Effect of Psychological counseling in overcoming fear of self-injecting and self-testing among type 2 diabetic patients on insulin initiation

Abstract

Background: The initiation of insulin therapy is often one of the most difficult and important choices that individuals with diabetes have to make. Insulin therapy among Type 2 Diabetic patients (T2DM) often becomes necessary when oral hypoglycemic agents are no longer effective. During the initiation of insulin therapy patient experiences various psychological disturbances which leads to fear of self-injecting among self-testing. Although the number of studies was limited and identified adverse treatment outcomes in diabetes patients with fear of insulin, self-injection, and self-testing no studies have been focused on overcoming the fear of self-injecting and self-testing and evaluating its impact on the glycemic level. Thus, the current study aims at evaluating the effect of psychological counseling in overcoming the fear of self-injecting and self-testing among type 2 diabetic patients on first-time insulin. Method: The study conducted among 80 patients with uncontrolled Type 2 Diabetes Mellitus and who were prescribed with first-time insulin injection. These patients were randomly assigned to control arm and study arm. The short Diabetes Fear of Injecting and Self-testing Questionnaire (D-FISQ) composed by two subscales that access fear of self-injection (FSI) and fear of self-testing (FST) was administered individually to all the patients based on the inclusion criteria. In the control arm patients prescribed with first-time insulin was counseled by Diabetes Educators and they were administered with DFISQ Questionnaire at baseline and during the follow-up visit to the hospital. For patients in the study group, patients prescribed with first-time insulin was counseled by Diabetes Educators in addition to Diabetes Education counseling they were rendered with psychological counseling with regular intervals of follow up and was administered with DFISQ Questionnaire at baseline and during the follow-up visit to the hospital. Result: The finding highlights that patients on first-time insulin injection rendered with diabetes education and followed by psychological counseling had better psychological outcomes in overcoming the fear of self-injecting and self-testing. Conclusion: Thus psychological counseling has to be included as routine management for the patients prescribed with insulin injection for the first time.

Full text

EFFECT OF PSYCHOLOGICAL COUNSELING IN OVERCOMING FEAR OF SELF INJECTING AND
SELF TESTING AMONG TYPE 2 DIABETIC PATIENTS ON INSULIN INITIATION
1
Mary Jenifer Amalraj and
1
M.V. Hospital for Diabetes, Prof. M. Viswanathan Diabetes Research Centre, Chennai Tamil Nadu, India
2
WHO Collaborating Centre for Research, Education and Training in Diabetes, Chennai, Tamil Nadu, India
ARTICLE INFO
ABSTRACT
Background:
that individuals with diabetes have to make. Insulin therapy among Type 2 Diabetic patients (T2DM)
often becomes necessary
of insulin therapy patient experiences various psychological disturbances which leads to fear of self
injecting
treatment outcomes in diabetes patients with fear of insulin, self injection and self testing no studies
have being focused on overcoming fear of self injecting and self testing and evaluating its impact on
glycemic level. Thus, the cur
overcoming fear of self injecting and self testing among type 2 diabetic patients on first time insulin.
Method:
who were prescribed with first time insulin injection. These patients were randomly assigned to
control arm and study arm. The short Diabetes Fear of Injecting and Self
FISQ) composed by two subscales that access fea
was administered individually to all the patients based on the inclusion criteria. In the control arm
patients prescribed with first time insulin was counseled by Diabetes Educators and they were
administered with DFISQ Questionnaire at baseline and during the follow up visit to the hospital. For
patients in the study group, patients prescribed with first time insulin was counseled by Diabetes
Educators in addition to Diabetes Education counseling
counseling with regular intervals of follow up and was administered with DFISQ Questionnaire at
baseline and during the follow up visit to the hospital.
Result:
education and followed by psychological counseling
overcoming fear of self injecting and self testing.
Conclusion:
prescribed with insulin injection for the first time.
Copyright © 2017,
Mary Jenifer Amalraj and Vijay Viswanathan
which permits unrestricted use, distribution, and
reproduction
INTRODUCTION
Diabetes is fast gaining the status of a potential epidemic in
India
with more than 62 million diabetic individuals currently
diagnosed with the disease (Joshi and
Parikh
al., 2013).
Historically, insulin has been an underutilized ‘‘last
resort’ option in diabetes management. However, it is
becoming increasi
ngly valued because of its ability to promote
appropriate levels of glycemic control, lower risk of long term
complications (Brunton et al., 2006;
Riddle,
Kingdom Prospective Diabetes Study
, 1995, 1998 & 1999
*Corresponding author: Vijay Viswanathan,
M.V. Hospital for Diabetes, Prof. M. Viswanathan Diabetes Research
Centre, Chennai Tamil Nadu, India.
