Insulin injection practices among youngsters with diabetes in Tikur Anbesa Specialized Hospital, Ethiopia

Abstract

Purpose

The main aim of this study was to explore how participants were practicing insulin injections and assess its association with the insulin related-outcomes.

Methods

A hospital-based cross-sectional study was conducted among 176 youngsters with diabetes in Tikur Anbesa Specialized Hospital, Ethiopia. The inclusion criterion was the use of insulin treatment for a minimum of one year. Data about insulin injection practices was derived from participants’ report. Descriptive statistics was presented using frequency distributions and percentages for categorical variables while measure of central tendencies and dispersion for continuous variables. Chi-square test was employed to test for the association between compared variables.

Results

Participants were asked on how frequent they practice the appropriate insulin injecting practices. Based on that, eliminating air bubbles from a syringe, lifting skin fold during an injection, inserting a needle deep enough in the subcutaneous tissue, inspecting injection sites and self-monitoring of blood glucose were frequently done practices in more than 80% of the participants. Besides, over half of the participants reported that they frequently practice; insulin vial inspection, physical exercise, inject 1–3 cm apart from previous site, and insert a needle at 45⁰. Regarding insulin storage, more than half of them store opened insulin in the refrigerator, though it is advisable to store it at room temperature. Appropriate injection site rotation was reported by nearly one-third of the participants. Questions such as; gentle re-suspension of cloudy insulin, adjust insulin dose when necessary and change insulin syringe at every injection were reported by very few of the participants. Coming to glycemic control of our study subjects, 83% of them had HgbA1C of above 7.5% (non-optimal) and 31% reported at least one episode of hypoglycemia. Non-optimal glycemic control was explained by poor injection site hygiene (p < 0.038) and infrequent inspection of injection sites (p < 0.049).

Conclusion

Compared to previous studies, this study came with higher proportion of participants who frequently practice the appropriate insulin injection practices. However, it is still important to educate patients on some crucial injecting practices.

Background

Diabetes mellitus is a significant health problem worldwide [1]. It demands comprehensive therapy involving appropriate use of intensive insulin regimens, blood glucose monitoring, physical activity, body and device inspection and a healthy diet. The goals of these interventions are achieving better control of blood glucose and reducing complications [2, 3]. Since diabetes management involves self-injection of insulin, improper injection of insulin may result in poor glycemic control and insulin related adverse effects such as hypoglycemia, and injection-related skin problems. Therefore, patients must learn the correct insulin injection techniques to appropriately deliver the insulin into the subcutaneous tissues, to avoid intramuscular injections and to prevent complications [4].

Proper injection practices are essential for the optimal functioning of insulin in diabetes [5–7]. Be that as it may, a study by Connic et al. revealed that healthcare professionals rarely provide accurate and up-to-date instructions on proper insulin injection practices [5]. In addition, inappropriate usages of insulin and improper injection techniques have been reported by certain studies. Based on that, professionals were observed to rarely explain the importance of using an appropriate needle length for the patients’ subcutaneous tissue depth, proper rotation of injection sites, changing of needles between injections, storage of insulin and monitoring of their injection site for the presence of lipodystrophy. Rather the professionals gave due emphasis to the type and dose of insulin while little emphasis was given for insulin injection practices, [5, 7, 8].

Although evidence-based updates regarding insulin injection practices are emerging massively with time [9, 10], applying to clinical practices remains to be a tremendous challenge in developing countries. Besides, it is important to routinely educate patients about their disease and particularly about insulin-injection practices. Howbeit, it is not a default to get patients who merely have a single time education, at the very first of their treatment, about the disease and the drug in our region.

Studies aiming to explore insulin injection practice are timely and very critical, particularly for patients with inappropriate injection practice, which significantly affects their clinical outcome. As a result, patients would be advantageous as this study assess their injection practice and its effect on their clinical outcomes. Besides, research outputs from this study would be primarily beneficial to patients and prescribers for appropriate and efficient use of insulin. To the best of our knowledge, little is known about insulin injection practice in Ethiopia, in which the current study aimed to generate inferences for the study setting, Tikur Anbesa Specialized Hospital.

Methods

This was a cross-sectional study conducted at the diabetes center of Tikur Anbesa Specialized Hospital, Ethiopia. The diabetes center is supposed to provide a routine education about insulin injection practices for patients and/or their parents. Children and adolescent patients who were on insulin treatment for a minimum of one year and visited the center from April to July 2017 were enrolled in the study. However, patients who were using insulin treatment transiently such as decompensated patients with acute hyperglycemia and hospitalized patients with short-term insulin requirements were excluded from the study. A total of 176 patients were included in the study using a simple random sampling technique.

