بحث منشور الاستاذ المساعد الدكتورة سميرة محمد STUDY TO ASSESS THE ATTITUDE AND PRACTICE OF DIABETIC PATIENT
تاريخ النشر : 2016-09-30 18:28:31
عدد المشاهدات : 736
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ABSTRACT
Background: Diabetes Mellitus, the commonest endocrine disorder affects developed as well as developing
country. Prevalence of diabetes in Iraq was estimated to be 10.2 per cent in 2010. This estimate exceeded total prevalence
in the Middle East and North Africa region (9.3%) and is (nearly) equivalent to that of the USA (10.3%).
Objectives: The aim of the study is assess attitudes and practices related to insulin therapy and to
self-administration of insulin among diabetic patients in Basra City.
Methodology: The study was descriptive cross-sectional one, on sample of 100 patients with diabetes mellitus
attending outpatient clinic in Basra general Hospital and AL. Mawani Hospital. Structured questionnaire was used for the
purpose of data collection, by direct interviewing the patients including information about the socio demographic
characteristics, attitudes and practices regarding insulin therapy and self-administration if insulin ; the data collection was
carried out from November 2013 to February 2014.
Results: Regarding sex (58%) of the sample were females, (4%) of the sample was younger than 25 years,
Majority were married (90%), (12%) were illiterate, (28%) complete primary school, (46%) complete secondary school
(14%) had higher educational level, (50%) were unemployed, and (53%) of them had positive family history of diabetes.
Most of them (71%) diagnose after developmental of symptoms.
All patients in study consult regularly for their condition, (50%) of them prefer private clinic as facility for
consultation. (43%) of them check their blood glucose only when them fell ill. Hospitals considered as source of insulin for
( 41%) of patients, (66%) prefer the arm as a site of injecting insulin. Only (20%) of them use the insulin syringe for single
injection, (4%) of them dispose the used insulin needles in a special container at home, (97%) of them eat some food
shortly after insulin. Only (54%) had good practice level of correctly practicing self-administration of insulin. The rate of
correct practices among males was higher than the rates among females for the majority of the items, and among those who
were recently diagnosed
Conclusions: The patients in this study showed variations in attitudes regarding their illness, insulin therapy and
self-administration of insulin. The level of correctly practicing self-administration of insulin was low. Except for the
disposal of used insulin needles in a special container at home, the rate of correct practices regarding self –administration
of insulin among males was higher than the rates among females for the majority of the items.
International Journal of General Medicine
and Pharmacy (IJGMP)
ISSN(P): 2319-3999; ISSN(E): 2319-4006
Vol. 3, Issue 4, July 2014, 65-74
© IASET
66 Samira Muhammed Ebrahim, Utoor Talib Jassim & Doaa Mohammed Baji
Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0
Recommendations: Teaching program can be conducted in diabetes clinic regarding insulin and its
administration. And hospital and other health institutions should apply responsible steps to facilitate passage for better
educational level for patient with insulin self-administration.
KEYWORDS: Attitude, Practice, Diabetic Patient, Insulin, Self – Administration
INTRODUCTION
Diabetes Mellitus, the commonest endocrine disorder affects developed as well as developing country. In 2011,
336 million population have diabetes and estimated to reach 552 million by 2030 globally. Low and middle-income
countries have 80% diabetes burden. Diabetes will be the seventh leading cause of death in 2030[1].
Prevalence of diabetes in Iraq was estimated to be 10.2 per cent in 2010. This estimate exceeded total prevalence in the
Middle East and North Africa region (9.3%) and is (nearly) equivalent to that of the USA (10.3%)[2].
Persons with type 1 diabetes account for 5%-10% of those with diabetes, and with life style modifications, blood
sugar control, and insulin injections, they can live long productive live [3]..
Insulin therapy is a cornerstone of treatment in type 1 diabetes and, in many cases, also critical to the management
of type 2 diabetes [4]. Insufficient knowledge of insulin contributes to errors in its use that may cause adverse patient
outcomes. [5].
Diabetes is a complex and chronic condition that requires effective self-management by the individual in
partnership with healthcare professionals to prevent both acute and chronic complications [6]. Patient education and
self-care practices are also important aspects of disease management that help people with diabetes live normal lives[7]. It is
now accepted that the correct place for routine management of the person with diabetes is in primary care with supporting
services from specialists[8]. This study is important because it will help health care providers to recognize the feelings,
attitudes, and practices of the patients and provide educational support that patients need when they are on insulin. There is
a need for patients to gain awareness, because lack of awareness among many diabetic patients could lead to serious
complications. The aim of the study is assess attitudes and practices related to insulin therapy and to self-administration of
insulin among diabetic patients in Basra City.
