally, our recruitment strategy captured a heterogeneous patient sample—balanced by sex, age bracket, urban versus rural residence, diabetes type, and concurrent medication use—mirroring the real-world diversity of insulin users in Palestine. Such representativeness enhances the external validity of our findings and supports their generalizability to comparable populations in resource-limited environments.
This study has some limitations that should be acknowledged. First, the overall sample size was modest, limiting the precision and statistical power of our subgroup analyses. In particular, individuals with type 1 diabetes comprised only a small fraction of participants—reflecting their 5–10% prevalence among all diabetes cases and the fact that most type 2 patients are not insulin-treated. Consequently, our ability to detect differences in treatment satisfaction between diabetes types and to generalize findings to larger, more heterogeneous cohorts is constrained. Second, all key variables were derived from patient self‐report, introducing the potential for recall bias and social‐desirability effects. Participants may have overestimated adherence or underreported challenges, which could artificially inflate satisfaction scores and obscure true associations between behaviors, device preferences, and lived experience. Third, the cross‐sectional design precludes any inference of causality or temporal change. We did not implement educational or behavioral interventions, nor did we track changes in perceptions over time. As a result, we cannot determine whether modifying dietary flexibility, exercise habits, or device selection would lead to sustained improvements in treatment satisfaction. Finally, although our inclusion of patients with microvascular and macrovascular complications enhanced external validity, we did not capture detailed information on the type or severity of these sequelae. Complication burden can profoundly shape regimen flexibility, perceived treatment burden, and overall satisfaction; our inability to stratify by complication status limits insight into how specific comorbidities influence insulin‐use experiences. Future longitudinal studies should prospectively document complication profiles and examine their independent effects on adherence metrics, patient‐reported outcomes, and clinical endpoints in insulin‐treated populations.
Conclusion
In conclusion, insulin-treated patients reported suboptimal satisfaction across lifestyle flexibility, glycemic control, delivery‐device and total ITSQ scores. Satisfaction varied by diabetes type, adherence to dietary recommendations, and use of modern delivery modes. Further studies are needed to develop interventions that enhance insulin‐user experiences and to determine whether improved satisfaction reduces short- and long-term diabetes complications.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
An-Najah National University is acknowledged for making this study possible.
Author contributions
Ramzi Shawahna, Hatim Hijaz, Iyad Maqboul, and Mohammad Jaber were involved in the conception and design of the work, analysis, and interpretation of data, and drafting and final approval of the manuscript. Subhi Abu Hamad and Mohamad Egbaria were involved in the data acquisition, analysis, drafting of the work, and final approval of the version to be published. All authors approved the final manuscript.
Funding
This study did not receive any specific funding.
Data availability
All data analyzed in this study were included in the manuscript. The datasets used in the analysis or entered into statistical software can be obtained from the corresponding author upon making a reasonable request.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate
The study adhered to the local and international ethical principles of scientific and medical research involving human subjects, including those in the Helsinki Declaration. All methods were performed in accordance with the relevant guidelines and regulations. The study was approved by the Institutional Review Board (IRB) of An-Najah National University and the Office of Health Education of the Palestinian Ministry of Health. All patients provided written informed consent.
Consent to publish
Not applicable.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data analyzed in this study were included in the manuscript. The datasets used in the analysis or entered into statistical software can be obtained from the corresponding author upon making a reasonable request.