A self-constructed questionnaire was developed after reviewing literatures. It was adapted from materials prepared in the local language (Amharic) to educate patients regarding insulin injection practices, as well incorporating the recent article on Forum for Injection Technique (FIT) and a consensus for insulin injection technique from Association of Clinical Diabetologists-Italian Diabetes Healthcare Professionals (AMD-OSDI) [11, 12]. The questionnaire was not validated prior to the actual data collection; however, it was pretested in 10% of the total sample population and finally formulated as Likert scale (always, usually, sometimes, and never) rated questionnaire.

For data collection purpose, five nurses who had special training on diabetes and particularly regarding injection techniques were recruited. Medical records were employed as one source of data and participants were also given a self-administered questionnaire to report about their insulin injection practice.

In the present study, glycemic control was the main measure of outcome related to insulin. It included the level of glycated hemoglobin (HgbA1c %) and hypoglycemia. HgbA1c test was used as the most reliable form of diabetes monitoring assessment, providing a good indication of glycemic control over several months [13]. HgbA1c value ≤ 7.5% was normally accepted as an optimal level of control, whereas HgbA1c > 7.5% as non-optimal glycemic control in children less than 19 years [4, 13]. On the other hand, hypoglycemia was defined as the occurrence of one or more symptoms of hypoglycemia (such as poor concentration, irritability, palpitation, tiredness, sweating, strong hunger, dizziness, and tremor) and a confirmed self-monitoring blood glucose reading of less than or equal to 70 mg/dL [14].

Data was entered using Epi Data® version 3.1 and analyzed using SPSS® version 21. Frequency distributions and percentages were utilized to describe categorical variables whereas measure of central tendencies and dispersion were used to describe continuous variables. For categorical variables, comparisons between groups were performed using the chi-squared test. A p-value at or less than 0.05 was considered statistically significant.

Results

Sociodemographic characteristics

Of the 176 patients who were included in the final analysis, nearly equal number of males and females represented gender group giving 1:1.05 ratio. The average age of the subjects was about

11 years and ranged from 2 to 18 years. Over half of the participants were children (100, 56.8%). Subjects with a primary level of education comprised the highest proportion in the study (85, 48.3%). Details on demographic characteristics are found in Table 1

Table 1.

Socio-demographic characteristics of patients with type 1 diabetes (n=176)

Variable	Frequency	Percent
Sex
Male	86	48.9
Female	90	51.1
Age (years)
Children (1–12)	100	56.8
Adolescent (13–18)	76	43.2
Educational level
No schooling	2	1.1
Primary	85	48.3
Secondary	57	32.4
Higher	32	18.2
Person in charge of insulin injecting
Parents	99	56.3
Patients	77	43.8
Percentile adjusted BMI
Underweight	28	15.9
Healthy weight	130	73.9
Overweight	8	4.3
Obese	10	5.7

Duration of disease and insulin treatment

As shown in Table 2, nearly two-thirds (111, 63.1%) of the subjects were on insulin treatment for not more than five years. Nearly all (173, 98.3%) of the prescriptions contains both intermediate-acting and regular insulin in combination. Similarly, in all prescriptions insulin was prescribed to be injected two times per day. More than half (105, 59.7%) of the youngsters have been prescribed an insulin dose of above 0.7 units/kg. Insulin syringes needle size shorter than 8 mm was not available in the study setting.

Table 2.

Treatment-related characteristic of patients with type 1 diabetes (n=176)

Variable	Frequency	Percent
Insulin use duration (years)
≤ 5	111	63.1
> 5	65	36.9
Insulin type
Intermediate-acting insulin	3	1.7
Intermediate-acting insulin and regular	173	98.3
Daily insulin dose/kg
≤ 0.7 U/kg	71	40.3
> 0.7 U/kg	105	59.7
Insulin syringe type
Shanchuan	4	2.3
Dispovan	32	18.2
BD syringe	140	79.5

BD, Becton Dickinson

Insulin injecting practices

Participants were asked on how frequent they practice the appropriate insulin injecting practices. Based on that, nearly half (84, 47.7%) of the total participants had never clean their injection sites. Two-thirds (117, 66.5%) of the patients always inspect their insulin vials for any appearance change. A quite high proportion (145, 82.4%) of the participants reported that they always eliminate bubbles from the insulin syringe. Almost all (159, 90.3%) participants always inspect injection sites visually and palpate the skin for the presence of any abnormality. Nearly all the participants (164, 93%) have reported that they always lift the skin fold of the injection sites while administering insulin subcutaneously. Details about insulin injecting practices are depicted in Fig. 1. Regarding insulin storage practice, nearly half (95, 54%) of the participants storce opened insulin in refrigerator whereas majority (146, 83%) of them store unopened insulin in the refrigerator respectively (Fig. 2).

