Rajiv Gandhi University of Health Sciences Karnataka



swapna manthala

Submitted by

MRS SWAPNA MANTHALA

|RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, |

|KARNATAKA, BANGALORE. |

|PROFORMA FOR REGISTRATION OF SUBJECT FOR |

|DISSERTATION |

|1. |NAME OF THE CANDIDATE AND ADDRESS |SWAPNA MANTHALA |

| | |1ST year msc nursing student |

| | |Ratna college of nursing hassan |

|2. |NAME OF THE INSTITUTION | |

|3. |COURSE OF STUDY AND SUBJECT |1st Year M.Sc nursing, |

| | |(medical surgical Nursing) |

|4. |DATE OF ADMISSION OF THE COURSE | |

|5. |TITLE OF THE STUDY |“A Study On Assessing The knowledge regarding self |

| | |administration of insulin injection among diabetic |

| | |patients in selected hospitals with the view to develop |

| | |an instruction module.” |

|6. |BRIEF RESUME OF THE WORK | |

| |6.1 INTRODUCTION |Enclosed |

| |6.2 NEED FOR THE STUDY |Enclosed |

| |6.3 STATEMENT OF THE PROBLEM |Enclosed |

| |6.4 OBJECTIVES OF THE STUDY |Enclosed |

| |6.5 OPERATIONAL DEFINITIONS |Enclosed |

| |6.6 SAMPLING CRITERIA |Enclosed |

| |(I) INCLUSION CRITERIA |Enclosed |

| |(II) EXCLUSION CRITERIA |Enclosed |

| |6.7 ASSUMPTIONS |Enclosed |

| |6.8 REVIEW OF RELATED LITERATURE |Enclosed |

|7. |MATERIALS AND METHODS |

| |Sources of data: Data will be collected from the diabetic patients in selected hospitals. |

| |Method of data collection: Interview Method |

| |Does the study require any investigations of interventions to be conducted on the patients or other human being or animals? |

| |No. |

| |Has ethical clearance been obtained from your institution? |

| |YES. Ethical committee’s report is here with enclosed. |

|RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, |

|KARNATAKA, BANGALORE. |

|PROFORMA FOR REGISTRATION OF SUBJECT FOR |

|DISSERTATION |

|1. |NAME OF THE CANDIDATE AND ADDRESS |SWAPNA MANTHALA |

| | |1ST year msc nursing student |

| | |Ratna college of nursing hassan |

|2. |NAME OF THE INSTITUTION | |

|3. |COURSE OF STUDY AND SUBJECT |1st Year M.Sc nursing, |

| | |(medical surgical Nursing) |

|4. |DATE OF ADMISSION OF THE COURSE |2nd july 2009 |

|5. |TITLE OF THE STUDY |“A Study On Assessing The knowledge regarding self |

| | |administration of insulin injection among diabetic |

| | |patients in selected hospitals with the view to develop |

| | |an instruction module.” |

6. BRIEF RESUME OF THE INTENDED WORK

6.1. INTRODUCTION

One of the greatest challenges faced by the modern world is Diabetes mellitus (DM). The physical, social and economic factors involved in the management of diabetes are a continuous strain for the health sector and the government agencies. It is expected that approximately 366 million people will be affected by Diabetes mellitus by the year 20301.

Diabetes is a disorder characterized by hyperglycemia or elevated blood glucose (blood sugar). Our bodies function best at a certain level of sugar in the bloodstream. If the amount of sugar in our blood runs too high or too low, then we typically feel bad. Diabetes is the name of the condition where the blood sugar level consistently runs too high. Diabetes is the most common endocrine disorder. Sixteen million Americans have diabetes, yet many are not aware of it. Americans have a higher rate of developing diabetes during their lifetime. Diabetes has potential long term complications that can affect the kidneys, eyes, heart, blood vessels, and nerves2.

Although doctors and patients alike tend to group all patients with diabetes together, the truth is that there are two different types of diabetes which are similar in their elevated blood sugar, but different in many other ways. Diabetes is correctly divided into two major subgroups: type 1 diabetes and type 2 diabetes. This division is based upon whether the blood sugar problem is caused by insulin deficiency (type 1) or insulin resistance (type 2). Insulin deficiency means there is not enough insulin being made by the pancreas due to a malfunction of their insulin producing cells. Insulin resistance occurs when there is plenty of insulin made by the pancreas (it is functioning normally and making plenty of insulin), but the cells of the body are resistant to its action which results in the blood sugar being too high2.

