Level of insulin adherence among diabetes mellitus patients in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia, 2017: a cross-sectional study
Tewabe and Kindie BMC Res Notes
Level of insulin adherence among diabetes mellitus patients in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia, 2017: a cross-sectional study
Tilahun Tewabe 0
Selamsew Kindie 0
0 College of Medicine and Health Science, Bahir Dar University , Bahir Dar , Ethiopia
Objectives: The objective of this study was to know the level of insulin adherence and to identify factors affecting insulin adherence among diabetes mellitus patients in Felege Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia. Results: Prevalence of insulin adherence was 59.2%. Patients who are married [AOR = 0.3 (0.14-0.7)], have regular health care visit [AOR = 3.3 (1.5-7.5)] and accessing insulin with low cost [AOR = 2.9 (1.3-6.3)] were more likely to adhere insulin therapy than their counterparts. Recommendations to increase insulin adherence were: government and non-governmental organizations, volunteers and concerned bodies should support syringe and needles for diabetes patients, health care providers and responsible bodies should give intensive health education about the effect of stopping insulin medication.
Insulin adherence; Level; Felege Hiwot Referral Hospital; Bahir Dar; Ethiopia
Globally, prevalence of people living with diabetes (DM)
and is growing in all regions. In 2014 about 422 million
(8.5%) peoples had diabetes, compared to 108 million
(4.7%) in 1980 [
]. From these more than 14 million
people are in Africa and by 2040 this figure will be more than
DM is the commonest non-communicable disease
which is responsible for number of serious health
problems and complications in Ethiopia. Like many other
developing countries, in Ethiopia too, more attention is
given to the communicable diseases such as, HIV/AIDS,
tuberculosis and malaria. However, current studies
indicated that non communicable diseases like DM became
major public health problems in the country [
In Ethiopia national data on prevalence and
incidence of diabetes mellitus are lacking. However, patient
attendance rate, insulin therapy and admission rates in
major hospitals are rising. The WHO estimated number
of diabetes care in Ethiopia was 800,000 by the year 2000,
and this number is expected to increase to 1.8 million by
Diabetes mellitus is a challenging disease to manage
successfully. It has been reported that non adherence
rates for chronic illness regimens and lifestyle changes
was about 50% and patients with diabetes mellitus are
prone to substantial regimen adherence problems [
Non adherence to prescribed insulin therapy has been
and continues to be a major problem in the world. As
any chronic disease non adherence to insulin therapy has
been described as taking less than 80% of the prescribed
treatment which ranges from 23 to 77% [
Some studies in Ethiopia on non adherence rate to
treatment on diabetes mellitus patients showed: 70.9% in
Jimma University teaching hospital [
], 64.7% in Gonder
], 33.1% in Tikur Anbassa Hospital [
] showed of
diabetes patients had poor adherence to diabetic treatments
and another study on patient perception on diabetic
patients showed concerns were perceived and
experienced adverse effects, inconveniences in handling the
medications and access [
Adherence to insulin therapy is the major factor with
respect to treatment success rates. Poor adherence to
insulin therapy may have serious long term and
detrimental effect to the patient [
These non adherence to insulin medication is a
common problem in developing countries like Ethiopia,
where economic instability and inadequate access to
health care facilities is common [
Therefore, the purpose of this study was to assess
the level of insulin adherence and its associated factors
in Felege Hiwot Referral Hospital (FHRH), Bahir Dar,
Study area and setting
Institution based cross sectional study was conducted
from March 27 to June 12 2017. The study was conducted
in Felege Hiwot Referral Hospital (FHRH) which is found
in Bahir Dar city, northwest of Ethiopia. Bahir Dar is
the capital city of Amhara regional state. It is 564 kms
away from Addis Ababa. The population of the town is
318,429. The town has a total of 17 kebeles. FHRH is the
main referral hospital in the region. It provides obstetrics,
paediatrics, internal medicine, ophthalmology, general
surgery, gynaecology and orthopaedic surgery services.
There is also an emergency and outpatient departments
(OPD). The DM clinic is situated inside the outpatient
Sample size determination and sampling procedure
The sample size was calculated using single population
proportion formula by considering the following
assumptions; proportion (p) of insulin adherence which is 61%
], 95% level of confidence margin of error (d) = 5, 10%
non-response rate. Since the total population is less than
10,000, the sample size was adjusted using correction
formula. The final sample size became 182.
To select study participants consecutive sampling
technique was used, all diabetes mellitus patients who fulfil
the inclusion criteria and coming for follow up at the
time of data collection were included until the required
sample size is full filled.
