Insulin treatment adherence in type 2 diabetes mellitus patients: Literature review

One of the hallmarks of diabetes, a metabolic disease caused by a lack of secretion, work, or both insulins, is hyperglycemia. Although insulin is the most effective treatment for diabetes mellitus, most patients are reluctant to inject insulin. A problem that can arise from not taking insulin as prescribed at the initial dose is cardiovascular disease, which is a leading cause of morbidity and death in diabetics. The goal is to analyze the administration of insulin therapy in diabetic individuals who receive it. The PICO Strategy method is applied to research topics using populations/problems, interventions, comparisons, outcomes, and keywords relevant to Sciencedirect, PubMed, Nelitik, and Google Scholar (in Indonesian and English). The results of the review obtained were the compliance of Diabetes Mellitus (DM) patients in undergoing therapy, some participants were obedient to undergo insulin therapy regularly. Conclusion factors of non-compliance with insulin therapy often arise fear of hypoglycemia, discomfort and fear in using insulin injections


Introduction
Elevated blood sugar levels are a hallmark of diabetes, a chronic metabolic disease that gradually damages the heart, blood vessels, eyes, kidneys, nerves, and other organs.Hyperglycemia is a hallmark of diabetes, a metabolic disease caused by lack of insulin secretion, lack of insulin action, or both [1].The World Health Organization (WHO) estimates that 422 million people worldwide have diabetes, and most sufferers live in low-and middle-income countries.Every year, an additional 1.5 million people are diagnosed with this disease.Over the past few decades, there has been an increase in the number and prevalence of diabetic patients.According to projections made by the International Diabetes Federation (IDF), 537 million people worldwide, aged 20 to 79 years, will suffer from diabetes mellitus (DM) by 2021 [2].High blood sugar is the main reason Proper diabetes treatment can be used to prevent chronic complications.Treatment of diabetes often focuses on maintaining stable blood sugar levels and preventing complications due to high blood sugar levels.Insulin is currently a useful therapy for people with diabetes mellitus (DM), but insulin injections are usually rejected by patients Insulin administration is still a major problem because many type II diabetes patients do not adhere to insulin administration in daily life [3].Adherence is an important component of successful treatment for patients, including people with type 2 diabetes.If not compliant, the patient may lose the benefits of treatment and the condition may worsen further.The extent to which a person adheres to agreed advice from healthcare experts to undergo insulin therapy on time, adhere to diet, or make lifestyle changes is known as adherence to insulin therapy treatment [4].The success of treatment depends on the person himself, including knowledge of the disease and adherence to treatment.Adherence is determined by whether or not the patient's blood sugar levels are controlled [5].
Insulin therapy is a treatment that has a rapid onset of action, as indicated by the action of insulin, and converts glucose into glycogen and stores it in the liver, thereby lowering blood sugar levels.However, some patients choose to discontinue insulin use because they are not interested in insulin injections, which causes discomfort, fear of injections, or finds injections stressful.On the other hand, diabetic patients who are not adherent to insulin therapy may lose control of blood sugar levels more often than patients who are adherent [6].To provide efficient treatment, minimize complications from other diseases, and improve the quality of life of diabetic patients to maintain a stable condition, it is important to identify patients who do not adhere to the prescribed regimen [7].Improving adherence to optimize treatment outcomes can help individuals with diabetes mellitus avoid problems [8].

Method
This research uses a literature study design, by selecting and analyzing articles that are relevant and consistent with the research objectives.The literature study selection process was adapted from Preferred Reporting Items for Systematic Review (PRISMA) to search for and identify selected articles in the literature review.The study's inclusion criteria included the use of Indonesian and English with adherence keywords, insulin therapy, and diabetes mellitus.The article search process includes data used in four databases, literature search used in searching the database, including Pubmed data (33 articles), Google Scholar (58 articles), ScienceDirect (16 articles), and Neliti (13 articles).A detailed explanation of the article I received contains about adherence to the use of insulin to control blood sugar levels.To search for articles in any database by entering keywords, follow these steps: PubMed Database ((Adherence) AND (Insulin Therapy) AND (Diabetes).mellitus)), Google Scholar "Adherence of Insulin Therapy in Diabetic Patients", sciencedirect "Adherence, Insulin Therapy, Diabetes", Neliti "Keywords "Insulin Therapy, Diabetes".A total of 22 duplicate articles were issued, 29 full-text articles with responses were issued, and finally there were 5 articles with relevant content and in accordance with the research topic.