ISSN: 0975-833X
Vol.
Article History:
Received 02nd September, 2017
Received in revised form
07th October, 2017
Accepted 06th November, 2017
Published online 27th December, 2017
Citation: Mary Jenifer Amalraj and Vijay Viswanathan
among type 2 diabetic patients on insulin initiation”,
International Journal of Current Research
Key words:
Type 2 Diabetes,
Insulin-initiation,
Counseling,
Self-injecting,
Self-testing.
RESEARCH ARTICLE
EFFECT OF PSYCHOLOGICAL COUNSELING IN OVERCOMING FEAR OF SELF INJECTING AND
SELF TESTING AMONG TYPE 2 DIABETIC PATIENTS ON INSULIN INITIATION
Mary Jenifer Amalraj and
*,2Vijay Viswanathan
M.V. Hospital for Diabetes, Prof. M. Viswanathan Diabetes Research Centre, Chennai Tamil Nadu, India
WHO Collaborating Centre for Research, Education and Training in Diabetes, Chennai, Tamil Nadu, India
ABSTRACT
Background:
The initiation of insulin therapy is often one of the most difficult and important choices
that individuals with diabetes have to make. Insulin therapy among Type 2 Diabetic patients (T2DM)
often becomes necessary
when oral hypoglycemic agents are no longer effective. During the initiation
of insulin therapy patient experiences various psychological disturbances which leads to fear of self
injecting
among
self testing. Although the number of studies was limited and
treatment outcomes in diabetes patients with fear of insulin, self injection and self testing no studies
have being focused on overcoming fear of self injecting and self testing and evaluating its impact on
glycemic level. Thus, the current study aims at evaluating the effect of psychological counseling in
overcoming fear of self injecting and self testing among type 2 diabetic patients on first time insulin.
Method:
The study conducted among 80 patients with uncontrolled Type 2 Diabete
who were prescribed with first time insulin injection. These patients were randomly assigned to
control arm and study arm. The short Diabetes Fear of Injecting and Self
FISQ) composed by two subscales that access fear of self injection
was administered individually to all the patients based on the inclusion criteria. In the control arm
patients prescribed with first time insulin was counseled by Diabetes Educators and they were
administered with DFISQ Questionnaire at baseline and during the follow up visit to the hospital. For
patients in the study group, patients prescribed with first time insulin was counseled by Diabetes
Educators in addition to Diabetes Education counseling they were rendered with psychological
counseling with regular intervals of follow up and was administered with DFISQ Questionnaire at
baseline and during the follow up visit to the hospital.
Result:
The finding highlights that patients on first time insuli
education and followed by psychological counseling had better psychological outcomes in
overcoming fear of self injecting and self testing.
Conclusion:
Thus psychological counseling has to be included as routine manageme
prescribed with insulin injection for the first time.
Mary Jenifer Amalraj and Vijay Viswanathan
. This is an open access article distributed under the
reproduction
in any medium, provided the original work is properly
cited.
Diabetes is fast gaining the status of a potential epidemic in
with more than 62 million diabetic individuals currently
Parikh
, 2007; Kumar et
Historically, insulin has been an underutilized ‘‘last
resort’ option in diabetes management. However, it is
ngly valued because of its ability to promote
appropriate levels of glycemic control, lower risk of long term
Riddle,
2002; United
, 1995, 1998 & 1999
).
M.V. Hospital for Diabetes, Prof. M. Viswanathan Diabetes Research
Daily self-
injecting of insulin and frequent self
blood glucose (SMBG) are essential to adequately manage
insulin-requiring diabetes.
Insulin treated diabetic patients
need to inject themselves daily and are required to self test
their blood
glucose regularly. Although majority of patients are
able to integrate this task into their lives, patients prescribed
with first time insulin injections don't get used to daily
injecting/or self testing and suffer from longer lasting fear of
self injectin
g (FSI) or fear of self testing (FST)
1997; Mollema et al., 2000)
Patients with FSI and FST are
likely to have great difficulty in managing diabetes effectively.
Adherence to insulin therapy and self
problematic in a num
ber of patients
Morris et al., 1997; Evans
et al.,
al., 1997)
showed that 97% of insulin
International Journal of Current Research
Vol.
9, Issue, 12, pp.62773-62777, December, 2017
Mary Jenifer Amalraj and Vijay Viswanathan, 2017.