Adherence to insulin therapy.
Sociodemographic factors such as; age, sex, religion,
ethnicity, educational level, income, marital status,
support system, insulin availability, etc.
Insulin adherence has been described as taking above
80% of the prescribed treatment and/or agrees between
the patient and the health care provider for the last
Insulin non adherence has been described as taking
less than 80% of the prescribed treatment by omitting
insulin medication without health personnel order in
the last 1 month.
Data collection procedure and data quality control
The data was collected by using interviewer
administered structured questionnaires which was adopted and
modified from previous studies done on similar topics
]. The questionnaire was first prepared in English
and translated to Amharic local language for data
collection and pretested on 5% sample size in other
hospital and adjustments were done based on the result of
Two diploma nurses were recruited as data collectors
and one Bachelors of Science nurse was recruited as
supervisor. All data collectors and supervisor attended
a 1 day training course on the study protocol and
The collected data was checked manually for
completeness and consistencies, and then it was coded and
entered in EPI Info version 3.5.3 and exported to SPSS
version 16 for analysis. Descriptive statistics were used
to summarize the socio-demographic characteristics’
of the study participants and the level of insulin
adherence. To identify factors associated with insulin
adherence, binary logistic regression analysis carried out.
Strength of association was measured using odds ratio,
and 95% confidence intervals. Statistical significance
was declared at P value < 0.05.
Socio demographic characteristics
A total of 182 diabetes mellitus patients were
participated in this study, which made a response rate of
100%. Most 89 (48.9%) participants were between 31
and 55 years of age. In this study, 100 (54.9%) were
males and 82 (45.1%) were female. Regarding residence,
most 129 (70.9%) of the respondents were lived in
urban. Most participants 156 (85.5%) were Amhara by
ethnicity. More than half 114 (62.6%) participants were
married and out of them 104 (57.2%) were secondary
school and above educated. From total respondents of
this study, majority 109 (59.9%) of the respondents had
average monthly income of 500–1000 Ethiopian Birr
Insulin adherence and related characteristics
Greater than half 114 (62.6%) of participants lived with
diabetes mellitus for less than 5 years. Most 169 (92.9%)
of participants dosing schedule of insulin was twice a day,
and more than half 98 (53.8%) of participants visit health
care providers once in 3 months.
Majority 176 (96.7%) of the participants did not take
their insulin at the same time daily. About 155 (85.2%)
respondents took insulin treatment before meal. From
total respondents, 109 (59.9%) took their insulin
treatment correctly. Whereas 73 (40.1%) defaulted their
insulin medication. The reasons for stopping insulin
treatment is due to forgetting in 86 (47.3%) study
participants, about 23 (12.6%) study participants miss their dose
of insulin purposely among them 2 (1.1%) of the
respondents can’t afford the cost of insulin, 4 (2.2%) of the
respondents miss their insulin treatment due to nature of
their work, 6 (3.3%) of the respondents miss their insulin
because they dislike the therapy, and 6 (3.3%) miss their
treatment due to other reasons like religious practices.
About 42 (23.1%) of the respondents stop their
medication if they feel better, while 21 (11.5%) of the study
participants stop their medication when they feel worse.
Other reasons of the respondents stop their insulin
treatment includes: medication is expensive 6 (3.3%), take
too many medications 8 (4.4%), the medication is
complicated 4 (2.2%), inconvenience 4 (2.2%), not sure of the
insulin is beneficial 9 (4.9%) and other reasons like
preferring holy water than insulin 25 (13.7%) (Table 2).
Factors associated with insulin adherence
To identify factors associated with insulin adherence, first
variables were tested using bivariate analysis. Variables
which were associated in the bivariate analysis (P < 0.25)
were: sex, marital status, duration of disease, health care
visit, cost of insulin, presence of chronic illness, dosing
schedules, ability of carrying insulin out of home.
Variables which were associated in the bivariate analysis were
tested in the final multivariate logistic regression analysis.
After adjusting for potential confounders in the
multivariate logistic regression analysis: marital status, health
care visit and cost of insulin remained significant.
Marital status of the participants was significantly
associated with insulin adherence. Participants who
were not married were 0.3 times higher to adhere
insulin treatment than those who were married [AOR = 0.3
Health care visit of the participants was significantly
associated with insulin adherence. Participants who were
visiting health care providers once every month were
3.3 times higher to adhere insulin treatment than others
[AOR = 3.3 (1.5–7.5)].
Pertaining to cost of insulin, participants who got
insulin with free or cheap price were 2.9 times higher to
adhere insulin treatment than those who got high cost
[AOR = 2.9 (1.3–6.3)] (Table 3).
