


































2 Insulin Injection Technique in Tlemcen


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Insulin Injection Technique in Tlemcen, the Western Region of 
Algeria 

Mohammed Nassim Boukli Hacene, Meriem Saker, Amina Youcef, Houssam 
Boulenouar, Soumia Koudri, Souad Cheriet, Hafida Merzouk, Ali Lounici, Kaouel 

Meguenni 

Abou-Bekr Belkaïd University, Tlemcen, Algeria 

Abstract 

This study presents the second part of the results of the research on the insulin 
injection technique in patients in the region of Tlemcen, Algeria. The 100 patients 
included in the study were interviewed using the “patient” questionnaire in the Injection 
Technique Questionnaire (ITQ) 2016 survey and the results were compared with those 
of the ITQ 2016 worldwide survey. The more frequent use of injection pen needles 
longer than 6 mm exposes Algerian patients to the risk of IM injections and glycemic 
fluctuations. Hypoglycemic and hyperglycemic episodes are more frequent among 
Algerians whereas DKA is as frequent as around the world. Algerian patients expose 
themselves and others to injuries from insulin injection devices more than the global 
population. That happens mainly through improper disposal of the injection equipment 
and using public waste bins instead of designated containers for medical waste. This 
second part of the Algerian study on insulin injection technique provides new 
information and insights into patient practices. The gaps and deficiencies observed 
should be corrected in the future to improve this aspect of insulin users' care 
management. 

Introduction 

According to the International Diabetes Federation's latest figures, the incidence of 
diabetes in Algeria has increased to 7.2 percent among people aged 20 to 79, or one 
adult in every 16 people. Algeria is among the top ten countries in the world for both 
the number of children with type 1 diabetes and the number of new cases of type 1 
diabetes ("Atlas du diabète de la FID - Neuvième édition," 2019). As a result, 
strengthening diabetes control continues to be a national public health priority. 

Insulin is the gold standard treatment for type 1 diabetes, which is caused by a 
complete lack of this hormone in the body. It is also used in the early stages of type 2 
diabetes, but mostly as the last resort in this group of patients when the disease has 
progressed (Sorli & Heile, 2014). Mastering the injection technique allows the patient 
to deliver the desired dose of insulin in order to achieve the glycemic goal, making it 
critical in diabetes management.  In a previous work, we highlighted certain injection 
practices of Algerian patients using insulin. “Almost all Algerians prefer pens, injecting 
preferentially with 6- and 8-mm needles in thighs and arms instead of the abdomen; 
they do not seem to pay attention to re-suspending cloudy insulins and tend to overuse 
their pen needles”. This work constitutes the continuation of the previous paper on the 
“insulin injection technique of Algerian patients from the region of Tlemcen, Algeria”. 
Bearing that in mind, please refer to the previous part for more details on the 
germination of this work, its methodology and the results, as well as on the 
characteristics of the 100 surveyed patients (Boukli Hacene et al., 2020) .  



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Results 

Skipping injections 

Skipping an insulin injection is more common (77%) in the Algerian population 
compared to worldwide statistics, where most patients (55.6%) concede that they do 
so very rarely (several times a year), the highest percentage of our patients (44.2%) 
tend to skip their injection more frequently (several times per month). Like in published 
studies, forgetting is the main reason why most patients never reach their glycemic 
goal (Table 1) 

Table 1: Skipping injections for Algerian and other ITQ2016 patients 

Skipping injections Algeria Worldwide 
% N % N 

Skipping injections Yes 77 77 45 5870 
No 23 23 55 7274 

Frequency Often (several times a week) 15.6 12 9 419 
Sometimes (several times a month) 44.2 34 36 1759 
Almost never (several times a year) 40.3 31 56 2724 

Reason I forgot 33.54 54 52 3127 
I didn't eat 18.63 30 9 536 
I was sick (e.g. nausea and vomiting) 8.70 14 N/A N/A 
I just didn't want to inject 13.66 22 N/A N/A 
My glucose was too low 25 41 7 439 

 
Hypoglycemia, Diabetic Ketoacidosis (DKA) and Hyperglycemia  

The frequency of hypoglycemic and hyperglycemic episodes is higher among our 
patients (76% and 86%) compared to worldwide patients (57% and 47%), whereas 
DKA numbers are almost close between the two compared groups (77% vs 83%). 
Detailed information related to hypoglycemic, DKA and hyperglycemic episodes of 
Algerian patients are summarized in Tables 2, 3 and 4 respectively. 