“
Effect of Psychological counseling in overcoming fear of self injecting and self testing
International Journal of Current Research
, 9, (12), 62773-62777.
Available online at http://www.journalcra.com
z
EFFECT OF PSYCHOLOGICAL COUNSELING IN OVERCOMING FEAR OF SELF INJECTING AND
SELF TESTING AMONG TYPE 2 DIABETIC PATIENTS ON INSULIN INITIATION
M.V. Hospital for Diabetes, Prof. M. Viswanathan Diabetes Research Centre, Chennai Tamil Nadu, India
WHO Collaborating Centre for Research, Education and Training in Diabetes, Chennai, Tamil Nadu, India
The initiation of insulin therapy is often one of the most difficult and important choices
that individuals with diabetes have to make. Insulin therapy among Type 2 Diabetic patients (T2DM)
when oral hypoglycemic agents are no longer effective. During the initiation
of insulin therapy patient experiences various psychological disturbances which leads to fear of self
self testing. Although the number of studies was limited and
identified adverse
treatment outcomes in diabetes patients with fear of insulin, self injection and self testing no studies
have being focused on overcoming fear of self injecting and self testing and evaluating its impact on
rent study aims at evaluating the effect of psychological counseling in
overcoming fear of self injecting and self testing among type 2 diabetic patients on first time insulin.
The study conducted among 80 patients with uncontrolled Type 2 Diabete
s Mellitus and
who were prescribed with first time insulin injection. These patients were randomly assigned to
control arm and study arm. The short Diabetes Fear of Injecting and Self
-testing Questionnaire (D-
r of self injection
(FSI) and fear of self testing (FST)
was administered individually to all the patients based on the inclusion criteria. In the control arm
patients prescribed with first time insulin was counseled by Diabetes Educators and they were
administered with DFISQ Questionnaire at baseline and during the follow up visit to the hospital. For
patients in the study group, patients prescribed with first time insulin was counseled by Diabetes
they were rendered with psychological
counseling with regular intervals of follow up and was administered with DFISQ Questionnaire at
The finding highlights that patients on first time insuli
n injection rendered with diabetes
had better psychological outcomes in
Thus psychological counseling has to be included as routine manageme
nt for the patients
Creative Commons Attribution License,
cited.
injecting of insulin and frequent self
-monitoring of
blood glucose (SMBG) are essential to adequately manage
Insulin treated diabetic patients
need to inject themselves daily and are required to self test
glucose regularly. Although majority of patients are
able to integrate this task into their lives, patients prescribed
with first time insulin injections don't get used to daily
injecting/or self testing and suffer from longer lasting fear of
g (FSI) or fear of self testing (FST)
(Snoek et al.,
Patients with FSI and FST are
likely to have great difficulty in managing diabetes effectively.
Adherence to insulin therapy and self
-testing can be quite
ber of patients
(Ruggiero et al., 1997;
et al.,
1999). A survey (Ruggiero et
showed that 97% of insulin
-treated diabetic patients
INTERNATIONAL JOURNAL
OF CURRENT RESEARCH
Effect of Psychological counseling in overcoming fear of self injecting and self testing

reported to `always' or `usually' take their insulin medication as
recommended, but for blood-
glucose monitoring, 7.2% of the
study population indicated that they had never followed their
self-
testing recommendations over the past month. Various
patient-
related factors have been identified as important
obstacles to optimal self-management. Ho
wever, it is unknown
how often `non-
adherence' in diabetes is related to Fear of self
injecting and Fear of self testing.
Fear of injecting and self
testing is associated with poor glycemic control, clinical
complication, psychological co-
morbidities and p
well being among Diabetic population, (
Alex
Extreme fear of self-
injecting and injection phobia is likely to
compromise glycemic control as well as psychological distress
(Mollema et al., 2000; Fu et al., 2009).
Fear has a
impact on the treatment of patients with diabetes. Likewise,
fear of SMBG (finger prick) can be a source of distress and
may affect self-management.
Evidence suggests that fear of
blood and injury is associated with less frequent self
(Berlin et al., 1997; Metzger et al., 2010)
and poor glycemic
control (Metzger et al., 2010)
Paucity of studies have
identified poor health care counseling and several factors
leading to injection anxiety (De Coninck
et al.,
Diabetes Attitudes, W
ishes, and Needs (DAWN) study it is
found that more than half of insulin-
naive patients expressed
anxiety about starting insulin therapy (
Diabetes Attitudes,
Wishes, and Needs (DAWN) Study, 2005
)
these anxiety symptoms was strongly associat
monitoring, fewer daily insulin injections
(
1999). In a recent survey of insulin-
naive patients with type 2
diabetes, 28.2% of respondents reported that they would be
unwilling to take insulin if it were prescribed
often
involves negative perceptions, both the decision and the
therapy may present an emotional and logistical hurdle,
leading to patient resistance to treatment
(
1999; Berlin et al., 1997; Fitzgerald
et al.,
1997).