Fig. 1.

Insulin use practices

Fig. 2.

Insulin storage practices

In contrary to medical advice, 17.0% of the participants never re-suspend the cloudy insulin during injection time. Majority (154, 87.5%) of the participants reported that they measure and record blood sugar in most days of a week. Nearly two in three (112, 63.6%) of them reported that they perform physical exercises according to an order of healthcare providers. A few (15, 8.5%) participants reported that they adjust dose of insulin when necessary. Similarly, a few (33, 18.8%) participants were changing the needle of insulin syringe at every injection time. Near to one in three (54, 30.7%) of the participants move or rotate the injection site every week as recommended. About two-thirds (112, 63.6%) of the participants reported that they inject with 1-3 fingers apart from the previous injections. Details about the techniques of insulin injection are found in Table 3.

Table 3.

Insulin injection practices among study participants (n=176)

Parameter	n (%)
Rolling/tilting of cloudy insulin
No	30 (17.0)
< 5 times	67 (38.1)
6–10 times	50 (28.4)
11–15 times	18 (10.2)
16–20 times	11 (6.3)
SMBG on most days/week	154 (87.5)
Perform regular exercise	112 (63.6)
Insulin dose adjustment when necessary	15 (8.5)
Insulin syringe change
At every injection	33 (18.75)
Every 2–3 injections	88 (50)
Every 4–5 injections	55 (31.25)
Site rotation every week
Yes	54 (30.7)
No	122 (69.3)
Space measurement (1–3 cm) to inject in the same site
Yes	112 (63.6)
No	64 (36.4)
Syringe insertion angle with 8 mm needle length
Perpendicular	119 (67.6)
Diagonal	49 (27.8)

SMBG, Self-Monitoring of Blood Glucose

Concerning to injection site rotation, nearly half (44%) of the participants reported that they rotate injection sites based on physicians’ advice. And the most frequently used injection site was arm (50, 28.4%) followed by thighs (28, 15.9%) and abdomen (20, 11.4%) (Fig. 3).

Fig. 3.

Frequently used injection sites

Insulin-related outcomes

Hypoglycemia

Hypoglycemia was assessed by asking patients whether they manifested one or more of the following symptoms; poor concentration, irritability, palpitation, tiredness, sweating, strong hunger, dizziness, and tremor during the previous month. Then it was confirmed by self- monitoring blood glucose reading of less than or equal to 70 mg/dL. Based on that, around one in three (56, 31.8%) of the total interviewed participants reported at least one episode of hypoglycemia during the previous month. However, the number of hypoglycemic episodes did not found to have a statistically significant association with the number of self-monitoring blood glucose reading as well as physical exercises.

Glycemic control

In the present study, a quite high proportion (146, 83%) of the patients had HgbA1C of greater than 7.5% and this was declared as non-optimal glycemic control. A chi-squared analysis revealed a statistically significant relationship between non-optimal glycemic control and the independent variables; poor injection site hygiene (P-0.038) and injection sites inspection (P-0.049). However, other parameters were not significantly associated with glycemic control (Table 4).

Table 4.

