O R I G I N A L P A P E R
Knowledge, attitude, and practice concerning hypoglycaemia, insulin use, and insulin pens in Vietnamese diabetic
outpatients: Prevalence and impact on safety and disease control
Thi Kim Cuc Ngo PharmB
1| Thi Ha Vo PharmB, PhD
2,3| Chuyen Le Assoc. Prof., PhD, MD
41Faculty of Pharmacy, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
2Faculty of Pharmacy, Pham Ngoc Thach University of Medicine, Ho Chi Minh, Vietnam
3Department of Pharmacy, Nguyen Tri Phuong Hospital, Ho Chi Minh, Vietnam
4Pharmacology Department, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
Correspondence
Chuyen Le, Pharmacology Department, Hue University of Medicine and Pharmacy, Hue University, Hue V-49000, Vietnam.
Email: [email protected]
Funding information
Hue University of Medicine and Pharmacy
Abstract
Rationale, Aims, and Objectives:
This study aimed to assess the knowledge, attitude, and practice (KAP) of Vietnamese diabetics in an outpatient setting regarding hypoglycaemia, insulin use, and insulin pen and to evaluate the factors related to the KAP, adverse drug reactions (ADRs), and glycaemic control status.
Methods:
We interviewed patients by 16-item questions on knowledge and eight questions on attitude, and requested the patient to demonstrate the injection tech- nique with a sampled insulin pen.
Results:
The response rate was 74% (148 patients included). The proportions of patient having a good knowledge, positive attitude, and good practice were 45.9%, 78.4%, and 44.6%, respectively. The two most common incorrect steps in using insu- lin pen were skipping to prime pen needle (90.9%) and not removing the used needle from the pen after using (87.8%). Patients using insulin at least 1 year had better knowledge (P = .025), more positive attitude (P = .017), and better practice of using insulin pen (P = .042). Patients had more positive attitude of insulin's role (P = .038) if they either used insulin in combination with oral diabetic medications or had history of using insulin vials. The number of patients having good knowledge was statistically significant higher in participants who previously received counselling from health professionals (P = .001). We also found a positive correlation between good knowl- edge of patients and good practice skills (P < .001). Patients with poor practice of insulin were more likely to have ADRs at the injection sites (P = .013). The patients with poorer level of knowledge had significant higher risk of hypoglycaemia (P = .001). KAP levels did not correlate with glycaemic control status.
Conclusions:
The majority of outpatients had positive attitude towards insulin's role;
however, their knowledge and practice of hypoglycaemia and using insulin pen needs improvement. This study will be helpful in the planning of patient education strategies.
K E Y W O R D S
attitude, diabetes, insulin pen, knowledge, practice
Thi Kim Cuc Ngo and Thi Ha Vo are the shared first coauthors.
J Eval Clin Pract.2020;1–10. wileyonlinelibrary.com/journal/jep © 2020 John Wiley & Sons Ltd 1
1 | I N T R O D U C T I O N
The number of people with diabetes in the world has risen to 422 million in 2014. WHO estimates that diabetes was the seventh leading cause of death in 2016. Diabetes prevalence has been rising more rapidly in the middle- and low-income countries.1Vietnam is situated in the Southeast Asia region with a surface area of 365 000 km2and a population of approximately 97 million (2018), ranking as the 15th most populous country in the world.2Vietnam has both the highest and fasted-growing rate of diabetes in South- east Asia. In Vietnam, the prevalence of diabetes has almost dou- bled within the past 10 years and has consequently been recognized as a major public health burden. The age-adjusted com- parative prevalence of diabetes in the population of Vietnam was approximately 6% in 2017.3
Insulin is the main treatment for type 1 diabetes (T1DM) and in many cases of uncontrolled type 2 diabetes (T2DM). According to the Institute of Safe Pharmaceutical Practices of America,4 insulin is classified as a high-alert medication and associated with medication errors in the United States. In 2015, the fifth National Diabetes Inpatient Audit (NaDIA) in England and Wales deter- mined that errors associated with insulin affected 45% of patients who used insulin, a significant increase over 2013.5Nguyen et al reported in 2014 a medication errors rate of 28% in the prepara- tion and administration of insulin in two Vietnamese hospitals– all with potential moderate/severe outcome.6The related issues include lack of knowledge about insulin, a misconception of the role of insulin therapy, and errors in the practice of using insulin techniques in diabetic patients.7-10These important causes may lead to non-adherence to medicines, reduction of the effective- ness of treatment, and increase the risk of adverse drug events such as severe hypoglycaemia, injection sites reactions, and diabe- tes complications.11,12
In many countries in the world, the pharmacists play a key role in diabetes management and improvement of patient health.13 However, the Vietnamese pharmacists' clinical role is still limited.
