Barriers to self-injecting are common among diabetes patients who are on insulin and coordinated efforts are needed to overcome them.

This was according to a cross-sectional study carried out to study the possible factors that may act as barriers to effective self-injection of insulin among diabetic patients at the three referral hospitals in Bhutan.

“Understanding the barriers will contribute towards increasing the effectiveness of physician communication, ensuring better medication adherence, achieving glycaemic control and preventing complications,” it states.

The study was conducted from January to June 2017 where all patients on insulin therapy for more than three months were included. About 207 responded on insulin therapy with the mean age of 55 years. The mean duration of diabetes was 10.6 years.

About 77 (37.2 percent) respondents said that injection dexterity was an issue while 37 respondents (17.8 percent) reported they would miss their insulin shots if their caregivers were unavailable.   

“The fear of injection was more common when respondents were supplied with the ‘1 ml syringe’ instead of the insulin syringe,” the study states. “Patients also had fear of side effects such as weight gain and hypoglycaemia.”

These factors, the study stated to act as an inertia for both the initiation of therapy and titration of insulin doses. “The use of an insulin pen has better uptake compared to conventional insulin syringes but in Bhutan, the essential medicine list neither provides insulin pen nor its cartridge.”

The study states that insulin, despite its increasing cost, is prescribed to selected cases of diabetic patients with an aim to achieve good glycaemic control, which is the level of blood sugar in a person with diabetes mellitus.

“The benefits of adequate glycaemic control in reducing complications, morbidity and mortality risks are well established,” it states.

With an estimated 40,000 persons with diabetes across the country, injectable insulin is made available up to the district hospitals in Bhutan.

Although the majority (86.4 percent) of the respondents knew why insulin was injected, 72 percent found that the healthcare personnel’s demonstration on the use of insulin was inadequate and 24.2 percent felt that they did not receive enough information on how to inject insulin.

A review in 2015 showed that glycaemic control was achieved only in 38 percent of diabetic patients in general in Bhutan.

With a steady increase in the burden of diabetes and other non-communicable diseases in the country, the study states that insulin may be made available even to the primary level health centres.

“Analogue insulin contributes a significant share to the increasing cost of diabetes treatment and more efforts are needed to address the barriers to insulin therapy to bring about improved glycaemic control in our patients.”

A limited number of participants from the eastern regional referral hospital due to poor availability of data was one of the limitations of the study.

It states that the study was conducted in the three referral hospitals where there are dedicated physicians and nutritionists to provide care for patients with diabetes. “The situation might be different in district hospitals where care is provided by general doctors.”

Dechen Tshomo