Diabetes Mellitus (DM) is a significant and growing global health issue, affecting approximately 537 million adults worldwide as of 2021, with projections suggesting a sharp increase over the coming decades [1]. Insulin therapy remains an essential component in the management of both Type 1 diabetes and advanced Type 2 diabetes, especially when glycemic targets cannot be achieved with oral agents alone. However, the effectiveness of insulin therapy heavily depends not just on dosage but also on the patient’s technique of administration [2]. Improper insulin injection techniques can lead to complications such as lipohypertrophy, inconsistent insulin absorption, unexplained hypoglycemia, and poor glycemic control [3]. Studies conducted in various Indian populations have highlighted concerning gaps in patients' knowledge about proper insulin administration, including correct injection sites, site rotation, storage practices, and disposal of used needles [4, 5]. In addition to personal health risks, improper techniques can also place a burden on healthcare systems through increased hospitalizations and treatment of avoidable complications. The hilly regions of North India, including Shimla, face unique challenges such as geographical isolation, varying levels of health literacy, and limited access to structured diabetes education, which may contribute to poor insulin administration practices. This study was designed to assess the awareness of proper insulin injection techniques among insulin-dependent diabetic patients residing in Shimla and to identify gaps that could guide future educational interventions.

Study Design and Setting

This descriptive, cross-sectional study was conducted over a period of three months (January to March 2025) in Shimla, Himachal Pradesh. Participants were recruited from outpatient departments of two government hospitals: IGMC and AIMSS Chamiana

Study Population

The study population consisted of adults aged 18 years and above diagnosed with Type 1 or Type 2 diabetes mellitus who had been using insulin therapy for at least 6 months.

Sample Size Calculation

A sample size of 200 participants was estimated based on an expected awareness rate of 50%, 95% confidence interval, and 7% margin of error.

Sampling Technique

A convenience sampling method was used, where eligible patients visiting the OPD during the study period were invited to participate.

Data Collection Tools

A pre-designed, pretested structured questionnaire was used for data collection. The questionnaire had four sections:

Demographic Profile:

Age, gender, educational level, duration of diabetes, type of diabetes, and source of insulin prescription.

Knowledge Assessment:

• Insulin Storage: Knowledge about recommended storage temperature (2–8°C), storage during travel, and expiry date checks

• Injection Sites: Awareness of recommended subcutaneous injection sites (abdomen, thigh, upper arm, buttocks)

• Needle Usage: Understanding of single-use recommendations and self-reported needle reuse practices

• Injection Site Rotation: Knowledge and practice of rotating injection sites to avoid lipohypertrophy

• Disposal Practices: Awareness of and adherence to safe disposal of used syringes/needles

• Educational Exposure: Whether the participant had attended formal diabetes education sessions

Observation Checklist

During the interview, healthcare professionals observed whether participants could correctly demonstrate the insulin injection technique using a model.

Scoring System

Each correct response was awarded 1 point. A total score of 12 was possible. Scores were classified as:

• Poor Awareness: 0–5

• Moderate Awareness: 6–8

• Good Awareness: 9–12

A total of 200 insulin-dependent diabetic patients participated in this study. Among the participants, the majority were male (62%), while females accounted for 38% (Table 1). The age distribution was broad, with most participants falling between the 40–65 year age bracket (mean age: 52.4 ± 11.8 years). Educational status varied, with 30% having only primary or no formal education, 45% completing secondary education, and   25%   holding   graduate   or   postgraduate   degrees.  When asked about the duration of their diabetes, 44% reported being diagnosed for less than 5 years, 32% had been living with diabetes for 5–10 years, and 24% had been insulin-dependent for more than a decade (Table 1). This distribution highlights the chronic nature of insulin therapy across different stages of diabetes.

Table 1: Participant Characteristics

Table 2: Knowledge and Practice Assessment

Knowledge about insulin handling and administration was found to be highly variable (Table 2). While 84% of participants correctly identified the recommended insulin storage temperature (2–8°C) and demonstrated awareness of checking expiry dates, only 47% could accurately identify all the recommended injection sites, including the abdomen, thigh, upper arm, and buttocks. Knowledge of single-use guidelines for insulin needles was reported by only 42% of respondents, and worryingly, 58% admitted to reusing needles-an unsafe but common practice, particularly among patients from lower-income backgrounds. Site rotation-a key aspect of insulin injection to prevent lipohypertrophy and ensure effective absorption-was practiced by only 39% of patients. Awareness of proper disposal methods for used insulin needles and syringes was also low, with only 32% following safe disposal practices. Moreover, only 28% of participants had ever attended a structured diabetes education session, indicating a gap in formal instruction and reinforcement of correct insulin use techniques (Table 2).