Glycemic control in comparison with insulin usage of participants

Parameter			HgA1C%	p value
		Optimal (≤7.5%)	Non-optimal (>7.5%)
Routine hands hygiene	Yes	15 (15.8)	80 (84.2)	0.632
	No	15 (18.5)	66 (81.5)
Routine injection site hygiene	Yes	17 (24.3)	53 (75.5)	0.038*
	No	13 (12.3)	93 (79.5)
Routine inspection of insulin vial	Yes	24 (20.5)	93 (79.5)	0.085
	No	6 (10.2)	53 (89.8)
Routine elimination of air bubbles in the syringe	Yes	25 (17.2)	120 (82.8)	0.881
	No	5 (16.1)	26 (83.9)
Routine injection sitevisual inspection and palpation	Yes	30 (18.9)	129 (81.1)	0.049*
	No	0 (0.0)	17 (100)
Injection site frequently used	Arm	4 (8.0)	46 (92.0)	0.174
	Thigh	7 (25.0)	21 (75.0)
	Abdomen	4 (20.0)	16 (80.0)
	Rotate all	15 (19.2)	63 (80.8)
Rolling/tilting of cloudy insulin	< 10 times	26 (17.7)	121 (82.3)	0.734
	10–15 times	3 (16.7)	15 (83.3)
	15–20 times	1 (9.1)	10 (90.9)
Storage of opened insulin	Refrigerator	15 (15.8)	80 (84.2)	0.745
	Sand	6 (22.2)	21 (77.8)
	Room To	9 (16.7)	45 (83.3)
Storage of unopened insulin	Refrigerator	28 (19.2)	118 (80.8)	0.177
	Sand	1 (9.1)	10 (90.9)
	Room To	1 (5.3)	18 (94.7)
Routine SMBG done	Yes	29 (18.8)	125 (81.2)	0.096
	No	1 (4.5)	21 (95.5)
Routine physical exercise	Yes	23 (20.5)	89 (79.5)	0.103
	No	7 (10.9)	57 (89.1)

*Statistically Significant: P ≤ 0.05

SMBG, Self-Monitoring of Blood Glucose

HgbA1C%, Glycated Hemoglobin

Discussion

An assessment of the overall usage of insulin and in particular the injection techniques as well as insulin-related outcomes was done among patients with diabetes type 1. We discussed our findings by first stating the evidence-based practice and then compared it with the local practice. Subsequently, possible implication of the outcomes was provided. In addition, our discussion focused on important findings/themes based on factors which might affect glycemic control and/or leads to adverse effects.

Evidence-based guidelines recommends insulin syringe of no longer than 6 mm in children and adolescents. This is to prevent intramuscular injection which is a painful, leads to fast absorption and hypoglycemic events [10, 15, 16]. However, in the present study, all insulin syringe needles were 8 mm in length. This was due to lack of syringe needles shorter than 8 mm in the study area and the whole continent.

Patients should always wash their hands with soap and water before injection. Similarly, injection sites should be always cleaned using either soap with water or antiseptics such as alcohol [10, 15, 16]. However, this practice was reported by only half of the study subjects. However, our study found a higher percentage of participants who clean injecting sites compared to a study done by Connic et al [5]. As a result, patients who kept their injection sites clean were found to have significantly lower HgbA1C% (≤ 7.5%) compared to those who did not routinely clean (p-0.041). This might be due to the fact that those who had better injection site hygiene have better commitment and compliance with other recommendations.

Patients should inspect insulin vials for any appearance change and eliminate air bubbles in the syringe at every injection [10, 15, 16]. Two-thirds of the study participants did inspect insulin vial and eliminate air bubbles. This finding was higher than the data given by Ahmad et al (28.1%) [17]. Air bubbles in the syringe, if not eliminated appropriately, might affect the dosing of insulin and leads to poor glycemic control [10, 15, 16].

Children and adolescents with needle length of ≥ 8mm should inject by lifting a proper skin fold with the thumb and index finger (possibly with the addition of the middle finger) then needle should be inserted at 45⁰ (diagonally) and completely [10, 15, 16]. Nearly all subjects of our study inject by lifting a proper skin fold unlike the study by Strauss et al [7]. Needle was inserted at 45⁰ and completely in above one-quarter of the subjects and this was in line with a study done by Coninck et al [5]. This practice should be encouraged to prevent intramuscular injection as well as to reduce painful sensation [15].

Injecting sites’ skin manipulation before or after insulin administration is not generally recommended [10, 15, 16]. In contrary to this recommendation, it was practiced by about half of our study subjects. Skin manipulation is not advised because it facilitates insulin absorption and results in hypoglycemic events [15].

Injection sites should be inspected by health care providers at every visit, especially if lipohypertrophy (LH) is already present. Moreover, patients should always inspect their own sites to detect LH [10, 15, 16]. Fortunately, this practice was reported by nearly all of our study participants unlike a report given by Connic et al (36%) [5]. Thus, injection sites inspection was significantly associated with optimal glycemic control. This might be due to the fact that patients could early detect abnormal changes of the injection sites and rotate to the normal sites.