The basic concepts of clinical pharmacy were introduced in Vietnam in 1990,14 and in 2012, the Ministry of Health (MOH) released the Guidelines on Clinical Pharmacy Practice in Hospitals to encourage and develop clinical pharmacy activities.15Recently, MOH published in 201916 the Guidelines on Clinical Pharmacy Practice for non-communicable diseases (NCDs) in which diabetes is one of targeted NCDs for this national program. Most diabetic patients are treated at home and pharmacists can play an important role in patient counselling of drug use.17 Therefore, this study aimed to assess the knowledge on hypoglycaemia and insulin use, attitude on insulin use, and practice regarding insulin pen use among diabetics in an outpatient setting at a teaching hospital; and to determine factors related to the knowledge, attitude, and prac- tice (KAP), adverse drug reactions (ADRs), and glycaemic control status. The study's findings will help the hospital's clinical pharmacy team in establishing the next educational interventions for diabetic patients.
2 | M E T H O D S
2.1 | Study design and participants
A descriptive study was conducted in a teaching hospital (Hue Univer- sity Hospital) between March 2018 and May 2019 in Hue, Vietnam.
The eligibility criteria for this research study were: (a) being 18 years of age or older; (b) being diagnosed with type 1 and/or 2 dia- betes and not pregnant; (c) being prescribed one or more of the dis- posable insulin pens for a minimum of 8 weeks; (d) self-administering insulin pens, (e) having information about a glycated haemoglobin (HbA1c) test and fasting plasma glucose (FPG) test, and (f) being will- ing to participate in the research study. The criterion of 8 weeks insu- lin pen use was chosen to observe the alteration in HbA1c levels.
The exclusion criteria were: (a) being not physically or mentally able to carry out the interview and (b) already surveyed.
The sample size was calculated using the following formula:
n=z21−α
2Pð1−PÞ=d2:
wherenwas the required sample size;z21−α
2was 1.96 according to the accepted error of 5% and two-sided effect;Pwas 8.5% (the rate of patients were following all competency components of prefilled insu- lin pen usage among diabetes patients in Saudi Arabia18); anddwas 0.05 (confident limit around the point estimate).
The required minimal sample size was 120 patients. For conve- nience of the sampling process, on each day of survey, the first three to five consecutive adult outpatients who were waiting for drug sup- ply at the pharmacy after visiting the Department of Endocrinology and Metabolism outpatient clinic were selected and explained about the survey; and if willing, interviewed in a separate space by one phar- macist (T. K. C. N.). The surveys were carried out 1 or 2 days per week. Consequently, 148 patients who fulfilled the research criteria were enrolled in this study.
2.2 | Measurement instruments
The patient information was collected through a direct interview. The questionnaire consisted of socio-demographic and medical back- grounds of the patients, and three domains namely, KAP of insulin pen using techniques.
2.3 | Socio-demographic and clinical characteristics form
The socio-demographic data (age, gender, location, level of education, and occupation) and diabetes-related data (type, duration of diabetes, duration of insulin therapy, family history, comorbidity, and diabetic treatment) were collected by interviewing patient and double- checking the data in the outpatient medical records. Regarding the
treatment outcomes, the HbA1c and other parameters were col- lected from the patients' medical records in the last 3 months. We asked each patient about ADRs, hypoglycaemia, and reactions at the injection sites including (a) lipodystrophy (lipohypertrophy, lipoatrophy), (b) pain, (c) bleeding, (d) bruise, (e) insulin leakage, and/or (f ) broken needle which occurred during the previous 3 months. The presence of at least one of them was accepted as a complication.
2.4 | Development of KAP questionnaire and data collection
The questionnaire used for the survey related to KAP was constructed after reviewing of similar questionnaires used in other studies7,11and was modified by the author (T. K. C. N.) and underwent content vali- dation by a peer group comprising two senior clinical pharmacists (T. K. C. N. and T. H. V.) and one endocrinologist (C. L.). Experts reviewed whether the questionnaire was appropriate with the objec- tives and item generation through literature review. The questionnaire was pre-tested on a group of three diabetic outpatients to ensure that it was unambiguous. From feedbacks of piloting, some questions were reworded or placed in a better order. The final questionnaire had 16 questions related to knowledge, 8 questions pertained to attitude, and 10-step checklists of practice steps.
Knowledge was measured using 16 questions related to hypoglycaemia and insulin use. Example of questions covering knowl- edge was‘What are causes of hypoglycaemia?’ Answers were pro- vided with multiple choices and‘Don't know’followed by correct and incorrect responses to further evaluate the responses. One point was offered for each correct response and the total score was calculated.
Score ranges of 0 to 8 and 9 to 16 were considered as poor and good knowledge, respectively.
An attitude was assessed using eight 5-point Likert scale related to patient's opinion on insulin role. For example,‘Insulin use helps to prevent complications of diabetes’. Responses to above questions were assessed with five categorical responses: (a) strongly disagree, (b) disagree, (c) neither agree nor disagree, (d) agree, (e) strongly agree.