Overall knowledge scores, based on the study’s scoring system, were concerning. Nearly half of the participants (48%) fell into the 'Poor Awareness' category, with scores between 0 and 5 out of 12. About 34% demonstrated 'Moderate Awareness' (scores of 6–8), and only 18% showed 'Good Awareness,' scoring 9 or above. This clearly illustrates that the majority of patients had inadequate understanding of proper insulin injection technique. In addition, needle reuse practices were particularly prevalent, with over half of the patients (58%) reporting that they reuse needles, largely due to financial constraints or lack of awareness about the risks involved. A significant association was observed between educational    status    and    knowledge    scores  (Table 3). Patients with higher educational attainment, particularly those with graduate or postgraduate qualifications - were far more likely to score in the 'Good Awareness' range (42%), compared to just 5% of those with primary-level education or less. Conversely, 75% of illiterate or minimally educated patients fell into the 'Poor Awareness' category, compared to only 18% of graduates. This relationship was statistically significant (p<0.01), emphasizing the role of education in promoting health literacy regarding insulin administration.

Table 3: Association Between Education Level and Awareness Score

These findings underscore the widespread knowledge gaps in proper insulin injection technique among people with diabetes in Shimla, especially in relation to practical behaviors like site rotation, needle reuse, and waste disposal.

The findings of this study clearly show a significant knowledge gap regarding proper insulin injection techniques among diabetic patients in Shimla. While a large proportion of participants demonstrated awareness of insulin storage conditions, the understanding of critical aspects such as correct injection sites, the importance of site rotation, and safe disposal practices was notably insufficient. These results are consistent with those of Patil et al. [4], who reported similar patterns in an Indian tertiary care population, where improper mixing, site rotation, and disposal of used needles were found to be widespread. One particularly concerning observation in this study was the high prevalence of needle reuse, which was reported by over half of the participants. Needle reuse is a common but risky practice that has been associated with lipohypertrophy, injection site infections, and variable insulin absorption, which negatively affect glycemic control. A nationwide study by Frid et al. [3] emphasized the strong link between such poor practices and the high occurrence of injection-related complications in Indian diabetic patients. Additionally, the study identified a significant correlation between educational level and knowledge about insulin technique. Participants with higher education were more likely to demonstrate good awareness, echoing the findings from Choudhary et al. [5], who observed that lower literacy was associated with higher needle reuse and poorer injection site practices in central India. Another important gap highlighted was the lack of structured diabetes education. Few participants had ever attended formal insulin injection training, a situation similar to what Gupta et al. [6]  reported   in   their   study   of   North   Indian  diabetic  patients, where substantial gaps in knowledge and a negative attitude toward insulin use were both prevalent. These results underscore the pressing need for regular, structured educational programs focusing on insulin injection techniques, delivered by trained diabetes educators or healthcare professionals. Such programs have been shown to significantly reduce complications and improve self-management outcomes [3, 5]. Local health authorities should consider integrating visual aids, practical demonstrations, and culturally sensitive communication strategies to address these gaps, especially in semi-urban and geographically challenging areas like Shimla.

Despite the long-standing use of insulin among this population, awareness and adherence to correct insulin injection techniques are suboptimal in Shimla. Educational interventions and ongoing counseling are essential for improving patient practices and outcomes.

Acknowledgment

We thank the staff of IGMC and AIMSS Chamiana for their support and the participants for their cooperation.

1. IDF Diabetes Atlas, International Diabetes Federation, 2021.

2. ADA. “Improving care and promoting health in populations: Standards of care in diabetes-2024.” Diabetes Care, vol. 47, no. Supplement_1, December 2023, pp. S11-S19. http://dx.doi.org/10.2337/dc24-s001.

3. Frid, Anders H., et al. “New insulin delivery recommendations.” Mayo Clinic Proceedings, vol. 91, no. 9, September 2016, pp. 1231-1255. http://dx.doi.org/10.1016/j.mayocp.2016.06.010

4. Patil, Milind, et al. “Assessment of insulin injection techniques among diabetes patients in a tertiary care centre.” Diabetes & Metabolic Syndrome: Clinical Research & Reviews, vol. 11, no. 1, November 2017, pp. S53-S56. http://dx.doi.org/10.1016/j.dsx.2016.09.010

5. Choudhary, Animesh, et al. “Practice of insulin injection techniques among persons with diabetes in central India: An observational survey.” International Journal of Advances in Medicine, vol. 8, no. 5, April 2021, pp. 648-652. http://dx.doi.org/10.18203/2349-3933.ijam20211434

6. Gupta, Manisha, et al. “Knowledge, attitude, and practices of insulin use among type 1 diabetes patients in north India – a cross-sectional study.” Eastern Journal of Medical Sciences, vol. 6, no. 1, May 2021, pp. 9-12. http://dx.doi.org/10.32677/ejms.2021.v06.i01.002