In this study the level of adherence to insulin was 59.9%
which is similar studies conducted in Adama 61% [
and Jimma (61%) [
]. This finding is greater than results
found in Sudan (45.6%) [
] Turkey (55.7%) [
However it is lower than the study done in Addis Ababa 66.8%
]. The difference might be due to methodological
variations between studies and differences in socio cultural,
economical, health and health service utilization and
perceptions regarding the importance of good adherence,
drug availability characteristics between respondents
of the referenced areas and this study.
In this study marital status of respondents was
significantly affected level of adherence to insulin therapy.
Which is similar to studies done in Adama [
]. This may be due to the fact that mirage adds
accountability for self by decreasing forgetfulness,
ignorance to treatment and gives social support from
husband/wife as well from relatives and friends.
Respondents who have regular health care follow up
in every month had good adherence than those who
have irregular follow up. Regarding to health care visit:
74 (40.7%) had follow up once in a month, 98 (53.6%)
had follow up once in 3 month and 10 (5.5%) had follow
up once in 6 month.
Cost of insulin was significantly associated with level
of adherence to insulin therapy. Which is similar to
studies done in Jimma [
] and Iran [
]. This is due
to the fact that most of the study participants are poor
who have less than 500 birr income per month which
can not cover the cost for living, housing and buying
Regarding the schedule of insulin, the most common
frequency was twice a day 169 (92.9%). Which is
similar with a study done in Iran 65% of respondents
practiced twice a day. This discrepancy might happen due to
management protocol and socioeconomic differences.
Regarding frequency of using a needles, about 54.9%
study participants reused a single needle for 2–6 days,
52 (23.6%) used a single needle for seven or more days,
15 (8.2%) respondents used a single needle once as
recommended and the rest 15 (8.2%) respondents used a
single needle twice a day. The same study in Iran [
showed that most of the respondents reused insulin
needle more than once. The practice of using needle as
recommended deferred in these two study areas. This
might be due to lack of knowledge and differences in
socio-economic status between study areas.
In this study some respondents 53 (29.1%) developed
adverse reaction to insulin injection. The study in Spain
] about 64.3% of the respondents develop adverse
reactions at the injection site. This might be due to lack
of adequate knowledge regarding necessity of rotation
of site of injection or careless of changing of injection
site or due to skin vulnerability to climate changes.
About 153 (84%) respondents in this study carry
insulin out of home. A study done in Malaysia [
about 68.9% of the respondents carry their insulin out of
home. So this indicates slight difference to our research.
This might be due to nature of job socio economic
differences between the countries.
In this study, about 168 (92.3%) study participants
discard insulin opened after 1 month whereas 14 (7.7%)
of the respondents use insulin opened after 1 month
this might be due to the thought that the insulin will be
expired or decreased its potency.
In this study level of adherence to insulin therapy
was 59.9%. Marital status, regular health care visit and
cost of insulin were determinant factors for insulin
adherence in the study area. Recommendations to increase
adherence to insulin therapy were: government and
nongovernmental organizations should support syringe and
needles for diabetes patients, health care provider and
responsible bodies should give intensive health education
about the importance of adherence to insulin therapy and
the effect of non adherence to insulin treatment.
A limitation of this study is that only the quantitative
aspects of insulin therapy adherence was assessed. Since
the study is a descriptive study it has a limitation to find
additional determinant factors of insulin therapy.
BDU: Bahir Dar University; AOR: adjusted odds ratio; CL: confidence level; DM:
diabetes mellitus; SD: standard deviation; WHO: World Health Organization.
TT and SK contributed to the design of this study. Authors conceived and
designed the study, collected, analyzed and interpreted data; drafted the
manuscript for important intellectual content. The author reviewed and
revised the draft further. Both authors read and approved the final manuscript.
The authors would like to thank Felege Hiwot hospital staffs, study
participants, data collectors and supervisors for their cooperation during the entire
The authors declare that they have no competing interests.
Availability of data and materials
The data of this study can’t be shared publically due to presence of sensitive
(confidential) participants’ information.
Consent for publication
Ethics approval and consent to participate
Ethical clearance was obtained from Bahir Dar University, school of nursing,
research ethics review committee. Each study participant was adequately
informed about the objective of the study and anticipated benefits and risk
of the study by their data collector. Verbal consent was obtained from study
participants for protecting autonomy and ensuring confidentiality and it was
approved by the ethical review committee. Respondents were also told the
right not to respond to the questions if they didn’t want to respond or to
terminate the interview at any time.
This study received financial support from Bahir Dar University school of
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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