Insulin Adherence and Barriers among Patients with Diabetes in Saudi Arabia
Author(s): Mohammed Saad Alqahtani*, Mohammed Mesfer Alqahtani, Talal Zaidan Alruwaili, Sultan M Alkahtani, Abdulmajeed M Alshaikhi, Abdulaziz A Basalem, Turki M Bin Saqyan, Khalid A lkhudhairi and Abdullah A Twair
Abstract
Insulin adherence and barriers among patients with diabetes in Saudi Arabia ABSTRACT Introduction Diabetes is one of major metabolic chronic diseases that demand a continuous medical attention. Diabetes is classified generally into 2 types mainly; Type 1 Diabetes (T1DM) known to have absolute insulin deficiency which occurs due to autoimmune B-cell destruction and Type 2 Diabetes (T2DM) in which the body develops insulin resistance that occur due to the progressive loss of adequate B-cell insulin secretion. And there are other types such as Gestational and specific types which occur due to other causes. According to the World Health Organization (WHO), Saudi Arabia is the second highest country in the Middle East regarding the rate of diabetes, and ranks the seventh worldwide. Almost 3 million people of the population are pre-diabetic and 7 million are diabetic. As diabetes has a multisystem effect on general health outcome that includes macrovascular complications, such as, stroke coronary heart disease and peripheral vascular disease, and there are other microvascular complications, such, retinopathy and neuropathy, end-stage renal disease along with lower-extremity amputations. Diabetes management must be based on the pathophysiology of the disease. Therefor type 1 and type 2 diabetes may differ in their management. Insulin is an essential treatment for type 1 but type 2 is more complex, thus the treatment highly depends on individual bases and the progression of the disease. Along with an intensive non-pharmacological lifestyle modification program. Insulin regulates the metabolism of glucose in the body. Both types of diabetes can benefit from the use of exogenous insulin. There are different types of insulin based on the mode of action with different onset of action, duration and peak effect that is based on the patient needs. Therefore, insulin is commonly classified into, rapid, short, intermediate and long acting. Rapid acting insulin taken before meal " prandial or pre-bolus " and long-acting insulin last up to 24 hours and taken once to twice daily, and Premixed insulin’s (mixtures of prandial and basal insulin’s twice daily. The usual injection sites are the abdomen, front or lateral of thigh, lateral aspect of arm, and lateral upper quadrant. Rotation of injection are important. The standard route of insulin delivery is subcutaneous insulin injections. There are many ways to deliver insulin subcutaneously such as vials and syringes, insulin pens, and insulin pumps. Glucose-control highly depends on patient's adherence. However, there are many barriers that may affect adherence to the use of insulin; such as being busy, skipping meal, social distress and emotional problems. An international study done in China, France, Japan, Germany, Spain, Turkey, the UK or the USA shows (33.2%) of patients reported insulin non-adherence at least 1 day in the last month, with an average of 3.3 days. (72.5%) of physician's report that their typical patient does not take their insulin as prescribed, with a mean of 4.3 days per month of basal insulin non-adherence and 5.7 days per month of prandial insulin non-adherence and there is a local study in Saudi Arabia that included a sample size of 387, reported that the level of adherence with basal bolus insulin was 61.9%. and that there was no significant difference in the level of adherence between the two genders. With the highest adherence level being in the younger age groups (14-29). As there is insufficient local data our aim is to assess diabetic patients™ adherence and barriers to insulin therapy. Aim: This study aimed to assess diabetic patients™ adherence and barriers to insulin therapy. Patients and methods this is a cross-sectional study conducted among diabetic patients (type 1 and type 2) in Saudi Arabia. A self-administered questionnaire was distributed among the targeted patients using social media platforms. The questionnaire includes basic demographic characteristics, assessment of adherence to insulin, and assessment of barriers to insulin adherence. Results: 336 diabetic patients participated (females 75.6% vs. males 24.4%). Type 1 diabetes constituted most of the patients (92.6%) with fast-acting insulin’s being the most common insulin used (83.3%). 72.9% were worried about the occurrence of hypoglycemia events. Those who thought that insulin injections caused bruising and embarrassment were the independent significant predictors of poor insulin adherence while being married and having social or private health insurance were the independent significant predictors of good insulin adherence. Conclusion: About half of the diabetic patients were adherent to insulin therapy. Being married and having medical insurance are likely to have better adherence than the other patients while believing that insulin injections can cause bruising and embarrassment negatively affected their adherence to insulin therapeutic regimen. Keywords Diabetic patients, insulin adherence, barriers, diabetes Statistical Analysis The data were analyzed using Statistical Packages for Social Sciences (SPSS) version 26 Armonk, NY: IBM Corp. Adherence to insulin has been measured using 6 statements as illustrated in Figure 2, where a 5-point Likert scale type of categories as the answer options ranging from “always†coded as 1 to “never†coded as 5. The total adherence score had been calculated by adding all 6 items and a score range from 6 to 30 had been generated which means, the higher the score the higher adherence to insulin. By using 60% as a cutoff point to determine the level of adherence, patients were classified as poor adherence if the score was 60% or below while above 60% were classified as good adherence. Continuous variables were presented using means and standard deviations while categorical were summarized using numbers and percentages. The level of adherence was compared with the socio-demographic characteristics and the barriers toward insulin adherence by using the Chi-square test. Significant results were then placed into a multivariate regression model to determine the independent predictor associated with poor adherence where the odds ratio, as well as the 95% confidence interval, was also being reported. A p-value cut-off point of 0.05 at 95% CI was used to determine statistical significance.