The average scores of the attitude of each patient ranged above 3 point were categorized as having positive attitudes.
Practice was assessed by using a 10-step checklist when demand- ing patients to demonstrate how to inject with similar sample pens.
Pharmacists observed patients and each step was assessed in order to evaluate the correct and incorrect practice. One point was offered for each correct step and the total score was calculated. Score ranges of 0 to 5 and 6 to 10 were considered as poor and good practice, respectively.
According to the American Diabetes Association Guidelines 2019,19FPG target range is 80 to 130 mg/dL (4.4-7.2 mM/L) and a HbA1C is <7% (53 mM/mol) for non-pregnant adult patients.
Less stringent HbA1C (<8%) and FPG (90-150 mg/dL) are appro- priate for patients with more complicated disease features or the elderly.
2.5 | Ethical considerations
The study was approved by the local university ethical review board (Document Number: H2018/060). The study was conducted in a spirit of respecting the private information and patients had oral informed consent before data collection. After data collection, the patients who were incorrectly implementing the steps of insulin injection were trained by the researchers until the erroneous implementation is corrected.
2.6 | Statistical analysis
All data were analysed by using SPSS software version 20.0. Data were expressed in frequency, percentage, mean ± SD after checking that all data was normally distributed. Chi-squared test was used for inter-group comparison of categorical variables and assessment the correlation between the variables. Fisher's exact test for some cells which have expected counts less than 5. All analyses were two-tailed.
ThePvalue of <.05 was considered to be statistically significant.
3 | R E S U L T S
3.1 | Patient characteristics and clinical profile of participants
We interviewed 200 patients: 14 patients refused to participate;
38 patients were excluded because of incomplete data. A total of 148 patients were included in the study of which the response rate was 74%. The majority (62.2%) were female and 60 years and older (63.5%).
Regarding the educational level, only 14.8% had higher educational level than high school. More than a half of the patient (55.4%) lived in urban areas. The retired people or unemployed (66.2%) was the predominant group and 20.3% of them had family history of diabetes (Table 1)
The majority were diagnosed as type 2 diabetes mellitus (96.6%) with comorbidities (89.2%); had diabetes at least 5 years or more (70.3%); and had insulin treatment of 1 year or more (70.3%). The mean FPG result and HbA1C levels were 10.6 ± 4.1 mM/L and 8.4 ± 1.6 mg/dL, respectively.
There were 35.9% and 24.4% of patients achieved treatment goals.
There were only two types of insulin used: Insulin Aspart (70/30) and Insulin Glargine. The majority of patients were prescribed Insulin Aspart (70/30) Pen (79.7%). A large group of patients (87%) admitted that they had been treated with insulin vial previously. Eighty-nine patients (60.1%) had received counselling for insulin pen from the health professionals previously. The majority (73.6%) of patients took oral diabetes medication in combination with insulin.
Regarding the ADRs of the respondents, 77.7% of them experi- enced at least one complication at the injection sites such as bruise (65.5%), pain (60.1%), bleeding (31.1%), insulin leakage (20.9%), lipo- dystrophy (14.9%), distortion, and bending of needle (4.7%). The clini- cal data revealed that nearly half of the participants (45.3%) had hypoglycaemia recently.
3.2 | Knowledge regarding hypoglycaemia and insulin
Of the 16 questions related to knowledge, the mean score of right answers was 8.2 ± 2.3 compared to the maximum score of 16 and 45.9% had good knowledge. Frequency distributions of true responses regarding knowledge were presented in Table 2.
3.3 | Attitude regarding insulin therapy
Of the 148 participants, 78.4% had a positive attitude about using of insulin with a mean score of 3.4 ± 0.5 compared to the maximum score of 5. Frequency distributions of patients' responses regarding attitudes were presented in Figure 1.
3.4 | Practice skill regarding using of the insulin pen
There were 66 patients (44.6%) had a good practice of insulin pens.
The mean score of right practice was 5.2 ± 1.4 compared to the maxi- mum score of 10. Frequency distributions of correct steps regarding insulin pen injection were reported in Table 3.