METHODOLOGY
· Design of the Study: Descriptive, Cross Sectional Study.
· Setting of the Study: AL- Basra General Hospital and AL_Mawani Hospital In Basra City.
· The Sample of the Study: Convenient sample of 100 diabetic patients attending outpatient clinic, of both male
and female were selected. The sample was selected according to special criteria as patients being on insulin
therapy. Structured questionnaire was used for the purpose of data collection; the data collection was carried out
from November 2013 to February 2014.
The questionnaire that used for direct interviewing the patients by 2 senior nursing students aiming to reduce the
anxiety of the patients during the interview. The questionnaire consisted of three parts. First part consisted of questions
regarding the socio demographic characteristics of the patients including sex, age, marital status, education, occupation,
and family history of diabetes. Second part consisted of questions regarding duration of the disease, how it was diagnosed,
A Study to Assess the Attitude and Practice of Diabetic Patient towards Self-Administration of Insulin in Basra City, Iraq 67
www.iaset.us editor@iaset.us
consultation facilities, and information about blood glucose testing. The third part of the questionnaire aimed to gather
information regarding insulin administration, fears and problems related to insulin self-administration and the correct
practices related to self-administration of insulin. Poor practice level was considered if the participant practice less than
(50% of correct practices), from (50% to 69% of correct practices) was considered as fair practice level, and if the
participant practice (70% and more of correct practices) then the score considered good.
· Statistical Analysis: Analysis was made by using SPSS version 16, data was expressed in
(frequency and percentage). Chi-squared test was used to examine the association between the groups and a
probability of less than 0.05 was considered to be statistically significant.
RESULTS
Table (1): showed that (58%) of the sample were females and (42%) were males. Regarding age (4%) of the
sample was younger than 25 years, (54%) of them between (25-49) years of age and (42%) were above 50 years of age.
Majority were married (90%), regarding the educational level of the respondents (12%) of them were illiterate, (28%)
complete primary school, (46%) complete secondary school and only (14%) had higher educational level (46%), (50%)
were unemployed, and (53%) of them had positive family history of diabetes.
Table 1: Socio- Demographic Characteristics of the Participants
Variable No. %
Sex
Male 42 42
Female 58 58
Age
<25 4 4
25-49 54 54
50+ 42 42
Marital status
Single 10 10
Married 90 90
Education
Illiterate 12 12
Primary 28 28
Secondary 46 46
Higher education 14 14
Occupation
Unemployed 50 50
Self employed 28 28
Governmental employed 16 16
Retired 6 6
Family history of diabetes
Positive 53 53
Negative 47 47
Total 100 100
Table (2): showed that (35%) of the patients were diagnosed as diabetic for more ten years and over. And (58%)
start taking insulin for less than 5 years. Most of them (71%) diagnose after developmental of symptoms and (29%) of
them diagnosed accidently.
All patients in study consult regularly for their condition, (50%) of them prefer private clinic as facility for
consultation. Majority (98%) of them give advices for newly diagnosed patients with diabetes in their family. All the
participants received nutritional advices regarding diabetes and (75%) of them follow these advices.
68 Samira Muhammed Ebrahim, Utoor Talib Jassim & Doaa Mohammed Baji
Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0
Table 2: Participant's Attitudes toward their Illness
Question Answer No. %
< 5 years 35 35
When you diagnosed with diabetes ? 5-9 years 30 30
10+years 35 35
< 5 years 58 58
When you start to take insulin therapy? 5-9 years 28 28
10+years 14 14
Accidentally 29 29
How your disease was diagnosed ?
71 71
After development of
symptoms
Do you consult regularly for your condition ? Yes 100 100
No 0 0
Private clinic 50 50
What health facility do you prefer ?
General hospital 25 25
Diabetic clinic 10 10
Health center 15 15
Do you give advices for newly diagnosed patients Yes 98 98
with diabetes in your family No 2 2
Have you received any nutritional advices Yes 100 100
regarding diabetes ? No 0 0
Yes 75 75
Do you follow these advices ?
