Around five years ago, when M. Balusamy, 72, was told he would need injections to control his diabetes, the retiree was apprehensive. “What if I had problems with the shots?” he wondered. Until then, he had been on tablets and a controlled diet. But given that he switched to injections, today his blood sugar is well under control.
Handling anxiety
For many people with type 2 diabetes (a condition characterised by the body being unable to effectively use its natural insulin to control blood sugar) the prospect of self-administering injections appears scary. To determine if this anxiety could be handled through psychological counselling, the M.V. Hospital for Diabetes, Royapuram in Chennai recently conducted a study.
One group of patients received psychological counselling after they had been told to start their injections in addition to the regular counselling from diabetes educators, while the control group only had the counselling with diabetes educators. All the patients were about to start injections for the first time. Results showed that those who received psychological counselling better overcame their fear of self-injecting and self-testing.
“About 40% of people with diabetes require insulin injection after about six to eight years, when oral medications are not enough to bring down their blood sugar levels,” says Vijay Viswanathan, head of the hospital. But the thought of self-injecting made patients reluctant, he adds. They believed injections to be the last resort and wanted to avoid them or feared they would get used to them and later find it difficult to be weaned off them.
“Reluctance on the part of the patient to start insulin injections when advised to do so can lead to poor control of diabetes and complications, including in the kidney and eyes,” he says. This is of particular concern in India, with the number of diabetic people in the country estimated to be 72 million. The Chennai-based study, published in the International Journal of Current Research , had 80 patients ranging from the ages of 30 to 70 and living with diabetes for at least two years.
All patients were given a questionnaire to assess their fear of self-injection and self-testing. The group that got psychological counselling addressing their various concerns had a significant drop in their HBA1C levels, while the other group did not record much of a drop. HBA1C is a test to determine average blood sugar levels of the last three months. The first group also reported a lower fear of injections and self-testing than the other group.
Studies from many parts of the world have revealed that a fear of injections is common among patients with type 2 diabetes and is associated with poor glycemic control and lower adherence to therapy.
Explaining it
This fear, some researchers suggest, may have its roots in human evolution. In past centuries, even a non-fatal puncture wound could have caused a fatal infection and individuals who feared being struck by thorns or knives may have been less likely to die in accidents. Thus protecting oneself from jabs and pokes, the argument goes, could mean higher survival rates.
“There are lots of myths about insulin and the fear of injecting it is very common,” says P. Dharmarajan, Director, Institute of Diabetology, Rajiv Gandhi Government General Hospital, Chennai. He says that it took time to convince patients to start it and most have tried to postpone it. “We have to counsel them to begin insulin. Patients should understand that it needs to be taken when required and that it is a life-saving hormone.”
Jaichitra Suresh, consultant physician at SIMS Hospital, Vadapalani, Chennai, says the goal of treatment now is to start insulin early in order to preserve the insulin reserves in the body. “But most patients believe that starting insulin is the end and that it will lead to complications, when actually it is begun to keep blood sugar under control in order to avoid complications. If they are not advised properly, some even drop out of treatment,” she says.
“Now that we know it helps, psychological counselling should be the norm for patients starting insulin for the first time, for them to overcome their fear of injections and help build confidence to take insulin regularly,” says Dr. Viswanathan. An article in Diabetes Update (Summer 2017), a publication of Diabetes UK, a charity for people affected by diabetes, spoke of the importance of needle selection and good injection techniques. Research into needle technology and newer modes of insulin delivery can also potentially help, it says.
zubeda.h@thehindu.co.in