Table 2: Hypoglycemia for Algerian and ITQ2016 patients 

Hypoglycemia  Algeria Worldwide 
% N % N 

During the last 6 months Yes 76 76 57 5605 
No 24 24 43 4170 

Frequency of needing 3rd  
party assistance  

None  9.2 7 57 3563 
1-2 times  32.9 25 24 1502 
3-5 times 21.1 16 9 587 
More than 5 times 36.8 28 9 559 

Needed hospitalization Yes 18 18 8 594 
No 82 82 92 6563 

Number of finger-pricks 
 to check blood glucose  

> 4 times a day 11 11 
  

3-4 times a day 35 35 
  



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1-2 times a day 31 31 
  

Several times a week 13 13 
  

Rarely or never check 10 10 
  

 
Tables 3: Diabetic ketoacidosis for Algerian and ITQ2016 patients 

DKA Algeria Worldwide 
% N % N 

Hospitalization Yes 23 23 17 1680 
No 77 77 83 7949 

Timing  I've had DKA but only when I was first 
diagnosed with diabetes 

47.8 11 49 867 

I've had DKA but not within the last six 
months 

17.4 4 37 643 

I've had DKA within the last six months 34.8 8 14 248 
 
Table 4: Hyperglycemia for Algerian and ITQ2016 patients 

Hyperglycemia Algeria Worldwide 
% N % N 

Occurrence Yes 86 86 47 4531 
No 14 14 53 5079 

Frequency  More than 5 high readings/week 26.7 23 24 1179 
3 to 5 high readings/week 32.6 28 26 1306 
1 or 2 high readings/week 25.6 22 26 1279 
An occasional high reading (less than 4 
times/month) 

15.1 13 24 1198 

 
Needle Stick Injury (NSI) 

About half (48%) of Algerians admit that a family member could accidentally get stuck 
by their needles, most often children (63.8%) because sharp material hangs within 
hands’ range for 56.9% of the surveyed patients (Table 5). Also, the great majority of 
Algerian patients (80%) recap needles, which constitute a risk for accidental pricking, 
and put injection material into the trash (90%). 

Table 5: Needle Stick Injury for Algerian and ITQ2016 patients 

Needle Stick Injury  Algeria Worldwide 
% N % N 

NSI Risk Yes 48 48 15 1423 
No 52 52 85 8276 

NSI 
Persons 

Children 63.8 37 23 368 
Other family members (e.g. spouse) 32.8 19 39 622 
House keeper or rubbish collector 3.4 2 8 129 
Nurse or other professional 0 0 5 73 
Yes 72.9 13 9 410 



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NSI 
Occurred 

No 27.1 35 91 4379 

Reason I don’t use devices that prevent injuries to 
others (safety devices) 

26.2 17 23 489 

I don’t have appropriate disposal containers 
for my used sharps 

16.9 11 36 760 

Used sharps are sometimes left in places 
where others might get stuck 

56.9 37 19 409 

I'm positive for hepatitis or another blood-
borne illness 

0 0 4 79 

 
Disposal of injection material 

Disposing of injection equipment dangerous for health and the environment in specific 
containers is a habit that has not yet entered Algerian consumers’ lifestyles, since the 
overwhelming majority gets rid of it in the trash compared to just over the half worldwide 
(Table 6). 

Table 6: Disposal of injection material for Algerian and ITQ2016 patients 
 

Algeria Worldwide 
% N % N 

Disposal of used pen 
needles /syringes 

Into a container specially made 
for used sharps 

2 2 21 2650 

Into a home container such as 
an empty bottle 

8 8 23 2943 

Into the rubbish with the cap on 80 80 48 6150 
Into the rubbish without 
recapping 

7 7 7 882 

I clip the needle and it stays in 
the clipper 

3 3 1 160 

What is done with the 
container?  

Put it into the rubbish 90 9 40 2489 
Take it to a pharmacist 0 0 13 791 
Take it to a doctor's office 0 0 6 389 
Take it to a laboratory 0 0 0 25 
Take it to the hospital or a clinic 0 0 22 1367 
Take it to a local deposit or 
collection service 

0 0 11 682 

None of the above 10 1 7 440 
 
TTD and HbA1c as a Function of LH 

The total daily dose (TTD) of insulin and glycosated hemoglobin (HbA1c) values in 
patients affected with LH versus those not suffering from LH and injecting into the LH 
bump area versus those avoiding this bad practice are not statistically significant (Table 
7). 