The need to use exogenous insulin to maintain good metabolic control has been increasingly acknowledged as a therapeutic option for diabetes mellitus type 2 (DM2) in addition to being a classical indication for diabetes mellitus type 1 (DM1). Multiple daily doses of insulin need to be injected into the subcutaneous tissue to achieve glycemic control, which has been shown to be an essential condition to prevent acute and chronic complications of this disease3.

The most used instrument among the several available in the market to inject insulin into the subcutaneous tissue is the disposable syringe due to its low cost, easy access, health professionals' familiarity with its use.

Due to the increased number of people with DM using insulin in recent years, more emphasis should be given to the standardization and improvement of insulin administration technique, focusing on properly teaching this technique so that people become aware of their responsibility and make less mistakes during insulin administration.

Self care is a crucial element in secondary prevention of diabetes. Diabetics have a poor level of knowledge about the disease and self-care and hence a very casual attitude towards the disease. This predisposes them to the risk of development of complications in later life. Health education is an area which needs to be addressed immediately to improve patients' knowledge and skills of diabetes self-care practices so that they can better contribute towards the management of their disease1.

6.2. NEED FOR THE STUDY

The greatest challenge faced by the modern world is Diabetes mellitus (DM). It is expected that approximately 366 million people will be affected by Diabetes mellitus by the year 2030.

According to W.H.O statistics, the global prevalence of diabetes in the year 2000 was 171,000,000 and it expected and approximated to be raised to 366,000,000 by 2030. Where as its long arms have widely spread in India too, by the statistical report of W.H.O, in the year 2000 the prevalence was 367,000 and expected to be raised to 635,000 by the year 2030 in India4.

The lifestyle disease known to be restricted to urban population in the country till a few years ago has now invaded rural India as well, with as much as 3% of the total rural population being diagnosed with diabetes. Urban diabetic patients are estimated to account for nearly 10% to 11% of the total 25 million patients in India. The disease presently affects 10% of the affluent class and nearly 33% of the lower levels of population. The prevalence of diabetes is 16.6% in Hyderabad, followed by Chennai with 13.5%, Bangalore with 12.4%, Delhi with 11.6%, and Mumbai with 9.3%.

By 2025, the number of diabetes patients is expected to increase by 41% in developed countries to 72 million from the present level of 51 million. In developing countries, the incidence of the disease would surge by 170% to 228 million from 84 million5.

The study was conducted on “awareness and knowledge of diabetes in Chennai”—the Chennai urban rural epidemiology study. A structured Questionnaire administered to 26,001 individuals, and the result shows that only 75% (19642/26001) of the whole population reported that they know about a condition called diabetes, nearly 25% of the Chennai population was unaware of the condition called diabetes. 602% of all participants and 76.7% of the self reported diabetic subjects know that the prevalence of diabetes was increasing in India. Only 22.27% of the whole population and 41.0% of the Known diabetic subjects were aware that Diabetes could be prevented. Awareness and knowledge regarding diabetes is still grossly inadequate in India. Massive diabetes education programmers are urgently needed both Urban and rural India6.

In patients with diabetes, physicians are often concerned about increasing functional limitations that may impede a successful self-management. In particular, the correct handling of the insulin injection requires complex self-management abilities. Among these functional limitations, loss of visual acuity, loss of manual abilities and cognitive decline are of most importance7.

A Survey on Diabetes Awareness, Risk Factors and Health Attitudes in a Rural Community’ made by a team of doctors from the Christian Medical College (CMC), Vellore, and doctors in Tripura and Australia in Khowai district of Tripura, revealed a nine per cent prevalence of diabetes in persons above the age of 30 among the survey population6.

This cross-sectional study aimed to describe the most common correct and incorrect self-administration techniques for insulin using disposable syringes by patients cared for by the Family Health Strategy (FHS), relate the findings to socio demographic variables and also identify the professional responsible for teaching this technique. A total of 169 patients were selected by simple random sampling in 37 FHS units in a city in the state of Minas Gerais, Brazil from August to October 2006. The results identified errors in all the steps recommended by the American Diabetes Association and Brazilian Diabetes Association for the safe administration of insulin, from hand washing to compression on the injection site. The study recommended the development of interventions focused on education of patients regarding insulin injection3.

The investigated the acquisition of skill in the self-administration of insulin (by insulin pens) among 79 diabetes outpatients at Ehime University School of Medicine in order to evaluate the influence of such skill on glycemic control. The degree of skill acquisition by patients with poor glycemic was significantly lower than that by those with good control and patients who had continuously used insulin pens over a 3-year period had higher rates of incorrect usage. In addition, the patients who kept the needle of the insulin pen pointing downwards for a certain period of time was significantly lower than that for those who held the needle downwards for less than this period of time. These results indicated that the precise acquisition of skill in the self-administration of insulin is necessary to achieve good glycemic control and that keeping the needle pointing downwards for a sufficient period of time is the most important factor in the self-administration procedure. They also suggested that medical staff should keep a check on the skill of patients in the self-administration of insulin and repeatedly provide instruction on this to patients8.