When using cloudy insulin (i.e., NPH and premixed insulin), the vial, cartridge or pen device should first be gently rolled 10 times, then tipped (not shaken) 10 times; finally, it should be inspected to ensure the suspension has a consistently milky white appearance [10, 15, 16]. In contrary, very few of our patients have reported that they re-constitute cloudy insulin by rolling up to 20 cycles. This was consistent with a study done by Frid et al [18]. However, a lower percentage was reported when compared to other studies [5, 19]. Adequate re-suspension of cloudy insulin is promoted to maintain the right dose of insulin so that to keep optimal glycemic control [10, 15, 16].

Based on the evidence-based guidelines, unopened insulin should be stored in refrigerator whereas it is preferable to store opened insulin at room temperature [10, 15, 16]. In our study, most of the study subjects store unopened insulin in the refrigerator. However, in contrary to the recommendation, considerably high proportion of the participants store opened insulin in the refrigerator. This finding was comparable with the data given by Frid et al [18] though it was lower than a finding reported by Ahmad et al [17]. Generally, administration of insulin which is stored at room temperature may reduce irritation, burning or painful injections, and facilitates the re-suspension of cloudy insulin [10, 15, 16]. However, issues regarding the effects of climate changes on the room temperature were not considered in this study.

A single insulin syringe needle should be used for only an injection [9, 10, 15]. However, a few of our participants have reported such a practice and this was much lower than a report given by Connic et al [5]. In the present study setting, needles of the syringe are either refunded by the Ethiopian Diabetes Association or buy from the market. The fact that the refunded needles are scarce enforces patients to use one needle for 4-5 injections. The use of single insulin syringe for multiple injections might lead to skin-related adverse effect and which in turn might end up with uncontrolled glycaemia [9, 10, 15].

Patients should divide each injection site into a quadrant (or halves when using thighs or buttocks) then using one quadrant per week and moving always clockwise. Injections within any quadrant or half should be spaced at least 1-2 cm from each other in order to avoid repeated tissue trauma [9, 10, 15, 16]. This was reported by around one-third and two-thirds of the participants, respectively. This was much lower than a report given by Connic et al [5]. Injection site rotation is mandatory to prevent skin-related adverse effects of insulin such as lipodystrophy, lesions and infections [10, 15, 16].

Episodes of hypoglycemia, in the one month period before the interview, were reported by about one-third of the participants. This percentage might have been underestimated because it was analyzed based on the self-reported hypoglycemic symptoms and self-monitoring blood glucose readings. However, it was much higher than a report given by Baruah et al [8]. This might be due to the side effect of insulin, the disease itself and injection site lipodystrophy.

Though non-optimal glycemic control was explained by few of the study variables, it does not mean that appropriate insulin injection practices are not mandatory rather the poor glycemic control might be explained by other practices other than variables included in this study. Therefore, this finding requires further investigation by incorporating factors which might affect glycemic control.

Conclusion

The present study revealed how exactly participants were utilizing insulin and also assessed the effect of injection practices on diabetic outcomes. Overall, this study showed that insulin injecting practices was considerably satisfactory except few but crucial practices. Therefore, a routine education on appropriate insulin usage and in particular on the proper injection techniques should be given at every hospital visit.

Limitation of the study

The study was conducted in a single center and sample size was not enough due to the limited number of patients who fulfilled the inclusion criteria. In Addition, a self-constructed questionnaire was employed which requires further validation process.

Abbreviations

AMD

Association of Clinical Diabetologists

OSDI

Italian Diabetes Healthcare Professionals

BMI

Body Mass Index

CI

Confidence Interval

FIT

Forum for Injection Technique

HbA1C

Glycated Hemoglobin

LH

LipohypertropHY

mg/dL

milligram per deciliter

SD

Standard deviation

Funding information

This work was supported by Addis Ababa University.

Data availability

The datasets supporting the conclusions of the study are available with the authors. Any additional data will be available on request.

Compliance with ethical standards

Conflicts of interest/competing interests

The authors declare that they have no conflicts of interest.

Ethics approval

This study was conducted in accordance with the Declaration of Helsinki, and approval for the study protocol was granted by the Ethics Review Board of Tikur Anbesa Specialized Hospital.

Consent to participate

Participants and their parents were informed of their written consent prior to involving them in the study. Human rights were kept safe throughout the study.

Consent for publication

Consent is received from all authors to publish the study.