 



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Table 7: TDD of insulin and HbA1c as a Function of LH for Algerian and ITQ2016 
patients 

Population  
characteristics 

TDD  
Algeria (UI) 

TDD  
Worldwide 

(UI) 

HbA1C  
Algeria (%) 

HbA1c  
Worldwide (%) 

Mean± 
SD 

N Mean 
± SD 

N Mean± 
SD 

N Mean± 
SD 

N 

Presence of LH 
Yes  56.75 ± 

35.17 
44 55.2 ± 

33.0 
2192 8.68 ± 

2.68 
44 8.85 ± 

2.7 
2205 

No 53.61 ± 
31.32 

56 45.1 ± 
31.5 

4889 8.28 ± 
1.55 

56 8.30 ± 
1.9 

4795 

Total 54.99 ± 
32.94 

100 39.9 ± 
17.2 

7081 8.46 ± 
1.96 

100 8.47 ± 
2.2 

7000 

Injecting into LH 
Yes  56.45 ± 

35.08 
8 56.1 

±33.2 
1644 8.88±1.32 8 NI 

No  53.38 ± 
16.85 

36 47.1 ± 
32.2 

2064 8.71±2.48 36 NI 

Total 45.23 ± 
21.17 

44 51.1 ± 
32.9 

3708 8.75 ± 
2.31 

44 NI 

HbA1c: Glycosated Hemoglobin, NI: Uninformed, TDD: Total daily dose of insulin 
 
 

Risk of IM injection  

Hirsch and collaborators estimated intramuscular injection risk depending on needle 
length and injection site (Hirsch, Byron, & Gibney, 2014). Whether injecting into the 
abdomen, thighs or arms, Algerian patients have a 25% greater risk of getting stuck 
deeper than in the subcutaneous tissue area and of touching the muscle when using 
pen needles longer than 6-mm. (Frid, Hirsch, Menchior, Morel, & Strauss, 2016). The 
Table 8 adapted from Hirsch et al. (2014) was generated assuming that injections were 
performed straight at 90° angle without pinch-up and that a patient may use more than 
one site to inject insulin. 

Table 8: Estimated IM injection risk by body site for Algerian and ITQ2016 patients 
 

Abdomen 
N 
% 

Thigh 
N 
% 

Buttocks 
N 
% 

Arm 
N 
% 

12.7 mm 0  0  0 0 
12 mm 1  

1.56% 
1  
1.19% 

0 1  
1.23% 

10 mm 1  
1.56% 

2   
2.38% 

0 2  
2.46% 

8 mm 15   
23.43% 

21  
25% 

0 24  
29.62% 

  



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6 mm 23  
35.93% 

29 
 34.52% 

1  
100% 

28  
34.56% 

5 mm 14  
21.87% 

19  
22.61% 

0 15  
18.51% 

4.5 mm 1  
1.56% 

2  
2.38% 

0 2  
2.46% 

4 mm 7  
10.93% 

8  
9.52% 

0 9  
11.11% 

 
Discussion 

The risk and the occurrence of needle stick injury are more frequent in the Algerian 
study population compared with the population worldwide. Our findings incriminate 
negligence and nonchalance of the patients, who tend to leave their injection tools 
within the reach of others, especially children. Algerian patients disposing of their 
injection material in special containers may be considered as marginal, and those 
taking this effort have no other choice, forced as they are by the lack of services or 
health care related waste collecting services, but to dispose of the containers into the 
public rubbish.  

The fight against insulin therapy waste is not optimal in many parts of the world 
(Hassan, Shalaby, Atalla, & Younis, 2021; Montoya, Thompson, Boyle, Leighton, & 
Cook, 2021; Moray, Manjunath, & Shalini, 2020). Our country should not be left behind, 
which is why Algerian health authorities must make greater efforts in this field. Firstly, 
a better education should be carried out to alert and alarm DM patients on insulin of 
the danger of sharp contaminated products being vehicles for a number of blood-borne 
diseases. This is critical as the poor knowledge of insulin users on this particular point 
has been highlighted in many studies (Frid et al., 2016; Hasan et al., 2019a; Moray et 
al., 2020). Secondly, education alone cannot yield significant results and an effort must 
be made to ensure the availability of home containers and their collection at the level 
of local health institutions. Positive results were obtained when this approach was 
adopted in some countries, for example in Malaysia (Hasan et al., 2019b). 

Hospitalizations of Algerian patients due to DKA are almost as common as around the 
world. Even though mostly described in the pediatric population, more than 80% of 
patients experiencing this life-threatening preventable condition due to diabetes are 
adults (Kitabchi, Umpierrez, Miles, & Fisher, 2009). Thus, DKA is experienced by 
around one third of the cumulative T2DM patients (Nyenwe & Kitabchi, 2016). A recent 
publication suggests that in this last category of patient, the main precipitating factor of 
DKA is skipping or missing an insulin injection (Flores et al., 2020). This fits perfectly 
with our results (77% of the Algerian patients miss their insulin dose). Therefore, we 
suggest that insulin adherence should be reviewed at every medical visit, even a 
routine one. 