T A B L E 1 Baseline data of participants (n = 148)
Parameter Distribution N (%)
General features Age
18-59 54 (36.5)
≥60 y old 94 (63.5)
Sex
Male 56 (37.8)
Female 92 (62.2)
Location
Urban areas 82 (55.4)
Rural areas 66 (44.6)
Level of education
High school and lower 126 (85.2)
Graduate or higher 22 (14.8)
Active occupation
Yes 50 (33.8)
No 98 (66.2)
Diabetic profile Type
Type 1 5 (3.4)
Type 2 143 (96.6)
Duration of diabetes
<5 y 44 (29.7)
≥5 y 104 (70.3)
Duration of insulin use
<1 y 44 (29.7)
≥1 y 104 (70.3)
Insulin cost paid by health insurance
100% 34 (23.0)
<100% 114 (77.0)
Family history of having diabetes
Yes 30 (20.3)
No 118 (79.7)
Comorbidity
Yes 132 (89.2)
No 16 (10.8)
Diabetic treatment Insulin pen
Type 1 138 (93.2)
Type 2 10 (6.8)
Used to take insulin vial
Yes 100 (67.6)
No 48 (32.4)
Used to take other insulin pen
Yes 55 (37.2)
No 93 (62.8)
T A B L E 1 (Continued)
Parameter Distribution N (%)
Combining with oral anti-diabetic medicines
Yes 109 (73.6)
No 39 (26.4)
Had received counselling from health professionals
Yes 89 (60.1)
No 59 (39.9)
Treatment outcomes
Glycaemic control−value (mean ± SD)
HbA1c (%) 8.4 ± 1.6
FPG (mM/L) 10.6 ± 4.1
Glycaemic control−prevalence (%)
HbA1c 53 (35.9)
FPG 36 (24.4)
Adverse drug reactions previous month Hypoglycaemia
Yes 67 (45.3)
No 81 (54.7)
Problem at injection sites
Yes 115 (77.7)
No 33 (22.3)
Abbreviations: FPG, fasting plasma glucose; HbA1c, glycated haemoglobin.
3.5 | Factors associated with KAP results
Analysis of factors associated with KAP results was summarized in Table 4. Patients taking insulin 1 year or more had better knowledge (P= .025), more positive attitude (P= .017), and better practice of insulin pen (P= .042). Patients using insulin in combination with oral diabetic medications or having history of using insulin vials had more positive attitude of insulin role (.038). Those having good knowledge was statistically significant higher in participants who received counselling from health professionals previously (P= .001). We also found a positive correlation between patients' good knowledge and good practical skills (P< .001). Other independent variables, such as age, sex, location, occupation, level of education, duration of diabetes, family history, and comorbidity, did not affect significantly the KAP results.
3.6 | KAP results associated with ADRs and glycaemic control status
Patients with poor practice of insulin were more likely to have ADRs at the injection sites (P= .013). The patients with poor level of knowl- edge about hypoglycaemia and insulin use had significant higher risk
of hypoglycaemia (P= .001). However, KAP levels did not correlate with both FPG and HbA1c control status (Table 5).
4 | D I S C U S S I O N S
4.1 | Knowledge regarding hypoglycaemia and insulin
Hypoglycaemia is one of the most common acute complications of diabetes mellitus. The knowledge of patients about hypoglycaemia will help them in the prevention and management of the problem. The study revealed that the majority of patients were familiar with symp- toms and remedial measures for hypoglycaemia, but much fewer patients knew the level of glycaemia considered as hypoglycaemia as well as the precipitating factors of hypoglycaemia or using glucometer to check blood glucose at home. The poor knowledge maybe the rea- sons of hypoglycaemia during the previous month (57.5%). This hypothesis was supported by the statistical analysis that showed patients having good knowledge were less likely to become hyp- oglycaemic (P= .001) (Table 5). These findings are consistent with the prior study done in India.20 They found that only 66.1% diabetic patients had good knowledge on hypoglycaemia. However, Kahsay et al found that self/family blood glucose monitoring at home could not guarantee to minimize the occurrence of hypoglycaemia events.21 Regarding the knowledge of the insulin pen use, the majority of the patients knew various types of insulin, injection sites, requirement of rotation of the injection sites, injection site complications, and the right time to inject insulin regard to meals, and storage condition of spare insulin pens. However, the survey revealed that many patients did not have good knowledge on insulin needle and expiration date after opening the pen. For example, only nine patients (6.1%) knew how to use a new pen needle for each injection while the others (93.9%) reused needles many times for savings. If the needle is not removed from the pen between two injections, air may leak into the injector causing wrong dose insulin injection.11 Reusing the needle may result in distortion, bending of needle encountered in seven patients and can cause painful injections in 60.1%. Other studies reported that pen needle reuse was quite high in their study with a range of 50% to 80%10,11 and this problem increased the risk of lipohypertrophy.8,9,11Compared to other studies, this very disappoint- ing result of using correctly insulin pen in our study requires special attention of the clinical pharmacists in patient education.