No 25 25
Total 100 100
Table(3): showed that (44%) of studied patients do not have glucometer, and (43%) of them check their blood
glucose only when them fell ill, the majority of them (71.4%) were trained by pharmacist, (10.4%) of them trained by a
nurse, other diabetic patients act as source of training for (3.6%) of the participants.
Table 3: Practice of Blood Sugar Measurement
Question Answer No. %
No, I have no gluco meter 44 44
Do you check your blood glucose at you home?
Yes, Only when I fell ill 43 43
Yes, Regularly 13 13
Total 100 100
Doctor 3 5.4
Who trained you on measuring blood sugar?
Nurse 6 10.7
Pharmacists 40 71.4
Other diabetic patients 2 3.6
More than one source 5 8.9
Total 56 100
Table (4): showed that (59%) of diabetes patients uses other hypoglycemic medication with insulin, (43%) got
their insulin from private pharmacy hospitals considered as source of insulin for (41%) of patients, (90%) use insulin on
regular basis, (98%) of them keep their insulin in refrigerator, (66%) prefer the arm as a site of injecting insulin.
Regarding problems facing the participants (38%) of them faced no problem, (25%) faced redness and itching at
site of insulin injection, (40%) of them have no fear when they know need insulin therapy, (25%) of them fear of insulin
itself, while (18%) of them fear of pain and (17%) fear of hypoglycemia.
A Study to Assess the Attitude and Practice of Diabetic Patient towards Self-Administration of Insulin in Basra City, Iraq 69
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Table 4: Respondent's Practices and Attitudes toward Insulin Therapy
Question Answer No. %
Do you use other hypoglycemic medications with insulin? Yes 59 59
No 41 41
From where you get your insulin? Hospital 41 41
Health center 14 14
Private Pharmacy 43 43
Other sources 2 2
More than one source 5 8.9
When do you use your insulin therapy ? On regular basis 90 90
When I fell unwell 10 10
Where do you keep your insulin ? In refrigerator 98 98
On the shelf 2 2
At what site you prefer to inject yourself ? Arm 66 66
Thigh 25 25
Abdomen 9 9
What are the main problems you faced at the site of insulin No problem 38 38
injection? Redness and itching 25 25
Scar 23 23
More than one problem 14 14
What type of fears you faced when you knew you need No fear 40 40
insulin therapy? Fear of insulin itself 25 25
Fear of pain 18 18
Fear of hypoglycemia 17 17
Total 100 100
Only (50%) of participants check the expire date of insulin, all participants do change the site of injection
frequently, (97%) of them do not inject insulin on the scar or nevi, (55%) kept the insulin vial at room temperature at least
15 minute before been injected, (78%) wash their hands with soap and water before handling injection devices, (53%) of
them sterilized the site of injection, (92%) remove air bubbles from insulin syringe before injecting insulin. Only (20%) of
them use the insulin syringe for single injection, (4%) of them dispose the used insulin needles in a special container at
home, (97%) of them eat some food shortly after insulin injection as shown in table 5.
Table 5: Participant's Correct Practices Related to Self-Administration of Insulin (n=100)
Practices No. %
Checking the expire date of insulin 50 50
Changing the site of injections frequently 100 100
The site of injection should not be on scar or nevi 97 97
The insulin vial kept at room temperature at least for 15 minutes before injection 55 55
Washing hands with soap and water before handling injection devices 78 78
Sterilization of the site of injection 53 53
Removing air bubbles from the insulin syringe before injecting 92 92
Syringe should be used for one time only 20 20
Disposal of used insulin needles in a special container at home 4 4
Eating some food shortly after insulin injection 97 97
Comparing the rates of correct practices between males and females, it was found that except for practice of
Disposal of used insulin needles in a special container at home, the rate of correct practices among males was higher than
the rates among females for the majority of the items.
And the differences was statistically higher among males regarding the followings, keeping the insulin vial at
room temperature at least for 15 minutes before injection (66.7%), Washing hands with soap and water before handling
70 Samira Muhammed Ebrahim, Utoor Talib Jassim & Doaa Mohammed Baji
Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0
injection devices (88.1%), Sterilization of the site of injection (66.7%), and Syringe been used for one time only (31%), as
shown in table 6.
