Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter January 25, 2020

The relationship between the level of education and accuracy of insulin injection techniques in DM patients with measurement of HbA1c values

  • Anisyah Achmad EMAIL logo , Fatchur Rohmi Latifatus Sholihah , Wanda Fenny Oktavianti and Laksmi Sasiarini



Insulin therapy is a major part of diabetes treatment. The insulin injection technique must be done accurately and needs a professional process for diabetes mellitus (DM) patients. The aim of this research is to evaluate the relationship of education level pertaining to the accuracy of insulin injection techniques through HbA1c values.


We used a cross-sectional study with sampling using a purposive technique according to the inclusion criteria: diagnosed with DM and using insulin therapy with/without a combination of oral antidiabetic drugs, having HbA1c levels of data ± 3 months from the time of study, willing to become research respondents by signing informed consent. The study was conducted by filling out the questionnaire Forum for Injection Technique and Therapy Expert Recommendation (FITTER) and interviews.


Fifty subjects with primary education were able to perform insulin injection techniques with 20% accuracy while subjects with secondary education level showed 14% accuracy, and higher education 2%. All of these results had HbA1c values > 6.5%. 100 % of the subjects were provided with educational resources and 78% had a care-giver at home. Statistical analysis of correlation between levels of education with the accuracy of the insulin injection technique was carried out through the Somers’ correlation test (p = 0.81, r = −0.03). This study shows there is no relationship between the level of education and the accuracy of insulin injection techniques through HbA1c values. This might occur due to several factors such as information sources and caregiver’s practice.


Authors would like to thank the staff of Endocrine Poly Outpatient Installation at RSSA Malang who assisted in managing data. This paper has been presented at the 8th APPEN Conference and 2nd HPC Conference on 8 – 9 October 2019, Universitas Airlangga, Surabaya, Indonesia.

  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as revised in 2013), and was stated as ethical conduct with the issuance of Ethical Clearance Number 400/042/K.3/302/2019.


[1] Choa NH, Shaw JE, Karurangaa S, Huanga Y, da Rocha Fernandesa JD, Ohlroggea AW, et al. IDF diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. J Diab Res Clin Prac 2018;138:271–81.10.1016/j.diabres.2018.02.023Search in Google Scholar PubMed

[2] Koczmara C, Hyland S, Jelincic V. High alert: preventing insulin errors. Dynamics 2014;15:10–11.Search in Google Scholar

[3] Notoatmodjo S. Health promotion and behavioral sciences. Jakarta: Rineka Cipta., 2017.Search in Google Scholar

[4] Khattab M, Khader YS, Al-Khawaldeh A, Ajlouni K. Factors associated with poor glycemic control among patients with type 2 diabetes. J Diab Comp 2010;24:84–9.10.1016/j.jdiacomp.2008.12.008Search in Google Scholar PubMed

[5] Khan AR, Lateef ZNA, Al-Aithan MA, Bu-Khamseen MA, Ibrahim IA, Khan SA. Factors contributing to non-compliance among diabetics attending primary health centers in the Al Hasa district of Saudi Arabia. J FamCommu Med 2012;19:26–32.10.4103/2230-8229.94008Search in Google Scholar PubMed PubMed Central

[6] Goudswaard AN, Stolk RP, Zuithoff P, Rutten GE. Patient characteristics do not predict poor glycaemic control in type 2 diabetes patients treated in primary care. Eur J Epidem 2004;19:541–5, indexed in Al-Rasheedi AA. The role of educational level in glycemic control among patients with type II diabetes mellitus. Int J Health Sci 2014;8:178–87.10.1023/B:EJEP.0000032351.42772.e7Search in Google Scholar

[7] Al-Akour NA, Khader YS, Alaoui AM. Glycemic control and its determinants among patients with type 2 diabetes mellitus attending a teaching hospital. J Diab Metabol 2011;2:1–5.Search in Google Scholar

[8] ADA (American Diabetes Association). Standards of medical care in diabetes 2013. Diabetes Care 2013;36:11–66.10.2337/dc13-S011Search in Google Scholar PubMed PubMed Central