Many patients misunderstood that the in-use insulin pens had to be kept in the refrigerator at 2C to 8C. Mitchell et al10reported that three-fourths of users did not follow the manufacturer's instructions for storage of the in-use insulin pens. All patients knew the location of abdominal injection, but only 62.8% of patients knew more than one injection site on the body. A survey in China reported that more than 80% of patients only limited changes in the abdominal area.9The rep- etition of the same injection site increased the risk of lipohypertrophy.8In our study, 14.9% patients reported lipodystrophy compared to 29.0% in other study.8
T A B L E 2 Frequency distribution of correct response regarding knowledge
A. Question to assess hypoglycaemic knowledge N (%) A1. Know the blood glucose levels of hypoglycaemia 41 (27.7) A2. Understand causes of hypoglycaemia 47 (31.8) A3. Know the symptoms of hypoglycaemia 128 (86.5) A4. Know how to use glucometer to check blood
glucose at home
30 (20.3)
A5. Name measures to treat hypoglycaemia 130 (87.8) B. Question to assess insulin knowledge
A6. Know the various types of insulin 105 (70.9) A7. Know the body injection sites 93 (62.8) A8. Rotating the injection sites 138 (93.2) A9. Knowing the injection site complications 116 (78.4) A10. Knowing the right time to inject insulin regard to
meals
127 (85.8)
A11. Knowing the length of the insulin needle 43 (29.1) A12. Using a new needle for each injection 9 (6.1) A13. Disposing the used needles in a special
container at home
1 (0.7)
A14. Keeping the spare insulin pens in the refrigerator at 2C-8C
144 (97.3)
A15. Keeping the used insulin pens at room temperature below 28C
29 (19.6)
A16. Knowing the expiration date after opening the pen
36 (24.2)
Note: Total: mean ± SD: 8.2 ± 2.3. Good knowledge: 68 (45.9). Poor knowledge: 80 (54.1).
4.2 | Attitude regarding insulin therapy
Majority of the respondents had a positive attitude regarding insulin role to prevent complication, to improve health and to better control blood glucose, and also found insulin injection techniques easy and not-time consuming. However, patients were uncertain or their atti- tudes were clustered at the high and low extremes on insulin role compared to diet, exercise, and oral anti-hyperglycaemic agents' role, and dependence on physician for adjusting insulin use. Cosson et al22 evaluated perceptions of insulin therapy in patients with type 2 diabe- tes and found that two-thirds of adults reported that transitioning to
insulin therapy was less difficult than expected and 21% of adults con- sidered injections to be a major patient fear.
4.3 | Practice skill regarding using of the insulin pen
The three most common incorrect steps were skipping to prime pen needle (90.9%), not removing the used needle from the pen after using (87.8), and not holding for specific count time before the with- drawal of pen needle from skin (50.7%). Particularly, 44 of F I G U R E 1 Frequency distribution of patients' response regarding attitudes.
C1. Insulin use helps to prevent complications of diabetes. C2. Insulin use helps to improve your health. C3. Insulin use helps to control blood glucose better.
C4. Insulin injection techniques are very easy. C5. Insulin injections is not time consuming. C6. Once insulin is started diet, exercise, and oral anti-diabetic drugs are not enough to control diabetes. C7.
Starting insulin does not means my worse diabetic condition. C8. Insulin therapy does not make me more depend on a physician
T A B L E 3 Frequency distribution of correct steps regarding insulin pen practice
No. Steps
Insulin Aspart 70/30 (118 patients)
Insulin Glargine
(30 patients) Total 148 patients
N (%) N (%) N (%)
1 The insulin pen kept at room temperature at least for 15 min before injection
83 (70.3) 16 (53.3) 99 (66.9)
2 Washing hands with soap and water before handing injection devices
81 (68.6) 18 (60.0) 99 (66.9)
3 Remove the cap from the pen and gently roll the pen back and forth between the palms of your hands 10 times. Gently tip the pen up and down 10 times to ensure a consistently milky white appearance
74 (62.7) 30 (100) 104 (70.3)
4 Attach a needle to the pen 118 (100) 30 (100) 148 (100)
5 Remove air from the pen 14 (11.9) 1 (3.3) 15 (10.1)
6 Select the correct dose on the pen 112 (94.9) 28 (93.3) 140 (94.6)
7 Clean the skin where you will inject the insulin 82 (69.5) 23 (76.7) 105 (70.9)
8 Insert the needle straight into the skin and push the injection button to inject the insulin
115 (97.5) 29 (96.7) 144 (97.3)
9 Keep the needle in place for at least 6 s before pulling the needle out
59 (50.0) 14 (46.7) 73 (49.3)
10 Recap the used needle with the outer cap and remove the needle from the pen
13 (11.0) 5 (16.7) 18 (12.2)
Note:Total: mean ± SD: 5.2 ± 1.4. Good practice: 66 (44.6). Poor practice: 82 (55.4).