MATERIALS AND METHODS
A hospital based prospective follow up study was conducted
among 80 consecutive patients with
uncontrolled Diabetes
Mellitus and who were prescribed with first time insulin
injection at
tertiary care hospital, North Chennai India. The
study population incl
udes all patients aged 30
duration more of than 2 years. Psychological details pertaining
to fear factor on self injection and self testing were recorded
accordingly. During the study period 6 patients were dropped
from the study and their
data were not included in any of the
analysis. Patients with T1DM, major psychiatric disorder were
excluded from the study. Patients were assigned to control and
study arm based on randomization chart.
The short Diabetes
Fear of Injecting and Self-testing
Questionnaire (D
composed by two subscales that access fear of self injection
(FSI) and fear of self testing (FST)
was administered
individually to all the patients based on the inclusion criteria.
Group-1- Control arm
In the Control arm diabetes
education counseling was rendered
to the patients prescribed with first time insulin injection
certified diabetes educators. Pre
assessment on
of Injecting and Self-
testing was administered using DFISQ
questionnaire and post assessment wa
s administered using the
similar questions during the follow up visit to the hospital.
62774
Mary Jenifer Amalraj et al. Effect of psychological counseling in overcoming fear of self injecting and self testing
among type 2 diabetic patients on Insulin Initiation
reported to `always' or `usually' take their insulin medication as
glucose monitoring, 7.2% of the
study population indicated that they had never followed their
testing recommendations over the past month. Various
related factors have been identified as important
wever, it is unknown
adherence' in diabetes is related to Fear of self
Fear of injecting and self
testing is associated with poor glycemic control, clinical
morbidities and p
oor general
Alex
et al., 2009)
injecting and injection phobia is likely to
compromise glycemic control as well as psychological distress
Fear has a
negative
impact on the treatment of patients with diabetes. Likewise,
fear of SMBG (finger prick) can be a source of distress and
Evidence suggests that fear of
blood and injury is associated with less frequent self
-testing
and poor glycemic
Paucity of studies have
identified poor health care counseling and several factors
et al.,
2010). In the
ishes, and Needs (DAWN) study it is
naive patients expressed
Diabetes Attitudes,
)
and presence of
these anxiety symptoms was strongly associat
ed with less self-
(
Zambanini et al.,
naive patients with type 2
diabetes, 28.2% of respondents reported that they would be
unwilling to take insulin if it were prescribed
17 Insulin use
involves negative perceptions, both the decision and the
therapy may present an emotional and logistical hurdle,
(
Zambanini et al.,
et al.,
2000; Hunt et al.,
A hospital based prospective follow up study was conducted
uncontrolled Diabetes
Mellitus and who were prescribed with first time insulin
tertiary care hospital, North Chennai India. The
udes all patients aged 30
-70 with diabetic
duration more of than 2 years. Psychological details pertaining
to fear factor on self injection and self testing were recorded
accordingly. During the study period 6 patients were dropped
data were not included in any of the
analysis. Patients with T1DM, major psychiatric disorder were
excluded from the study. Patients were assigned to control and
The short Diabetes
Questionnaire (D
-FISQ),
composed by two subscales that access fear of self injection
was administered
individually to all the patients based on the inclusion criteria.
education counseling was rendered
to the patients prescribed with first time insulin injection
by
assessment on
Diabetes Fear
testing was administered using DFISQ
s administered using the
similar questions during the follow up visit to the hospital.
Group-2- Study arm
In the Study arm diabetes education counseling followed by
psychological
counseling was rendered to the patients
prescribed with first time insulin injection by
educators and psychologist
. Pre
of injecting and Self-
testing was administered using DFISQ
questionnaire. They were followed up ov
their specific concerns related to fear of self injecting and self
testing; post assessment was administered using similar
questions during the follow up visit to the hospital.
Diabetic Fear of Injecting and Self Testing (DFISQ)
DFISQ
was administered throughout the study. It consists of
15 questions with two domains which measures the
psychometric properties of Diabetes Fear of Injecting and Self
Testing (D-
FISQ). SPSS software was used to assess the data.
