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Adherence of Insulin Therapy in Diabetic Mellitus Patients in a Tertiary Care Hospital

Aim and Objective: The aim of this study is to evaluate the adherence of Insulin therapy in Diabetic mellitus patients and to identify the factors leading to poor adherence of Insulin therapy among diabetic patients in a tertiary care hospital. Methodology: A prospective study was carried out in the department of medicine in Saveetha medical college from January to June 2021. 50 diabetic patients were included in the study and their adherence to Insulin therapy was monitored and the patients with low adherence were assessed for the cause so that appropriate interventions can be taken to improve its adherence. Results: The study enrolled about 50 patients out of which 23 of them had low Insulin adherence. The main reasons for low adherence were expense of Insulin(40%),lack of knowledge of administration(36%), and others factors include family problems, having faith over alternative medicines and fear of side effects. Conclusion: Given the great prevalence of primary non-adherence and the variety of reasons for it, it is evident that these treatment barriers must be removed. Dedicated diabetes instructors at each diabetes clinic, as well as the availability of low-cost insulin and blood glucose monitoring devices for the disadvantaged, are essential to achieving this goal. Original Research Article Ahalya and Kumar; JPRI, 33(63A): 225-229, 2021; Article no.JPRI.74890 226


INTRODUCTION
Diabetes is a chronic noncommunicable disease characterized by an increase in plasma blood glucose (hyperglycaemia) which affects an estimated 69 million people in India [1].The main aim of diabetes management is to maintain a good glycemic control thereby reducing the possible micro and macro-vascular complications. To maintain a good glycemic control requires a good adherence to medical regime (oral diabetic drugs and insulin), diet, physical activity and proper self care [2,3]. There is a growing priority to improve the medical adherence to control this epidemic.
Non-adherence in taking medication can occur from unintentional factors like irregular access to oral hypoglycemic agents and Insulin and from Intentional factors like increasing complexity of regimen, fear of side effects of drugs and lack of perception of the benefits from taking medication by the patients [4][5][6][7].
Non adherence to treatment can lead to worsening of clinical conditions and poor outcome. As diabetes is a chronic disease that requires long treatment process with regular check ups, a study is being conducted in our tertiary care hospital to determine the adherence of insulin therapy in diabetic patients and to study the various factors affecting it, which will help to improve the quality of care given to the patients.

METHODOLOGY
A cross-sectional study was undertaken at a tertiary care hospital's medicine outpatient department (OPD). Patients with Type 2 diabetes who had been on insulin therapy for one or more years and were 18 years or older were included in the study. For the study, a convenience sample of 50 patients with a confirmed diagnosis of diabetes mellitus was chosen. Patients were encouraged to come to the hospital once a month for basic checkups and medication. To collect information, we conducted interviews with them and used a validated, semi-structured questionnaire. Gender, education, age, place of residence, occupation, marital status, and socioeconomic class were among the sociodemographic characteristics recorded in the survey. We also gathered data on behavioral factors including alcohol and tobacco use, as well as diabetes treatment specifics like length of treatment, drugs used, and comorbidities. Morisky's medication adherence scale was used to assess adherence to diabetes medications (MMAS Questionnaire). It's an eight-point structural scale. High adherence is indicated by a score of >8, medium adherence is shown by a score of 6-8, and low adherence is indicated by a score of 6-8. HbA1c levels of adhered and nonadherent patients were also compared to see how severe diabetes was in both groups and how it affected insulin adherence.

RESULTS
A total of 50 patients are included in our study after obtaining an informed consent from them. The study summarised that age group between 61-75yrs had the highest number of diabetic patients.
Females (62%)had higher preponderance of diabetes as compared to males and majority of them were rural dwellers(76%).Nearly less than half of patients were illiterate (28%) and nearly half of them had secondary education(34%). More then half of the patients (33%) had income of less then 10000. Around 31(62%) of them had diabetes for more then >5 years, 15(30%) had for between 1-5 years and 4(8%) had for less than 1 year.
Almost half of the participants 23(46%) delayed initiation of insulin therapy, while 27(54%) initiated insulin treatment immediately after their doctor's first prescription. The participants who delayed the insulin initiation were interviewed for the barriers in the initiation of insulin therapy.

DISCUSSION
In the current study, individuals with uncontrolled T2DM had a significant proportion of delayed insulin therapy initiation (23;46 %).Our study showed that glycemic control among Insulin adherent patients was well with 40% of them had HbA1c level <7.5 whereas in Insulin non adherent patients 34% had HbA1c >7.5.
Similar findings were seen in a recent study by Hosomura et al., [8] 29.9% of patients refused insulin therapy when recommended for the first time, with the refusal rate being particularly high among those with poorly managed diabetes (Hb1Ac 9%).
In a study conducted in Iran, there was a significant association between forgetfulness and adherence to insulin therapy in patients with diabetes, to evaluate adherence to insulin therapy in patients with diabetes and underlying factors affecting insulin non adherence among patients with T2DM. (24.9%) of T2DM patients (n=507) were adherent to insulin injections, whereas (46.3%) and (28.8%) were assessed to have medium and low adherence to insulin therapy, respectively [9]. A study conducted in Turkey [10] to examine insulin treatment adherence in type 2 diabetic patients started on various insulin regimens found a significant relationship between age and adherence , with the majority of younger patients non-adherent .Gender and adherence have a significant relationship according to this study. Females made up more than half of the nonadherents (78, 66.7%) which is similar to our study.
Similar findings were seen in the study of, Praveena Vasam et al. [11] and the study of Suresh k Sharma et al. [12] reported a high rate of delayed initiation of insulin therapy among patients with uncontrolled T2DM (46.7%) with a male preponderance.
The delay in insulin initiation is a multifactorial phenomenon. Physician concern for the risk of hypoglycemia and weight gain, a lack of resources (e.g. staff and material), a high workload, and ambiguity of roles in the primary care team were among the other barriers identified in this review [13].
Patients' lack of knowledge about insulin administration routes; insulin dose adjustment and injection site rotation; doubt about insulin's clinical benefits; fear of hypoglycemia; cost of insulin; lack of family support; needle phobia; and preference for alternative medical systems were identified as major barriers to insulin initiation in our study.
It has become important to improve the adherence of insulin therapy among patients to reduce the complications and increasing number of patients which is estimated to be 87 million by 2030 [14]. As a result, developing interventions to improve patient Insulin adherence and maintain long-term persistence necessitates at least a basic grasp of the factors that influence patient non-adherence to Insulin. This is especially true when the determinants are modifiable risk factors that can be targeted for positive improvements once identified.

CONCLUSION
According to the findings of study, Insulin adherence was low, that is mainly attributed to lack of knowledge among patients and financial barriers and there is a need to focus on improving adherence among type 2 diabetes patients because it leads to improved clinical outcomes and fewer problems. As a result, there is a clear need to enhance health-care systems to ensure that Insulin are available on a consistent basis, as well as to provide health education to patients and their families, emphasizing the importance of Insulin adherence. Other issues, such as side effects or drug unavailability, that contribute to nonadherence among diabetic patients should be investigated, and solutions developed to increase adherence.

CONSENT
Further informed written consent was obtained from all the patients before they were included in the study.

ETHICAL APPROVAL
Before starting the study, the Institution Review Board of Saveetha University has approved our protocol, later grant sanction form was obtained from HOD's of all department.