Studies suggest that the presence of lipohypertrophy and injecting into LH bumps are 
associated with an increased TDD of insulin and higher levels of HbA1c (Kumar et al., 
2021; Wang, Huang, Chen, & Tu, 2021), which is not demonstrated in this study 
probably due to the sample size. Focused detailed information on proper rotation sites, 
on the use of the recommended short 4-mm pen needle, on a single use of pen needles 
to reduce the occurrence of LH area and on avoiding injections into LH should be 



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received by all patients starting on insulin and those expressing the need for training 
by a professional (Bochanen et al., 2021; Chen et al., 2021) 

Insulin leakage, more common in Type 1 DM than in Type 2 DM and in patients who 
have or inject in LH bumps, thought to be caused by an insulin needle kept under skin 
for too short a time and by using longer needles, was reported by more than half of 
Algerians. 

Algerian health professionals might need to pay greater attention to the inspection of 
insulin injection sites. This would certainly help to detect problems earlier and more 
effectively as well as to correct some attitudes and complications, such as LHs, LH 
injections, inadequate rotations, insulin leaks and bleeding. This may lead to a lower 
injecting apprehension and a better quality of life. 

Conclusion 

Improvement of the insulin injection technique of Algerian patients will require effective 
involvement of the entire care chain: patient, health professional and health authorities: 
the first one by getting more involved, the second one by providing a more detailed 
and comprehensive injection education, and the last one by providing the first two with 
the necessary support and resources to catch up with the rest of the world in this 
matter. 

Acknowledgments 

Our sincere appreciation is extended to the staff and patients of the internal medicine 
department of Tlemcen’s University Hospital. 

References 

Atlas du diabète de la FID - Neuvième édition. (2019).   Retrieved from 
www.diabetesatlas.org 

Bochanen, N., Decochez, K., Heleu, E., Cuypers, J., Vercammen, C., Coremans, P., 
Vanhaverbeke, G., Shadid, S., Keymeulen, B., & Bolsens, N. (2021). Lipohypertrophy 
Monitoring Study (LIMO): effect of single use of 4 mm pen needles combined with 
education on injection site rotation on glycaemic control: confirmation of an unpleasant 
truth. Diabetic Medicine, e14672.  

Boukli Hacene, M. N., Saker, M., Youcef, A., Koudri, S., Cheriet, S., Merzouk, H., 
Lounici, A., & Alkhatib, N. (2020). Insulin injection technique in the western region of 
Algeria, Tlemcen. The Pan African Medical Journal, 36.  

Chen, L., Xing, Q., Li, J., Zhou, J., Yuan, Y., Wan, Y., Pflug, B. K., Strauss, K. W., & 
Hirsch, L. J. (2021). Injection technique education in patients with diabetes injecting 
insulin into areas of lipohypertrophy: A randomized controlled trial. Diabetes Therapy, 
12(3), 813-826.  

Flores, M., Amir, M., Ahmed, R., Alashi, S., Li, M., Wang, X., Lansang, M. C., & Al-
Jaghbeer, M. J. (2020). Causes of diabetic ketoacidosis among adults with type 1 
diabetes mellitus: insulin pump users and non-users. BMJ Open Diabetes Research 
and Care, 8(2), e001329.  



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Frid, A. H., Hirsch, L. J., Menchior, A. R., Morel, D. R., & Strauss, K. W. (2016). 
Worldwide injection technique questionnaire study: population parameters and 
injection practices. Paper presented at the Mayo Clinic Proceedings. 

Hasan, U. A., Mohd Hairon, S., Yaacob, N. M., Daud, A., Abdul Hamid, A., Hassan, 
N., Ariffin, M. F., & Yi Vun, L. (2019a). Effectiveness of diabetes community sharp 
disposal education module in primary care: an experimental study in north-east 
peninsular Malaysia. International Journal of Environmental Research and Public 
Health, 16(18), 3356.  

Hasan, U. A., Mohd Hairon, S., Yaacob, N. M., Daud, A., Abdul Hamid, A., Hassan, 
N., Ariffin, M. F., & Yi Vun, L. (2019b). Factors contributing to sharp waste disposal at 
health care facility among diabetic patients in north-east peninsular Malaysia. 
International Journal of Environmental Research and Public Health, 16(13), 2251.  