RESULTS
A total of 80
patients were included in the study out of which
40 patients were enrolled in the control arm and 40 in the study
arm among which 57.50% were male and 42.50% were female
in control arm likewise 62.50% were male and 37.50% were
female in study arm. Mean age
patients was 52.10 and 52.38 respectively. Gender details of
study subjects are shown in Table 1
Fig. 1.
HBA1C Status of study subjects
The mean score of HBA1C during first and follow up visit
among control and study ar
m is presented in table 2 and shown
in fig 1. As represented in table and figure
show a significant differences in HBA1C at follow up visit
when compared to first visit where as in study arm significant
differences were observed in HBA1
visit compared to first visit.
depicts that in control arm with routine diabetes education
counseling no much difference were found in psychological
fear measuring self injecting of insulin and self
glucose. Where as in the Study arm with routine diabetes
education counseling followed by psychological intervention
addressing various psychological concerns related to fear, had
better psychological outcome and
observed in fear measuring self injecting of insulin
Mary Jenifer Amalraj et al. Effect of psychological counseling in overcoming fear of self injecting and self testing
among type 2 diabetic patients on Insulin Initiation
In the Study arm diabetes education counseling followed by
counseling was rendered to the patients
prescribed with first time insulin injection by
diabetes
. Pre
assessment on Diabetes Fear
testing was administered using DFISQ
questionnaire. They were followed up ov
er phone addressing
their specific concerns related to fear of self injecting and self
testing; post assessment was administered using similar
questions during the follow up visit to the hospital.
Diabetic Fear of Injecting and Self Testing (DFISQ)
was administered throughout the study. It consists of
15 questions with two domains which measures the
psychometric properties of Diabetes Fear of Injecting and Self
-
FISQ). SPSS software was used to assess the data.
patients were included in the study out of which
40 patients were enrolled in the control arm and 40 in the study
arm among which 57.50% were male and 42.50% were female
in control arm likewise 62.50% were male and 37.50% were
female in study arm. Mean age
of the control and study arm
patients was 52.10 and 52.38 respectively. Gender details of
study subjects are shown in Table 1
.
HBA1C Status of study subjects
The mean score of HBA1C during first and follow up visit
m is presented in table 2 and shown
in fig 1. As represented in table and figure
Control arm did not
show a significant differences in HBA1C at follow up visit
when compared to first visit where as in study arm significant
differences were observed in HBA1
C (p<0.0001) at follow up
Table 3 and figure 2 clearly
depicts that in control arm with routine diabetes education
counseling no much difference were found in psychological
fear measuring self injecting of insulin and self
testing of blood
glucose. Where as in the Study arm with routine diabetes
education counseling followed by psychological intervention
addressing various psychological concerns related to fear, had
better psychological outcome and
significance difference was
observed in fear measuring self injecting of insulin
(p<0.0001)
Mary Jenifer Amalraj et al. Effect of psychological counseling in overcoming fear of self injecting and self testing

and self testing of blood glucose
(p<0.0001).
finding indicates that the intensive psychological intervention
among patients taking insulin injection for the first time paved
way for significant glycemic control (HBA1C) by reducing the
fear of self testing and self injection. Thus st
highlighted that standard education advice with psychological
counseling showed significant improvement
diabetes effectively by addressing psychological fear of self
Fig. 2.
Bar diagram representing significance changes in fear factor of self injecting and self testing among the study population
Variable
Sex
Table 2. Comparison of the study subjects during the first visit and the follow up Visit on the Hba1c status
CONTOL GROUP( N=40)
First visit
Follow up visit
HBA1C
Mean SD Mean
SD
11.10 2.00 11.04
2.04
**Significant at 0.01 level.
Table 3.
Comparison of the study population on their fear factor of self injecting and self testing
Variables
Fear of self injecting of insulin (Before Intervention)
Fear of self injecting of insulin (After Intervention)
Fear of self testing of blood glucose
(Before Intervention)
Fear of self testing
of blood glucose (After Intervention)
**Significant at 0.01 level.
Table 4. Representing significant difference in control and study group between male and female at follow up visit
Group (Control)
Male(N=23)
Mean
HBA1C
11.00
Self injecting of insulin
15.00
Self testing of blood glucose
24.48
Group (Study)
Male(N=25)
Mean
HBA1C
8.56
Self injecting of insulin
3.52
Self testing of blood glucose
6.48
62775
International Journal of Current Research,
(p<0.0001).