Table 6: Participant's Correct Practices Related to Self-Administration of Insulin According to sex (n=100)
Correct Practices
Male Female Chi-
Square
P Value
No. % No. %
Checking the expire date of insulin 21 50 29 50 0.000 1.000
Changing the site of injections
frequently
42 100 58 100 - -
The site of injection should not be on
scar or nevi
42 100 55 94.8 2.240 0.135
The insulin vial kept at room
temperature at least for 15 minutes
before injection
28 66.7 27 46.6 3.982 0.046
Washing hands with soap and water
before handling injection devices
37 88.1 41 70.7 4.301 0.038
Sterilization of the site of injection 28 66.7 25 43.1 5.430 0.020
Removing air bubbles from the insulin
syringe before injecting
40 95.2 52 89.7 1.032 0.310
Syringe should be used for one time
only
13 31 7 12.1 5.425 0.020
Disposal of used insulin needles in a
special container at home
1 2.4 3 5.2 0.949 0.482
Eating some food shortly after insulin
injection
41 97.6 56 96.6 0.095 0.757
Table 7 showed that (19%)of the participants had poor level of correct practices regarding self-administration of
insulin, (27%) had fair level and (54%) had good practice level.
Table7: Score Level of Participant's Correct Practices Related to Self-Administration of Insulin
Score Level No. %
Poor (<50%) 19 19
Fair (50-69%) 27 27
Good (70% and over ) 54 54
Total 100 100
The level of correct practices related to self-administration of insulin was statistically lower for those who were receiving
insulin for more than 10 years than the other groups as shown in table 8.
Table 8: Score Level of Participant's Correct Practices Related to
Self-Administration of Insulin by the Duration of Insulin Therapy
Duration
Poor Fair Good Chi-
Square
P Value
No. % No. % No. %
< 5 years 11 19 15 25.9 32 55.2
5-9 years 1 3.6 8 28.6 19 67.9 14.416 0.006
10+years 7 50 4 28.6 3 21.4
Total 19 19 27 27 54 54
DISCUSSIONS
Living with diabetes is not easy, and achievement of glycaemic control requires from the patient to undertake
self-care behaviours with persistent ability to maintain attention and alertness over prolonged periods of time. The majority
of patients do not achieve glycaemic goals because of barriers related to insulin dose adjustment, self-monitoring of blood
A Study to Assess the Attitude and Practice of Diabetic Patient towards Self-Administration of Insulin in Basra City, Iraq 71
www.iaset.us editor@iaset.us
glucose and fear of hypoglycaemia [9]
.
The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men[10].
Results in this study showed that the majority of patients who self-insulin administration were females (58%), this study
was slightly similar to Bahrain's study were the female are (60.6%)[11]
. Regarding age the majority (54%) of them between
(25-49) years, this results was different from India's study were those aged less than 50 years represent (26%)[12], the
majority of participant of our study (90%) were married, this study was similar to Jordan study(91% ) were married [13].
In our study the majority (47%) had secondary school education, while in Kesihatan (46%) were also secondary school[14].
In this study (53%) had positive family history of diabetes, this was lower than what was found in cross sectional study on
403 diabetic patients, 202 Malaysian and 201 from the UAE, where more than three quarter of Malaysian respondents
(77.2%) were had a family history of diabetes compared to the UAE counterpart (64.7%)[ 15].
In this study (35%) of the participants had history of diabetic for less than 5 years, similar to the result of study
involving 59 diabetic patient in Kasturba Hospital in india[16], and lower than what was reported in a study of 199 diabetic
patient attending the outpatient clinics of Aga Khan University Hospital, Karachi, Pakistan [17].
The difference rate of those who receive insulin therapy for the group of less than 5 years was higher than those
who had history of diabetes this could be explained by that some of the patient were previously of type 2 diabetes mellitus
and after period of time they became in need of insulin this agree with statement of American Diabetes Association the
injection of insulin may be needed by patients with type 2 diabetes for intermittent or continuous glycemic control [12].
In this study most of patient (71%) diagnose after developmental of symptoms, while in United Arab Emirates 69% were
diagnosed after developmental of symptoms[15].
In our study (44%) of patients do not have glucometer, this was higher than (31%) that was found among 100
diabetic patients visiting Diabetes Care Unit in Pakistan [18].
In present study (59%) of patients were on both insulin and oral hypoglycemic drugs, this results was different
from Jordan study just (18%) of them were on both insulin and oral hypoglycemic drugs [13]. The majority (66%) of
participant preferred arm as injection site followed by upper thighs, then the abdomen. Absorption is fastest with injection
in the abdomen, followed by the arms, thighs, and buttocks [19]. Redness and itching at site of insulin injection was reported
by (25%) by the patients, while in Finland (46%) had a redness at site of injection [20] ]. in our study (40%) of participant
faced no fear when they knew their need insulin therapy while the least fear was of hypoglycemia as reported by (17%) of
the patients while in Spain (53.3%) of the sample fear from hypoglycemia[21].