T A B L E 4 Factors related to KAP of participants
Independent variables Good knowledge Positive attitude Good practice
Age P= .275 P= .267 P= .161
18-59 (n = 54) 28 (51.9) 45 (83.3) 20 (37.0)
≥60 y old (n = 94) 40 (42.6) 71 (75.5) 46 (48.9)
Sex P= .353 P= .091 P= .090
Male (n = 56) 23 (41.1) 48 (85.7) 20 (35.7)
Female (n = 92) 45 (48.9) 68 (73.9) 46 (50.0)
Location P= .660 P= .769 P= .850
Urban areas (n = 82) 39 (47.6) 65 (79.3) 36 (43.9)
Rural areas (n = 66) 29 (43.9) 51 (77.3) 30 (45.5)
Active occupation P= .480 P= .732 P= .064
Yes (n = 50) 25 (50.0) 40 (80.0) 17 (34.0)
No (n = 98) 43 (43.9) 76 (77.6) 49 (50.0)
Level of education P= .103a P= .574a P= .357a
High school and lower (n = 126) 54 (42.9) 100 (79.4) 54 (42.9)
Graduate or higher (n = 22) 14 (63.6) 16 (72.7) 12 (54.4)
Duration of diabetes P= .246 P= .516 P= .343
<5 y (n = 44) 17 (38.6) 33 (75.0) 17 (38.6)
≥5 y (n = 104) 51 (49.0) 83 (79.8) 49 (47.1)
Duration of insulin use P= .025* P= .017* P= .042*
<1 y (n = 44) 14 (31.8) 29 (65.9) 14 (31.8)
≥1 y (n = 104) 54 (51.9) 87 (83.7) 52 (50.0)
Family history of having diabetes P= .9292 P= .452 P= .798
Yes (n = 30) 14 (46.7) 22 (73.3) 14 (46.7)
No (n = 118) 54 (45.8) 94 (79.7) 52 (41.1)
Comorbidity P= .433a P= .195a P= .604a
Yes (n = 132) 59 (44.7) 101 (76.5) 60 (45.5)
No (n = 16) 9 (56.2) 15 (93.8) 6 (37.5)
Used to take insulin vial P= .282 P< .001* P= .229
Yes (n = 100) 49 (49.0) 87 (87.0) 48 (48.0)
No (n = 48) 19 (39.6) 29 (60.4) 18 (37.5)
Combining with oral anti-diabetic medicines P= .731 P= .038* P= .546
Yes (n = 109) 51 (46.8) 90 (82.6) 47 (43.1)
No (n = 39) 17 (43.6) 26 (66.7) 19 (48.7)
Had received counselling from health professionals P= .001* P= .612 P= .145
Yes (n = 89) 51 (57.3) 71 (79.8) 44 (49.4)
No (n = 59) 17 (28.8) 45 (76.3) 22 (37.3)
Knowledge P= .603 P< .001*
Good (n = 68) 52 (76.5) 41 (60.3)
Poor (n = 80) 64 (80.0) 25 (31.2)
Attitude P= .603 P= .134
Positive (n = 116) 52 (44.8) 48 (41.4)
Negative (n = 32) 16 (50.0) 18 (56.2)
Abbreviation: KAP, knowledge, attitude, and practice.
aFisher's exact test for some cells which have expected counts less than 5.
*P< .05: statistically significant.
118 (37.3%) patients using mixed insulin did not mix them before injection. Medication errors related to insulin pen practice were reported commonly in many studies.10 Mitchell et al revealed that three-fourths of users did not follow the manufacturer's instructions for proper administration and storage of insulin pens.10
4.4 | Factors associated with KAP results, ADRs, and glycaemic control status
We found a significant association between the patient's better knowledge and the patient's longer duration of insulin therapy (≥1 year) (P= .025) and receiving consultation from the health profes- sionals (P= .001). Several recent studies have shown the importance of hospital pharmacists performing patient education for diabetes mellitus.10,13,23
Patients having longer time with insulin treatment are more likely to have positive attitude (P= .017). This finding is similar to that of Cosson et al's study22conducted in France in 2019.
Our study also found that patients improved their attitude after switching from vials to insulin pen (P< .001). This is consistent with Ramadan et al's study24 in which 85.7% of pen users found it was
more convenient and significantly less painful than the conventional vial/syringe.
Patients using insulin combined with oral anti-diabetic drugs (OAD) had better attitude on insulin role (P= .038). A similar KAP sur- vey in India7found that patient using insulin with longer duration of OAD use (≥3 years) was associated with better perception on benefits of insulin use (P< .001), awareness that insulin is not habit forming in nature (P= .001), need for continuity in insulin use (P= .002), and the confidence for self-administration of insulin (P= .042).