Thus the present
finding indicates that the intensive psychological intervention
among patients taking insulin injection for the first time paved
way for significant glycemic control (HBA1C) by reducing the
fear of self testing and self injection. Thus st
udy have
highlighted that standard education advice with psychological
counseling showed significant improvement
in managing
diabetes effectively by addressing psychological fear of self
injecting
and self testing and due to which glycemic level gets
improvised among patients taking first time insulin injection.
Table 4 represents that in both the group male showed better
compliance in the parameters of HBA1C and self injecting of
insulin when comp
ared to female where as in self testing of
blood glucose parameter female showed better compliance in
study group when compared to male at follow up visit.
Bar diagram representing significance changes in fear factor of self injecting and self testing among the study population
Table 1. Gender details of study population
Variable
Group P-Value*
Control Study
Male 23 25 0.41
57.50% 62.50%
Female 17 15
42.50% 37.50%
Table 2. Comparison of the study subjects during the first visit and the follow up Visit on the Hba1c status
STUDY GROUP ( N=40)
Follow up visit
First visit Follow-
up visit
SD
Change
(Mean)
P value Mean SD Mean
SD
2.04
0.06 0.759 10.85 2.27 8.57
1.45
Comparison of the study population on their fear factor of self injecting and self testing
CONTROL (N=40)
STUDY (N=40)
Mean SD Change
(Mean) P-value Mean
Fear of self injecting of insulin (Before Intervention)
16.03 2.30 0.95 0.009 15.93
Fear of self injecting of insulin (After Intervention)
15.08 1.54 3.60
24.25 2.36 -0.35 0.423 24.53
of blood glucose (After Intervention)
24.60 1.19 6.28
Table 4. Representing significant difference in control and study group between male and female at follow up visit
Male(N=23)
Female(N=17)
Mean
SD Mean SD
11.00
2.27 11.09
1.76
15.00
1.57 15.18
1.55
24.48
1.34 24.76
0.97
Male(N=25)
Female(N=15)
Mean
SD Mean SD
8.56
1.40 8.59
1.58
3.52
1.53 3.73
2.28
6.48
3.53 5.93
3.52
International Journal of Current Research,
Vol. 9, Issue, 12, pp.62773-
62777, December
and self testing and due to which glycemic level gets
improvised among patients taking first time insulin injection.
Table 4 represents that in both the group male showed better
compliance in the parameters of HBA1C and self injecting of
ared to female where as in self testing of
blood glucose parameter female showed better compliance in
study group when compared to male at follow up visit.
Bar diagram representing significance changes in fear factor of self injecting and self testing among the study population
Table 2. Comparison of the study subjects during the first visit and the follow up Visit on the Hba1c status
up visit
SD
Change
(Mean)
P value
1.45
2.28 0.0001**
Comparison of the study population on their fear factor of self injecting and self testing
STUDY (N=40)
SD Change
(Mean) P-value
2.12 12.33 0.0001*
* 1.82
3.30 18.25 0.0001*
*
3.49
Table 4. Representing significant difference in control and study group between male and female at follow up visit
P-Value*
1.76
0.88
1.55
0.73
0.97
0.46
P-Value*
1.58
0.94
2.28
0.73
3.52
0.64
62777, December
, 2017

DISCUSSION
Psychological counseling plays an important role in managing
diabetes. Psychological problems such as depression, stress
and anxiety also have adverse effects in the management of
diabetes. T2DM patients prescribed with first time insulin
injection suffer from various psychological stages of grief such
as denial, fear, anxiety, bargaining and acceptance which leads
to poor glycemic control in patients. Psychological problems
such as stress and anxiety have adverse effects on fear of self
injecting and self testing and in managing diabetes effectively.
Injection phobia is a severe and limiting fear of needles
classified as an anxiety disorder in the Diagnostic and
Statistical Manual of Mental Disorders IV (DSM-IV-TR).
Patients often consider insulin as the last treatment option, as a
form of punishment or failure of self control (Mollema et al.,
2000) but fear of needles and its association with pain remains
as one of the most important factor and this fear has a negative
impact on the treatment of patients with diabetes (Fu et al.,
2009). Paucity of studies have shown that Psychological
barriers and fears such as fear of self-injection and personal
phobia about blood, needle and pain as well as perceived side
effects also hindered insulin acceptance (Mohamed Azmi
Hassali et al., 2014). Fear of injectable therapy is a main
concern for many patients (Davida et al., 2015). Individuals
with diabetes often feel that insulin is the beginning of the end.