Result Figure 1 Article Selection Process Flowchart Based on PRISMA-ScR
Based on a study of several research journals, it can be displayed in a summary table of research results as follows: In this study, 62% of type 2 diabetes patients were likely to start insulin therapy.There was a statistical difference between the total items of positive and negative attitudes towards insulin therapy (agree/disagree) and acceptance of insulin therapy (P <0.05).Since 38% of type 2 diabetes patients refuse to start insulin therapy, it seems that effective communication between doctor and patient as well as ongoing follow-up by health care providers can increase positive attitudes toward insulin injections.

Discussion
One of the most important components of successful patient therapy is adherence, along with other elements including an appropriate treatment regimen, accuracy in medication selection, and patient support to lead a healthy lifestyle.In a study by Saibi et al., (2020) A total of 65 respondents (37.1%) reported taking antidiabetic drugs with a high adherence rate, while 71 respondents (40.6%) reported a moderate adherence rate.Of the total, 39 respondents (22.3%) achieved a high level of compliance.The 110 respondents fall into the moderate and poor compliance categories can be used to find out the reasons behind their non-compliance.One of the most important elements in a patient's therapeutic success is adherence, along with other elements including appropriate treatment regimen, accuracy in medication selection, and patient support [9].Namely the boredom of taking anti-diabetic drugs regularly for a long time, sometimes for life, late payment of drugs, and drugs run out because respondents are too lazy to return to treatment as usual, low attention so no one reminds to take medicine.Respondents did not understand the use of drugs such as insulin injections with their families.Injectable insulin requires daily injections, which can cause discomfort and fear in using insulin injections.In addition, working hours are very busy and falling asleep at night before taking medicine, so it makes you feel scared.Based on the results of the study, individuals with low medication adherence may experience uncontrolled blood sugar levels, while individuals with good adherence are able to maintain stable blood sugar levels.The boredom factor is the most common cause of non-compliance in respondents [10] In addition to the importance of insulin adherence to achieving treatment goals, there are other risk factors.A study by Farsaei et al., (2014) Morisky Green test results showed 99.4% of patients were adherent in insulin injections and only 2 patients were non-compliant.Factors that showed a significant association with insulin adherence in the type 1 and type 2 diabetes groups were: long-term intake, embarrassment, exacerbations after injections, and forgetting and neglecting insulin on sick days, hypoglycemia, medication costs, overweight, insulin deficiency, difficulty in preparing insulin [11].Simple insulin injections or administration do not affect insulin therapy.The study showed that dissatisfaction with the time it took for injections, embarrassment, and difficulty in preparing for injections were associated with decreased adherence in both type 1 and type 2 diabetes patients [12].
A study by Chefik et al., (2022) found that respondents who had a more positive attitude towards insulin therapy had up to 4.55 times greater adherence to insulin therapy than respondents who had a less positive attitude [7].The study also found that the adherence rate to insulin therapy was 121 (38.9%), mainly due to a diabetes diagnosis period of more than 15 years, poor attitude towards insulin therapy, and suffering from type 2 diabetes, in addition, the absence of a home blood glucose measuring device and poor physical condition, knowledge of insulin therapy, adherence to regular visits to the hospital, and taking two types of drugs.
A study by Bermeo-Cabrera et al., (2018) 83 (41.5%) patients were classed as adherent, and 117 (58.5%) as noncompliant.Only 22 patients (11%) received insulin therapy with excellent adherence [13].The following elements were associated with non-compliance: lack of a daily activity plan (46.1%), fear of hypoglycemia (41%), economic factors (15.4%), and insulin consumption (2.31 vs. 1.76 per year).The main factors associated with discontinuation of insulin use are lower socioeconomic status, fear of hypoglycemia, and increased daily insulin doses.The results of this study may help determine interventions to address and correct insulin treatment non-adherence in type 2 diabetes patients [14].
A study by Davoudi et al., (2020) in this study found some degree of adherence to insulin treatment in 62% of patients receiving insulin therapy and adherence and in 38% of patients not adhering to insulin therapy [2].The main factors that prevent patients from adhering to the use of insulin are fear of injections, fear of obesity, and how to handle insulin injections.Non-compliant patients also believe that insulin therapy may worsen their symptoms.These include fear of incorrect injection methods and discomfort with insulin injections.Fear of hypoglycemia after injections and insulin injections.Since 38% of type 2 diabetes patients are not adherent to insulin therapy, we believe that effective communication between physician and patient as well as ongoing follow-up by healthcare professionals will increase positive attitudes towards insulin injections [15].

Conclusion
Diabetes mellitus (DM) patients who receive insulin therapy generally report a degree of adherence to the treatment.Factors of non-compliance with insulin therapy often arise fear of hypoglycemia, discomfort and fear in using insulin injections

Disclosure of conflict of interest
No conflict of interest to be disclosed.