Duration on insulin therapy (≥1 year) and patient's good knowl- edge significantly improved the patient's practical skills (P= .042 and
<.001, respectively). Therefore, patients with good injection technique were less likely to get ADRs in injection sites (P= .013). Mitchell et al reported that correct usage scores of insulin pens were significantly higher if initial education on insulin pens was performed by a pharma- cist or nurse.10
Our study found that the KAP levels did not correlate with both FPG and HbA1c control status. However, Solanki et al in 201725 reported a positive correlation between KAP score and glycaemic control, with significance for only glycosylated haemoglobin but not fasting blood sugar, and postprandial blood sugar. One of the reasons was our KAP questionnaire only focused on hypoglycaemia and insu- lin pens but not broad diabetic management.
T A B L E 5 Factors related to results and ADRs of participants
Dependent variables Independent variables N (%) P
ADRs at injection sites Knowledge Good (n = 68) 56 (82.4) .210 Poor (n = 80) 59 (73.8)
Attitude Positive (n = 116) 88 (75.9) .306 Negative (n = 32) 27 (84.4)
Practice Good (n = 61) 45 (68.2) .013*
Poor (n = 87) 70 (85.4)
Hypoglycaemia Knowledge Good (n = 68) 21 (30.9) .001*
Poor (n = 80) 46 (57.5)
Attitude Positive (n = 116) 52 (44.8) .837 Negative (n = 32) 15 (46.9)
Practice Good (n = 61) 29 (43.9) .770
Poor (n = 87) 38 (46.3)
FPG controlled Knowledge Good (n = 68) 16 (23.5) .835
Poor (n = 80) 20 (25.0)
Attitude Positive (n = 116) 27 (23.3) .571 Negative (n = 32) 9 (28.1)
Practice Good (n = 61) 18 (29.5) .218
Poor (n = 87) 18 (20.7)
HbA1c controlled Knowledge Good (n = 68) 25 (36.8) .823
Poor (n = 80) 28 (35.0)
Attitude Positive (n = 116) 40 (34.5) .521 Negative (n = 32) 13 (40.6)
Practice Good (n = 61) 28 (45.9) .032
Poor (n = 87) 25 (28.7) Abbreviations: ADRs, adverse drug reactions; FPG, fasting plasma glucose.
*P< .05: statistically significant.
4.5 | Strengths and limitations
One of the major advantages of this study is to determine which knowledge patients lacked and the erroneous steps of insulin injec- tion, as well as related factors in order to shape the patient educa- tion and target specific patients for education. However, some limitations should be considered when interpreting the results.
Firstly, KAP questionnaire was focused only on insulin pen use, but not a broader coverage in treatment of diabetes. Secondly, patients in our study used only two types of insulin pens (Insulin Aspart 70/30 and Insulin Glargine) because of the hospital's limited resources.
5 | C O N C L U S I O N
We found in this study, the majority of Vietnamese diabetic patients in an outpatient setting, had positive attitude towards the insulin's role; however, their knowledge and practice of using insulin pen needs improvement. This study will be helpful in the planning of patient edu- cation strategies.
A C K N O W L E D G E M E N T S
The authors wish to thank hospital clinical pharmacists in Hue University Hospitals for helping us to conduct the research and patients for participating in evaluation the tool in this research, and Mrs Tuyen Ho for English language editing. This study was funded by Hue University of Medicine and Pharmacy.
C O N F L I C T O F I N T E R E S T
The authors declare no conflict of interest.
A U T H O R C O N T R I B U T I O N S
All authors designed the study. Thi Kim Cuc Ngo and Thi Ha Vo col- lected and analysed the data of the study. All authors are major con- tributors in writing the manuscript. All authors read and approved the final manuscript.
E T H I C S A P P R O V A L
Hue University of Medicine and Pharmacy.
R E F E R E N C E S
1. WHO. Diabetes. 2018. https://www.who.int/news-room/fact- sheets/detail/diabetes. Accessed January 16, 2020.
2. Central Intelligence Agency. The World Factbook: Vietnam. https://
www.cia.gov/library/publications/resources/the-world-factbook/
geos/vm.html. Accessed January 16, 2020.
3. Ngoc NB, Lin ZL, Ahmed W. Diabetes: what challenges lie ahead for Vietnam?Ann Glob Health. 2020;86(1):1.
4. Institute for Safe Medication Practices. ISMP Guidelines for Opti- mizing Safe Subcutaneous Insulin Use in Adults. 2017; https://
www.ismp.org/sites/default/files/attachments/2017-11/
ISMP138-Insulin%20Guideline-051517-2-WEB.pdf. Accessed January 16, 2020.
5. Health and Social Care Information Centre. National Diabetes Inpa- tient Audit – 2015. 2016; https://www.hqip.org.uk/wp-content/
uploads/2018/02/national-diabetes-inpatient-audit-2015.pdf.
Accessed June 29, 2020.
6. Nguyen HT, Nguyen TD, Haaijer-Ruskamp FM, Taxis K. Errors in preparation and administration of insulin in two urban Vietnam- ese hospitals: an observational study. Nurs Res. 2014;63(1):
68-72.