[9] Uddin I, Ahmad TJ, Kurkuman AR, Iftikhar R. Diabetes education: its effects on glycemic control. Ann Saudi Med 2001;21:1–3, indexed in Al-Rasheedi AA. The role of educational level in glycemic control among patients with type II diabetes mellitus. Int J Health Sci 2014;8:178–87.10.5144/0256-4947.2001.120Search in Google Scholar PubMed

[10] Sacks DB. Correlation between hemoglobin A1c (HbA1c) and average blood glucose: can HbA1c be reported as estimated blood glucose concentration. J Diab Sci Tech 2007;1:801–3.10.1177/193229680700100602Search in Google Scholar PubMed PubMed Central

[11] Budiman RA. Capita selecta questionnaire: knowledge and attitude in health research. Jakarta: Salemba Medika, 2013.Search in Google Scholar

[12] ADA (American Diabetes Association). Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33:62–9.10.2337/dc10-S062Search in Google Scholar PubMed PubMed Central

[13] Kapoor E, Collazo-Clavell ML, Faubion SS. Weight gain in women at midlife: a concise review of the pathophysiology and strategies for management. Mayo Clin Proc 2017;92:1552–8.10.1016/j.mayocp.2017.08.004Search in Google Scholar PubMed

[14] Rismayanthi C. Insulin therapy as an alternative treatment for diabetics. Medikora 2010;11:29–36.Search in Google Scholar

[15] Tandon N, Kalra S, Balhara YP, Baruah MP, Chadha M, Chandalia HB, et al. Forum for injection technique (FIT), India: the Indian recommendations 2.0, for best practice in insulin injection technique, 2015. Indian J Endocrinol Metab 2015;19:317–31.10.4103/2230-8210.152762Search in Google Scholar PubMed PubMed Central

[16] Siminerio L, Kulkarni K, Meece J, Williams A, Cypress M, Haas L, et al. Strategies for insulin injection therapy in diabetes self-management bleeding and bruising. Madison: American Association of Diabetes Educators, 2011.Search in Google Scholar

[17] Birkebaek NH, Solvig J, Hansen B, Jorgensen C, Smedeganard J, Christiansen JS. A 4 mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care 2008;31:e65.10.2337/dc08-0977Search in Google Scholar PubMed

[18] Silver B, Ramaiya K, Andrew BS, Fredrick O, Sarita B, Sanjay K, et al. EADSG guidelines: insulin storage and optimisation of injection technique in diabetes management. Diabetes Ther 2019;10:341–66.10.1007/s13300-019-0574-xSearch in Google Scholar PubMed PubMed Central

[19] Shafaat K, Hussain A, Kumar B, Rizwan Ul Hasan, Prabhat P, Yadav VK. An overview: storage of pharmaceutical products. World J Pharm Sci 2013;2:2499–515.Search in Google Scholar

[20] Arpit B, Varun G, Prashant T, Saksena T, Ranjan A, Gandhi P, et al. Last mile delivery of cold chain medicines – challenges and recommendations. Indian J Pharm Biol Res 2018;6:34–41.10.30750/ijpbr.6.1.6Search in Google Scholar

[21] Arisma BJN, Yunus M, Fanani E. Description of public knowledge about the risk of diabetes mellitus in Pakisaji. Malang Prev J 2017;2:1–8.10.17977/um044v2i2p67-75Search in Google Scholar

[22] Allen NA, Zagarins SE, Feinberg RG, Welch G. Treating psychological insulin resistance in type 2 diabetes. J Clin Transl Endocrinol 2017;7:1–6.10.1016/j.jcte.2016.11.005Search in Google Scholar PubMed PubMed Central

[23] Baig AA, Benitez A, Quinn MT, Burnet DL. Family interventions to improve diabetes outcomes for adults. Ann NY Acad Sci 2015;1:89–112.10.1111/nyas.12844Search in Google Scholar PubMed PubMed Central

Received: 2019-10-14
Accepted: 2019-11-12
Published Online: 2020-01-25

© 2019 Walter de Gruyter GmbH, Berlin/Boston

Downloaded on 10.6.2023 from
Scroll to top button