They fear taking the injection and feel that there is a stigma
associated with insulin and due to which HBA1C gets affected.
HbA1C reflects good glycemic control and is one of the
important targets for DM patients for reducing the risk of
complications (Anneli Rätsep et al., 2010).
The present study evaluated the effect of psychological
counseling addressing the psychological fear on self injecting
and self testing and to determine its impact on HBA1C among
T2DM prescribed with first time insulin injection and this is
the first study to analyze the fear factor and to determine
whether it changes with intensive psychological counseling.
Psychological factors play a major role in diabetes
management. The present study finding highlighted that in
study group significant improvement was observed in the
domains of fear on self injecting and self testing due to which
significant reduction in HBA1C was noted, where as in control
group, no much significant improvement was observed in the
domains of fear on self injecting and self testing due to which
no much reduction was observed in HBA1C. Thus, the
findings emphasized that psychological counseling showed a
better improvement in overcoming fear of self injecting and
self testing. Further with the routine diabetes education
counseling, fear factor on self injecting and testing remained
the same due to which no further improvements was observed
in HBA1C. Psychological therapy with routine diabetes
education counseling showed significant differences in the
domains of fear of self injecting and self testing and due to
which significant improvement was observed in HBA1C.
Thus, Psychological counseling plays an important role among
Type 2 Diabetic patients prescribed with first time insulin
injections.
Conclusion
In India, this is perhaps the first study in the domain of
psychological counseling addressing the fear factor of self
injecting and self testing and evaluating its impact on glycemic
level among patients prescribed with first time insulin
injection. The study highlights the importance of psychological
counseling among patients taking insulin injection for the first
time. It is also proven that patient offered with routine
education counseling followed by psychological counseling
has better outcomes in overcoming fear of self injecting and
self testing and due to which their HBA1C level gets
improvised. Thus the study recommends that patients
prescribed with first time insulin injection has to be rendered
with psychological support during the initiation of insulin for
the betterment of glycemic level and psychological wellbeing.
Acknowledgment
I acknowledge Sriram Ramachandran (Bio-statistician) for
analyzing the data and certified diabetes educators N.R
Jayasree, K.Sumathi, A. Farin banu and S.Deepika for the
support rendered throughout the studyin identifying the
patient's and to all diabetic patients on first time insulin who
participated in the study.
Conflict of Interest
The authors have not declared any conflict of interest
REFERENCES
Alex, Z. Ying Qiu, 2009. Larry Radican. Impact of fear of
insulin or fear of injection on treatment outcomes of
patients with diabetes, 1413-1420
Anneli Rätsep, Ruth Kalda and Margus Lember, 2010.
Meeting targets in type 2 diabetes care contributing to good
glycaemic control. A cross-sectional study from a primary
care setting in Estonia, European Journal of General
Practice, 85-91
Berlin, I., Bisserbe, J.C., Eiber, R., Balssa, N., Sachon, C.,
Bosquet, F., Grimaldi, A. 1997. Phobic symptoms,
particularly the fear of blood and injury, are associated with
poor glycemic control in type I diabetic adults. Diabetes
Care, 20:176–178.
Brunton, S. A., Davis, S. N. and Renda, S. M. 2006.
Overcoming psychological barriers to insulin use in type 2
diabetes. Clinical Cornerstone, 8(Suppl 2):19–26.
Davida F Kruger1, Susan LaRue, Phil Estepa, 2015.
Recognition of and steps to mitigate anxiety and fear of
pain in injectable diabetes treatment:Diabetes, Metabolic
Syndrome and Obesity: Targets and Therapy, 49-56
De Coninck, C., Frid, A., Gaspar, R., Hicks, D., Hirsch, L.,
Kreugel, G., Liersch, J., Letondeur, C., Sauvanet, J.P.,
Tubiana, N., Strausse, K. 2010. Results and analysis of the
2008–2009 Insulin Injection Technique Questionnaire
survey. J Diabetes.
Diabetes Attitudes, Wishes, and Needs (DAWN) Study.
Barriers to treatment. Available at: http://www.dawnstudy.
com. Accessed September 29, 2005
Evans, JMM, Newton, R.W., Ruta, D.A., MacDonald, T.M.,
Stevenson, R.J., Morris, A.D. 1999. Frequency of blood
glucose monitoring in relation to glycaemic control:
observational study with diabetes database. BMJ, 319: 83-
86.
Fitzgerald, J. T., Gruppen, L. D., Anderson, R. M., Funnell,
M.M., Jacober, S. J., Grunberger, G., et al. 2000. The
influence of treatment modality and ethnicity on attitudes
in type 2 diabetes. Diabetes Care, 23, 313–318.
