2 Insulin Injection Technique in Tlemcen Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 3 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) . Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 4 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 Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 5 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 Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 6 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). Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 7 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% Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 8 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 Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 9 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. Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 10 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] Global Partners in Education Journal – Special Edition March 2022, Vol. 10, No. 1 http://www.gpejournal.org ISSN 2163-758X 11 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.