By looking at the statistics it is clear that diabetes is affecting the people in drastic way. By reviewing the previous studies its evident that the diabetic patients have lesser knowledge regarding its management especially in the aspects such as self administration of insulin injection. Many studies have recommended the education programmes for the diabetic patients.

Researcher has come across many diabetics during clinical practice as well as at the place residence who found difficult to administer insulin by self. Considering all this researcher decided to undertake study to assess knowledge and improve the patients lnowledge by providing instruction module.

6.3. STATEMENT OF THE PROBLEM

“A Study On Assessing The knowledge regarding self administration of insulin injection among diabetic patients in selected hospitals with the view to develop an instruction module.”

6.4. OBJECTIVES

1) To assess the level of knowledge regarding self administration of insulin injection among diabetic patients in selected hospitals.

2) To find out the association between the knowledge regarding self administration of insulin injection of diabetic patients and selected demographic variables.

3) To develop an instruction module regarding self administration of insulin injection.

6.5 OPERATIONAL DEFINITIONS

1. Knowledge: in this study knowledge refers to the awareness and understanding regarding insulin injection and administration.

2. Insulin: refers to the medication i.e exogenous hormone used to manage patients with diabetes.

3. Self administration of insulin injection: refers to the putting insulin liquid into body by puncturing the skin with syringe and needle.

4. Diabetic patients: In this study diabetic patient refers to the patients with metabolic disorder characterized by elevated level of glucose in blood.

5. Instruction module: refers to the written information regarding introduction to diabetes, insulin, procedure of insulin injection, and important guidelines related to insulin injection.

6.6 SAMPLING CRITERIA.

(i) INCLUSION CRITERIA

1. Patients diagnosed with diabetes and getting insulin.

2. Patients with at least one year history of diabetes.

3. Who are willing to participate in the study.

(ii) EXCLUSION CRITERIA

1. Freshly diagnosed diabetic patients.

2. Those who are not able to understand Kannada or English.

6.7. ASSUMPTIONS

1. It is assumed that diabetic patients have significantly lower level of knowledge regarding self administration of insulin injection.

6.8. REVIEW OF RELATED LITERATURE

“Review of literature is a critical summary of research on a topic of interest often prepared to put a research problem in a context or as the basis for an implementation project”

The review of literature is an integral component of any study or research project. It enhances the depth of the knowledge and inspires a clear insight in to the crux of the problem. Literature review throws light on the studies and findings reported about the problems under the study.

Abdellah and Levin states that the review of literature provides basis for future investigations, justifies the need for replication, throws light upon the feasibility of the study, indicates constraints of data collection and helps to relate findings of one to another.

According to W.H.O statistics, the global prevalence of diabetes in the year 2000 was 171,000,000 and it expected and approximated to be raised to 366,000,000 by 2030. Where as its long arms have widely spread in India too, by the statistical report of W.H.O, in the year 2000 the prevalence was 367,000 and expected to be raised to 635,000 by the year 2030 in India4.

The cross-sectional study with the aim to describe the most common correct and incorrect self-administration techniques for insulin using disposable syringes by patients cared for by the Family Health Strategy (FHS), relate the findings to socio demographic variables and also identify the professional responsible for teaching this technique. A total of 169 patients were selected by simple random sampling in 37 FHS units in a city in the state of Minas Gerais, Brazil from August to October 2006. The results identified errors in all the steps recommended by the American Diabetes Association and Brazilian Diabetes Association for the safe administration of insulin, from hand washing to compression on the injection site. The study recommended the development of interventions focused on education of patients regarding insulin injection3.

The investigated the acquisition of skill in the self-administration of insulin (by insulin pens) among 79 diabetes outpatients at Ehime University School of Medicine in order to evaluate the influence of such skill on glycemic control. The degree of skill acquisition by patients with poor glycemic was significantly lower than that by those with good control and patients who had continuously used insulin pens over a 3-year period had higher rates of incorrect usage. In addition, the patients who kept the needle of the insulin pen pointing downwards for a certain period of time was significantly lower than that for those who held the needle downwards for less than this period of time. These results indicated that the precise acquisition of skill in the self-administration of insulin is necessary to achieve good glycemic control and that keeping the needle pointing downwards for a sufficient period of time is the most important factor in the self-administration procedure. They also suggested that medical staff should keep a check on the skill of patients in the self-administration of insulin and repeatedly provide instruction on this to patients8.