7. Choudhury SD, Das SK, Hazra A. Survey of knowledge-attitude- practice concerning insulin use in adult diabetic patients in eastern India.Indian J Pharmacol. 2014;46(4):425-429.
8. Frid AH, Hirsch LJ, Menchior AR, Morel DR, Strauss KW. World- wide injection technique questionnaire study: injecting complica- tions and the role of the professional.Mayo Clin Proc. 2016;91(9):
1224-1230.
9. Ji J, Lou Q. Insulin pen injection technique survey in patients with type 2 diabetes in mainland China in 2010.Curr Med Res Opin. 2014;
30(6):1087-1093.
10. Mitchell VD, Porter K, Beatty SJ. Administration technique and stor- age of disposable insulin pens reported by patients with diabetes.
Diabetes Educ. 2012;38(5):651-658.
11. Tosun B, Cinar FI, Topcu Z, et al. Do patients with diabetes use the insulin pen properly?Afr Health Sci. 2019;19(1):1628-1637.
12. Rubin RR, Peyrot M, Kruger DF, Travis LB. Barriers to insulin injection therapy: patient and health care provider perspectives.Diabetes Educ.
2009;35(6):1014-1022.
13. Hughes JD, Wibowo Y, Sunderland B, Hoti K. The role of the pharma- cist in the management of type 2 diabetes: current insights and future directions.Integr Pharm Res Pract. 2017;6:15-27.
14. Vo TH, Bedouch P, Nguyen TH, et al. Pharmacy education in Vietnam.
Am J Pharm Educ. 2013;77(6):114.
15. Vietnamese Ministry of Health. Circular 31/2012/TT-BYT - Guide- lines on Clinical Pharmacy Practice in Hospitals. 2012; http://vbpl.vn/
boyte/Pages/vbpq-van-ban-goc.aspx?ItemID=71552. Accessed February 6, 2020.
16. Vietnamese Ministry of Health. Guidelines on Clinical Pharmacy Prac- tice for Pharmacists in Non-Commucable Diseases. 2019. https://
kcb.vn/vanban/quyet-dinh-so-3809-qd-byt-ngay-27-thang-8-nam- 2019-ve-viec-ban-hanh-huong-dan-thuc-hanh-duoc-lam-sang-cho- duoc-sy-trong-mot-so-benh-khong-lay-nhiem. Accessed February 6, 2020.
17. Le TQ, Le TMN, Vo THP, et al. Effectiveness of educational interven- tions on knowledge and counseling regarding common cold manage- ment: the case of community pharmacists in Hue, Vietnam.J Appl Pharm Sci. 2020;10(5):119-126.
18. Sweidan BA, Al Ajlouni MM, Robert AA, Alzaid AA. Competency of prefilled insulin pen usage among diabetes patients in Saudi Arabia: a cross-sectional study.Curr Diabetes Rev. 2019;15(3):240-246.
19. American Diabetes Association. 6. Glycemic targets: standards of medi- cal care in diabetes—2019.Diabetes Care. 2019;42(suppl 1):S61-S70.
20. Shriraam V, Mahadevan S, Anitharani M, et al. Knowledge of hypogly- cemia and its associated factors among type 2 diabetes mellitus patients in a tertiary Care Hospital in South India.Indian J Endocrinol Metab. 2015;19(3):378-382.
21. Kahsay H, Fantahun B, Nedi T, Demoz GT. Evaluation of hypoglyce- mia and associated factors among patients with type 1 diabetes on follow-up care at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.J Diabetes Res. 2019;2019:9037374.
22. Cosson E, Mauchant C, Benabbad I, et al. Perceptions of insulin therapy in people with type 2 diabetes and physicians: a cross-sectional survey conducted in France.Patient Prefer Adherence. 2019;13:251-260.
23. Ichiki Y, Kobayashi D, Kubota T, et al. Effect of patient education for diabetic outpatients by a hospital pharmacist: a retrospective study.
Yakugaku Zasshi. 2016;136(12):1667-1674.
24. Ramadan WH, Khreis NA, Kabbara WK. Simplicity, safety, and acceptability of insulin pen use versus the conventional vial/syringe device in patients with type 1 and type 2 diabetes mellitus in Leba- non.Patient Prefer Adherence. 2015;9:517-528.
25. Solanki JD, Sheth NS, Shah CJ, Mehta HB. Knowledge, attitude, and practice of urban Gujarati type 2 diabetics: prevalence and impact on disease control.J Educ Health Promot. 2017;6:35.
How to cite this article:Ngo TKC, Vo TH, Le C. Knowledge, attitude, and practice concerning hypoglycaemia, insulin use, and insulin pens in Vietnamese diabetic outpatients:
Prevalence and impact on safety and disease control.J Eval Clin Pract. 2020;1–10.https://doi.org/10.1111/jep.13454