Regarding the percentage of procedures related to checking the expire dates of insulin, washing hands, removing
air bubbles from the syringe before injection were higher than what was found for the pre test and lower than that for the
post test after implementation individual planned teaching on self-administration of insulin for patients with diabetes
mellitus in Bangalore [22]
.
In the present study all participant changing the site of injections frequently, helping in reducing irritation,
bruising, and risk of infection, it is also critical for lipohypertrophy prevention, a complication reported in nearly 50% of
individuals using insulin who fail to rotate injection sites [23].
Manufacturers of disposable syringes and pen needles recommend that they only be used once. One potential
issue, which arises with reuse of syringes or needles, is the inability to guarantee sterility[24]. We identified a large
72 Samira Muhammed Ebrahim, Utoor Talib Jassim & Doaa Mohammed Baji
Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0
percentage of the participants reuse the disposable syringe, this unhealthy behavior need to be changed by education to
prevent complications. Proper disposal of used syringes and needles is important to the prevention of accidently injuries
from discarded needles, We identified a large percentage of patients who inappropriately disposed of used insulin needles
as only (4%) of the participants dispose the used insulin needles in a special container at home, much lower than the result
for convenience sample of 50 patients from two local independent pharmacies, a private endocrinology practice, and a
pharmacy services clinic in an ambulatory internal medicine clinic at an academic medical center in Richmond, Virginia
(44%) dispose the used insulin needles in a special container at home [25].
In present study (54%) of participant had good practice about insulin self-administration, (27%) fair and (19%)
poor level. These results were better than the result of study for the purpose of assessment of the practice regarding insulin
self-administration on sample of 60 diabetic patients in India revealed that (72%) of the subjects had poor practice; (28%)
of them had fair practice, and none of them had good practice[26]
. In our study the level of correct practices related to
self-administration of insulin was statistically lower for those who were receiving insulin for more than 10 years than the other group
this could be explained by that they consider insulin therapy as part of their routine activity that not need so much consideration.
CONCLUSIONS
· The patients in this study show variations in attitudes regarding their illness, insulin therapy and
self-administration of insulin.
· The level of correctly practicing self-administration of insulin was low
· The main defect in correctly practicing self-administration of insulin were in the aspect of reusing the syringe and
the disposal of used insulin needles in a special container at home.
· Except for the disposal of used insulin needles in a special container at home, the rate of correct practices
regarding self –administration of insulin among males was higher than the rates among females for the majority of
the items
· The level of correct practices related to self-administration of insulin was statistically lower for those who were receiving
insulin for more than 10 years than the other groups.
RECOMMENDATIONS
· Educating program can be conducted in the outpatient clinic and primary health care centers regarding insulin and
its administration. A booklet could be used with illustrations given to the patients including information covering
aspects of diabetes, insulin therapy and it's administration.
· There is need for future study on larger sample of patients to be able to generalize the results to the larger
population.
REFERENCES
1. Shettigar S, Ashwini Kamath A, Alva GL, Latha T. and Raju NJ. Traning on improving the competency level of
self administration of insulin among type 2 diabetes patients. Nitte University Journal of Health Science NUJHS
2013; Vol. 3(3):42-47
A Study to Assess the Attitude and Practice of Diabetic Patient towards Self-Administration of Insulin in Basra City, Iraq 73
www.iaset.us editor@iaset.us
2. Maeng MH. World Diabetes Day – Diabetes in conflict areas. Stockholm International Peace Research
Institute 2013.
3. Mertig, RG,. 'The Nurse's Guide to teaching Diabetes Self- Management'. New York. Spring Publishing company
2007: PP. 1-168.
4. Strategies for Insulin Injection Therapy in Diabetes Self-Management. American Association of Diabetes
Educators 2011
5. Derr R L, Sivanandy MS, Bronich-Hall L, and Rodriguez A "Insulin-Related Knowledge Among Health Care
Professionals in Internal Medicine". Diabetes Spectrum 2007, 20(3): 177-185.
6. Robinson N. Self-management of diabetes for the hospitalised inpatient. Journal of Diabetes Nursing 2005 ; 9
( 7): 363-267
7. Alssema M, Schindhelm RK, Rijkelijkhuizen JM, Kostense PJ, Teerlink T, Nijpels G, Heine RJ and Dekke JM.
Meal composition affects insulin secretion in women with type 2 diabetes: a comparison with healthy controls.