Hassan, N. M., Shalaby, S. E. S., Atalla, A. O., & Younis, E. A. (2021). Toward safe 
environment: injection device disposal among diabetic patients attending tertiary care 
academic clinic in Middle Delta, Egypt. Environmental Science and Pollution Research, 
28(18), 23193-23203.  

Hirsch, L., Byron, K., & Gibney, M. (2014). Intramuscular risk at insulin injection sites—
measurement of the distance from skin to muscle and rationale for shorter-length 
needles for subcutaneous insulin therapy. Diabetes Technology & Therapeutics, 
16(12), 867-873.  

Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N. (2009). Hyperglycemic 
crises in adult patients with diabetes. Diabetes Care, 32(7), 1335-1343.  

Kumar, R., Gupta, R. D., Shetty, S., Prabhu, C. S., Sathyakumar, K., Mruthyunjaya, M. 
D., Jebasingh, F. K., Inbakumari, M., Christina, F., & Asha, H. S. (2021). 
Lipohypertrophy in insulin injecting patients with diabetes mellitus: an under-
recognized barrier for glycemic control. International Journal of Diabetes in Developing 
Countries, 41(2), 329-336.  

Montoya, J. M., Thompson, B. M., Boyle, M. E., Leighton, M. E., & Cook, C. B. (2021). 
Patterns of sharps handling and disposal among insulin-using patients with diabetes 
mellitus. Journal of Diabetes Science and Technology, 15(1), 60-66.  

Moray, K. V., Manjunath, K., & Shalini, A. J. M. (2020). The insulin sharps disposal 
study: Evaluation of a structured patient education initiative in an urban community 
health centre in India. Journal of Family Medicine and Primary Care, 9(12), 6164.  

Nyenwe, E. A., & Kitabchi, A. E. (2016). The evolution of diabetic ketoacidosis: An 
update of its etiology, pathogenesis and management. Metabolism, 65(4), 507-521. 
doi:10.1016/j.metabol.2015.12.007 

Sorli, C., & Heile, M. K. (2014). Identifying and meeting the challenges of insulin 
therapy in type 2 diabetes. J Multidiscip Healthc, 7, 267-282. doi:jmdh-7-267 [pii] 
10.2147/JMDH.S64084 [doi] 



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Wang, W., Huang, R., Chen, Y., & Tu, M. (2021). Values of ultrasound for diagnosis 
and management of insulin-induced lipohypertrophy: A prospective cohort study in 
China. Medicine, 100(29), e26743-e26743.  

Author Notes 
 
Dr. Mohammed Nassim Boukli Hacene graduated as a pharmacist in 2009, and 
completed a Magister in Clinical Pharmacy from the Jordan University of Science and 
Technology. In 2012, he began a career at the Faculty of Medicine of Tlemcen and 
currently also holds a position at the Tlemcen University Hospital Center. Dr Boukli is 
working on psychometric parameters and therapeutic education of diabetic patients, 
particularly those on insulin. 

Prof. Meriem Saker was born in Algiers and completed her primary education in 
Philadelphia, Pennsylvania. As she was always fascinated by natural sciences, she 
ended up becoming a Professor of Biology, Pathophysiology and Biochemistry of 
Nutrition. And all say she is an easy-going, ready to smile person. 

Dr Amina Youcef has a PhD from the University of Tlemcen and holds a position at 
the Faculty of Medicine of Tlemcen and is interested by the oxidative stress among 
patients suffering from cardiovascular diseases. 

Dr. Houssam Boulenouar obtained his PhD from the University of Oran, holds a 
position of Assistant Professor of Genetics at the University of Tlemcen and is a team 
leader at the Cancer Lab research. 

Soumia Koudri and Souad Cheriet graduated as Pharm D in 2019 and are currently 
employed in the private sector. 

Prof. Hafida Merzouk is a Professor of Pathophysiology, one of the Abou-Bekr 
Belkaïd University’s most cited authors, with countless publications and Pabionut's 
laboratory director. 

Prof. Ali Lounici is the Head of the Internal Medicine Department of Tlemcen 
University Hospital Center and manages the Laboratory of Research on Diabetes at 
the Faculty of Medicine of Tlemcen. 

Prof. Kaouel Meguenni, Head of the Faculty of Medicine of Tlemcen from 1999 to 
2008 and also former Director of the Thematic Research Agency for Research in 
Health Sciences currently leads the Department of Epidemiology at the Tlemcen 
University Hospital Center and the Cancer Lab Research at the Faculty of Medicine of 
Tlemcen. 