A cross-sectional study was carried out on the diabetic patients attending the outpatient clinic at three randomly selected rural primary health centers i.e. PHC Natekal, PHC Boliar, and PHC Amblamogaru in Dakshina Kannada District of Karnataka state in India in 2007. The data and responses were recorded on a semi structured pre-tested questionnaire. Patients' level of knowledge was assessed by asking questions. A total of 342 diabetics were studied. 181 (53%) were men and 161 (43%) were women. Men were found to be more aware than women and this difference was statistically significant. Only 52 (15%) of the respondents knew about the chronic complications of diabetes. Here also men had better knowledge than women but the difference was statistically non-significant. The present study has shown that diabetics in the area under study had a poor level of knowledge about the disease and self-care. Similar observations have been made elsewhere also. It was further observed that the attitude of the diabetics in the area under study, towards the disease, was very casual and only a few of them had put their knowledge into practice1.

This cross-sectional study aimed to compare two groups of patients with diabetes mellitus treated under the Family Health Strategy, with insulin self-administration versus non-self-administration, in relation to socio-demographic variables, perceived difficulties, and the person responsible for the self-application. A total of 269 patients participated, included through simple random sampling, from 37 Family Health Strategy units in the urban area of a municipality in the State of Minas Gerais, Brazil. The self-administration group consisted of 169 individuals (62.8%), as compared to 100 (37.2%) in the non-self-administration group. Comparing the two groups, schooling was statistically significant; 45% of those who did not self-administer reported absence of physical or cognitive difficulties that might prevent them from conducting the procedure, demonstrating the potential for adherence; 90% reported needing assistance in the insulin administration process at home, and of these, 75% reported receiving assistance from family members9.

The primary objectives of the present study were to describe self-reported understanding of DM and its treatment among elderly subjects with DM, and to determine whether poorer understanding of the disease and its treatment was predictive of medication-recall errors. Secondary objectives were to assess the potential association of certain demographic and disease-specific variables with subjects' understanding of DM and its treatment. METHODS: This was a cross-sectional survey of elderly subjects (age > or =65 years) with DM who were taking oral hypoglycemic medications and/or insulin and were seen at an outpatient DM clinic in British Columbia. The study questionnaire, which was administered at the clinic, included questions on self-reported understanding of DM and its treatment, sources of disease and drug information, and subjects' specific medication regimens. The study concluded that, despite a high self-reported understanding of DM and its treatment, 24.5% of subjects made at least 1 error in accurately recalling their medication regimen10.

The present descriptive study had the goals of characterizing type 1 diabetic children, according to socio-demographic variables and identifying the difficulties related to insulin self-management and home control. 34 type 1 diabetic children were interviewed at a big hospital. Results showed that 82.4% of children were white, 61.8% were female and 54.1% were from nine to eleven years of age, 67.7% were catholic, and 64% had the illness for 3 years. 35.3% of them learned insulin management with their mothers and 32.3% follow a schedule regarding insulin self-administration. Difficulties to perform home control are related to the available resources and lack of information. Results show the need for a planned work integrated by a multiprofessional team11.

The study conducted to explore medication knowledge and self-management practices of people with type 2 diabetes. Study conducted in Diabetes outpatient education centre of a university teaching hospital. 30 People with type 2 diabetes, 17 males and 13 females, age range 33-84, from a range of ethnic groups was studied. the study explored the ability to state name, main actions and when to take medicines. Performance of specific medication-related tasks; opening bottles and packs, breaking tablets in half, administering insulin, and testing blood glucose. Results showed medication knowledge and self-management was inadequate and could lead to adverse events12.

The study was conducted on “awareness and knowledge of diabetes in Chennai”—the Chennai urban rural epidemiology study. A structured Questionnaire administered to 26,001 individuals, and the result shows that only 75% (19642/26001) of the whole population reported that they know about a condition called diabetes, nearly 25% of the Chennai population was unaware of the condition called diabetes. 602% of all participants and 76.7% of the self reported diabetic subjects know that the prevalence of diabetes was increasing in India. Only 22.27% of the whole population and 41.0% of the Known diabetic subjects were aware that Diabetes could be prevented. Awareness and knowledge regarding diabetes is still grossly inadequate in India. Massive diabetes education programmers are urgently needed both Urban and rural India13.