62776 Mary Jenifer Amalraj et al. Effect of psychological counseling in overcoming fear of self injecting and self testing
among type 2 diabetic patients on Insulin Initiation

Fu, A.Z., Qiu, Y., Radican, L. 2009. Impact of fear of insulin
or fear of injection on treatment outcomes of patients with
diabetes. Curr Med Res Opin., 25(6):1413-20.
Hunt, L. M., Valenzuela, M. A. Pugh, J. A. 1997. NIDDM
patients’ fears and hopes about insulin therapy. The basis
of patient reluctance. Diabetes Care, 20(3), 292–298.
International Association of Diabetes and Pregnancy Study
Groups Consensus Panel, Metzger BE, Gabbe SG, Persson
B, Buchanan TA, Catalano PA, et al. 2012. International
association of diabetes and pregnancy study groups
recommendations on the diagnosis and classification of
hyperglycemia in pregnancy. Diabetes Care, 33(3):676-82.
Joshi, S.R., Parikh, R.M. 2007. India - diabetes capital of the
world: now heading towards hypertension. J Assoc
Physicians India, 55:323–4.
Kumar, A., Goel, M.K., Jain, R.B., Khanna, P., Chaudhary, V.
2013. India towards diabetes control: Key issues. Australas
Med J., 6(10):524-31.
Mohamed Azmi Hassali, Min-Wei et al. 2014. Why I do not
want to take insulin shots: Findings from a qualitative
study among diabetic patients in Malaysia, DOI: 10.1007/
s10389-013-0594-3
Mollema, E.D., Snoek, F.J., Heine, R.J., Van der Ploeg, H.M.
2000. The Diabetes Fear of Injecting and Self-testing
Questionnaire (D-FISQ): a psychometric evaluation.
Diabetes Care, 23: 765-769
Morris, A.D., Boyle, D.I., McMahon, A.D., et al. 1997.
Newton RW.Adherence to insulin treatment, glycaemic
control, and ketoacidosis in insulin-dependent diabetes
mellitus. The DARTS/MEMO Collaboration. Diabetes
Audit and Research in Tayside Scotland. Medicines
Monitoring Unit. Lancet, 350:1505- 1510.
Polonsky, W.H., Fisher, L., Guzman, S., Villa-Caballero, L.,
Edelman, S.V. 2005. Psychological insulin resistance in
patients with type 2 diabetes: the scope of the problem.
Diabetes Care, 28(10):2543–2545
Riddle, M. C. 2002. The underuse of insulin therapy in North
America. Diabetes/Metabolism Research and Reviews: 42–
49.
Ruggiero, L., Glasgow, R.E., Dryfoos, J.M., Rossi, J.S.,
Prochaska, J.O., Orleans, C.T. et al. 1997. Diabetes self-
management. Self-reported recommendations and patterns
in a large population. Diabetes Care, 20: 568-576.
Snoek, F.J., Mollema, E.D., Heine, R.J., Bouter, L.M., Van der
Ploeg, H.M. 1997. Development and validation of the
Diabetes Fear of Injecting and Self-testing Questionnaire
(D-FISQ): first findings. Diabet Med., 14: 871-876
United Kingdom Prospective Diabetes Study (UKPDS) Group.
1995. Overview of 6 years’ therapy of type II diabetes: A
progressive disease (UKPDS 16). Diabetes:1249–1258.
United Kingdom Prospective Diabetes Study (UKPDS) Group.
1998. Intensive blood-glucose control with sulphonylureas
or insulin compared with conventional treatment and risk
of complications in patients with type 2 diabetes (UKPDS
33).Lancet:837–853.
United Kingdom Prospective Diabetes Study (UKPDS) Group.
1999. Quality of life in type 2 diabetic patients is affected
by complications but not by intensive policies to improve
blood glucose or blood pressure control (UKPDS 37).
Diabetes Care:1125–1136
Zambanini, A., Newson, R. B., Maisey, M. and Feher, M. D.
1999. Injection related anxiety in insulin-treated diabetes.
Diabetes Research and Clinical Practice, 46(3), 239–246.
Zambanini, A., Newson, R.B., Maisey, M., Feher, M.D. 1999.
Injection related anxiety in insulin-treated diabetes.
Diabetes Res Clin Pract., 46(3):239-46.
62777 International Journal of Current Research, Vol. 9, Issue, 12, pp.62773-62777, December, 2017
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