The Hoorn prandial study'. European Journal of Clinical Nutrition 2009; 63: 398–404.
8. Burden ACF. Improving care for patients with diabetes: the role of simple reminders. Family Practice
2007; 24: 1–2.
9. Aschner P, Horton E,. Leiter L. A, Munro N, Skyler J. S. Practical steps to improving the management of type 1
diabetes: recommendations from the Global Partnership for Effective Diabetes Management. Int J Clin Pract
2010; 64: 295–304.
10. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and
projections for 2030'. Diabetes Care 2004; 27(5):1047-1053
11. Nasser J, MD, Habib F, Hasan M, Khalil. Prevalence of Depression among People with Diabetes Attending
Diabetes Clinics at Primary Health Settings. Bahrain Medical Bulletin 2009; 31(3):11-57
12. Viji P.T, Singh M. A study to Assess the Practice of Diabetic Patient Towards Self Care Activities for Longevity
of life. Scholars Journal of Applied Medical Sciences (SJAMS), 2014; 2(1):57-60
13. Khaldon K. AL-Sarihin MD, Mohammad H., khaled RN, Fares H. Haddad MD, Ibrahim I. AL-thwabia RN.
Diabetes knowledge among patient with diabetes mellitus at King Hussein Hospital. Journal of the ROYAL
MEDICAL SERVICES 2012;19(1):72-77
14. Ding C H, Teng C L, Koh C N. Knowledge of Diabetes mellitus among Diabetic and Non diabetic in ; Kinik
Kesihastan Seremban.Med Malaysia, 2006, 61(4): 399-404.
15. Mahdi, H. J. Hassan, Y. Aziz, N. A. Abdulrazzaq, H. A, Jirjees, F J. Abduelkarem A. R. Diabetes knowledge and
practice in Malaysian and the United Arab Emirates Diabetic patients. Research Journal of Phamaceutical,
Biological and Chemical Sciences 2013; 4(3):653-665.
16. Palaian S, Acharya LD, Rao PGM, Ravi Shankar P, Nair NM, and Nair NP. Knowledge, Attitude, and Practice
Outcomes: Evaluating the Impact of Counseling in Hospitalized Diabetic Patients in India. P&T Around the
World 2006, 31(7):383-395.
74 Samira Muhammed Ebrahim, Utoor Talib Jassim & Doaa Mohammed Baji
Impact Factor (JCC): 2.9545 Index Copernicus Value (ICV): 3.0
17. Rafique G, Azam S.I., and White F. Diabetes knowledge, beliefs, and practices among people with Diabetes
attending a university hospital in Karachi, Eastern Mediterranean Health Journal 2006; Vol. 12(5):590-598
18. Badruddin N, Basit A, Hydrie M.Z I, and Hakeem R. Knowledge, Attitude and practices of patients visiting a
diabetes care unit. Pakistan Journal of Nutrition 2002, 1(2):99-102
19. American Diabetes Association. Insulin administration. Diabetes care 2004; 27:106-109
20. Partanen T-M, Rissanen A. Insulin injection practices. Practical Diabetes 2000; 17(8):1-3
21. Belendez M, Mijares AH. Beliefs about insulin as a predictor of fear of hypoglycemia, research paper. Chronic
illness 2009:1-7
22. Parecatty T. Effectiveness of individual planned teaching on self-administration of insulin for patients with
diabetes mellitus, Receiving insulin in selected hospital management. MSc Thesis. University of health sciences
2005
23. Varder B, Kiziki S. Incidence of lipohypertrophy in diabetic patients and a study of influencing factors. Diabetes
research and clinic practice 2007; 77(2):231-236.
24. American Diabetes Association. Insulin administration. Diabetes Care 2002; 25:S112-S115
25. Musselman K T, Sicat BL, Thomas MH, Herbert M and Harpe SE. Patients knowledge and practice relating to
disposal of used insulin Needles. Innovation in pharmacy 2010;1(2):1-10
26. Nagarajui B, Padmavathi JV, Anand SC, Fayaz P, and Balachandra G."A study to Assess the knowledge and
practice of Insulin Self- Administration among Patients with Diabetic Mellitus", Asian Journal of Pharmaceutical
and Clinical Research 2012; 5(1): 63-66.