7.0. MATERIALS AND METHOD

7.1 SOURCE OF DATA: Data will be collected from the diabetic patients in selected hospitals.

7.2 METHODS OF DATA COLLECTION:

i) Research design : Non experimental Descriptive design

ii) Setting : A Selected hospitals.

iii) Sampling technique : Non probability purposive Sampling

iv) Population : All diabetic patients

v) Sample : Diabetic patients diagnosed at least one year back and getting insulin.

iv) Sample Size : 50

v) Method of data collection : Interview method

vi) Tools for data collection : Structured interview schedule on knowledge regarding self administration of insulin injection.

vii) Method of data analysis and interpretation:

The researcher will use appropriate statistical techniques for data analysis and

present in the form of tables, graphs and diagram.

Demographic data will be analyzed by frequency and percentage distribution.

The level of stress and subjective wellbeing will be analyzed by using mean and standard deviation.

The knowledge will be analyzed by Mean, Median and standard deviation and presented in terms of tables and graphs.

The association between knowledge and demographic variables will be analyzed by chi square test.

viii) Duration of study : 4 weeks

ix) Research variables : knowledge regarding self administration of insulin injection.

x) Demographic variables : Age, Gender, Type of family, family income,

Education, Marital status, Source of information, duration of illness etc.

xi) Projected outcome : The study will reveal the patients knowledge regarding self administration of insulin injection and the instruction module helps the diabetic patients to gain the knowledge regarding self administration of insulin.

7.3. Does the study require any investigations of interventions to be conducted on patient or animals? No.

7.4. Has ethical clearance been obtained from your institution?

Yes. Ethical committee’s report is enclosed.

8. BIBLIOGRAPHY

1. Dr J P, Majra and Dr. Das Acharya. Awareness Regarding Self Care among Diabetics in Rural India.middle east jur of fam med. [Serial online] Jul 2009 [cited on 2009 Nov 10]; 7(6). Available from URL:

2. James Norman. Diabetes Introduction. Endocrine web [Serial online] Sep 2009 [cited on 2009 Nov 10]; Available from URL: http/ /diabetes

3. Thaís Santos Guerra Stacciarini; Ana Emilia Pace; Vanderlei José Haas. Insulin self-administration technique with disposable syringe among patients with diabetes mellitus followed by the family health strategy. Rev. Latino-Am. Enfermagem [Serial online] July/Aug. 2009 [cited on 2009 Nov 10]; 17(4): Available from URL :

4. Prevalence of diabetes. Data and statistics by World Health Organization. Available from URL:

5. India to have 57 million diabetics by 2025. Dance with saddow [Serial online] 31 August, 2007 [cited on 2009 Nov 10]; Available from URL :

6. 9% prevalence of diabetes in persons above 30 among survey population. The hindu. Oct 17, 2009 [cited on 2009 Nov 10]; Available from URL :

7. A short performance test can help to predict adherence to self-administration of insulin in elderly patients with diabetes . Age and Ageing [Serial online]2006 [cited on 2009 Nov 10]; 35(4):449-450; Available from URL :

8. IDO KEIKO, YATSUZUKA YUMI, MORIOKA JUNKO, TAKEICHI KANA. And ISHIDA SHIRO at al. Influence of Skill in Self-administration of Insulin on Glycemic Control. Japanese Journal of Pharmaceutical Health Care and Sciences [Serial online] 2006 9cited on nov 2009);32(9);890-7. Available from URL:

9. Stacciarini TS, Haas VJ and Pace AE. Factors associated with insulin self-administration by diabetes mellitus patients in the Family Health Strategy. Cad Saude Public[Serial online] 2008 Jun(cited on Nov 2009);24(6):1314-22. Vailable from URL:

10. Villanyi D and Wong RY. Self-reported understanding of diabetes and its treatment among elderly ambulatory subjects in British Columbia. Am J Geriatr Pharmacother [Serial online] 2007 Mar (cited on Nov 2009);5(1):18-30. Available from URL:

11. Dall'Antonia C and Zanetti ML. Insulin self administration in children with diabetes mellitus, type . Rev Lat Am Enfermagem [Serial online] 2000 Jul (Cited on Nov 2009) ;8(3):51-8. Available from URL:

12. Dunning T and Manias E. Medication knowledge and self-management by people with type 2 diabetes. Aust J Adv Nurs [Serial online] 2005 Sep-Nov (Cited on Nov 2009) ;23(1):7-14. Available from URL:

13. Mohan D. Raj D, Dattam, at al. Awareness and knowledge ofdiabetes in chennai-the chennai Urban rural Epidemiology Study;Health Policy October 2003; 66(1): 61-72.

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