A Health Belief Model Approach
Analysis of psychological, social, and economic factors affecting insulin adherence in diabetes management
Diabetes Mellitus represents a group of metabolic diseases characterized by hyperglycemia resulting from abnormalities in insulin secretion, insulin action, or both7 . In Indonesia, this disease poses a significant public health burden that requires serious attention through medication and lifestyle modifications. One of the primary therapies for diabetes patients, especially when oral medications are no longer sufficiently effective, is insulin use.
However, in reality, many patients demonstrate non-adherence in their insulin use. According to research at Baiturrahim Hospital, out of 35 diabetes mellitus patients studied, only 40% showed high adherence to insulin therapy, while 31% had moderate adherence, and 29% had low adherence4 . This non-adherence impacts blood glucose control, potentially leading to serious complications.
Why do patients who need insulin often fail to use it consistently? The Health Belief Model (HBM) offers a theoretical framework to understand this behavior. This model explains how individual beliefs and perceptions about illness and treatment influence their decisions to take necessary health actions.
Essential treatment for diabetes management when oral medications become insufficient
Many patients struggle with consistent insulin use despite understanding its importance
The Health Belief Model (HBM) is a psychological framework developed in the 1950s by scientists from the United States Public Health Service to understand why people did not utilize tuberculosis screening programs2 8 . This model was later applied more broadly to predict various health behaviors, including adherence to chronic treatment regimens such as diabetes management.
This model assumes that a person's willingness to engage in health behaviors is influenced by six core factors2 6 8 :
Individual's belief about their risk of experiencing a health problem
Belief about how serious a health condition is and its consequences
Belief in the effectiveness of recommended actions to reduce risk or impact of disease
Evaluation of obstacles faced when performing health actions
Strategies or events that trigger acceptance of health actions
Belief in one's own ability to successfully perform necessary actions
In the context of insulin therapy, HBM helps us understand that patient adherence is not merely a matter of discipline, but rather the result of a complex psychological evaluation process involving all six factors mentioned above.
How patients view their susceptibility to diabetes complications and the potential severity of consequences significantly influences insulin adherence. Patients who understand that diabetes can lead to serious complications such as kidney disorders, blindness, and even amputation tend to be more motivated to be disciplined in using insulin.
However, research shows that many patients underestimate the risks they face. They may feel that the symptoms they experience are not too severe or think complications only happen to others. This misperception then contributes to non-adherence.
Patients continuously perform cost-benefit analysis unconsciously regarding insulin therapy. On one hand, they recognize the benefits of insulin in controlling blood sugar and preventing complications. On the other hand, they also consider various barriers they might face.
Common barriers perceived by patients in insulin use include7 9 :
Research at Sukoharjo Hospital showed that economic factors significantly determine diabetes treatment adherence, where patients with higher monthly income tended to be more compliant (OR = 2.887)1 .
Self-efficacy or patients' belief in their ability to inject insulin correctly significantly influences their consistency. Patients who lack confidence in injection techniques, fear making dosage mistakes, or worry about correct procedures tend to avoid insulin therapy.
Meanwhile, cues to action serve as external reminders that encourage patients to use insulin consistently. These cues can include:
Support from family members or caregivers
Ongoing engagement with healthcare providers
Phone or watch reminders for medication timing
Research by Della et al. proved that healthcare worker support has a significant relationship with treatment adherence in type 2 diabetes mellitus patients (p-value 0.028)5 .
Recent research provides empirical support for factors influencing diabetes treatment adherence. A cross-sectional study at Sukoharjo Hospital involving 85 type 2 diabetes mellitus outpatients found that only 43.5% of patients were classified as compliant with their treatment1 . Factors proven to significantly influence adherence were:
| Factor | p-value | Odds Ratio (OR) |
|---|---|---|
| Monthly Income | 0.018 | 2.887 |
| Type of Treatment | 0.007 | 3.551 |
| Treatment Frequency | 0.006 | 3.529 |
| Blood Glucose Level | 0.006 | 3.529 |
Table 1. Factors Significantly Influencing Diabetes Treatment Adherence Based on Research at Sukoharjo Hospital1
Meanwhile, a separate study at Panti Rini Hospital involving 60 respondents revealed that self-motivation factors had the strongest relationship with treatment adherence (p-value 0.000), followed by family support (p-value 0.002), and healthcare worker support (p-value 0.028)5 . Interestingly, in this study, education factors did not show a significant relationship with treatment adherence (p-value 0.673)5 .
| Factor | p-value | Description |
|---|---|---|
| Age | 0.036 | Significantly related |
| Gender | 0.045 | Significantly related |
| Occupation | 0.014 | Significantly related |
| Self-Motivation | 0.000 | Significantly related |
| Family Support | 0.002 | Significantly related |
| Healthcare Worker Support | 0.028 | Significantly related |
| Education | 0.673 | Not significantly related |
Table 2. Factors Related to Diabetes Treatment Adherence Based on Research at Panti Rini Hospital5
Education level showed no significant relationship with treatment adherence in diabetes patients, suggesting that knowledge alone is insufficient without motivation and support systems.
Various studies in Indonesia show variations in insulin adherence levels among diabetes patients. A descriptive observational study at Baiturrahim Hospital in 2022 involving 35 diabetes mellitus patients obtained the following picture of insulin therapy adherence:
| Adherence Level | Number of Patients | Percentage |
|---|---|---|
| High Adherence | 14 | 40% |
| Moderate Adherence | 11 | 31% |
| Low Adherence | 10 | 29% |
Table 3. Insulin Therapy Adherence Levels in Diabetes Mellitus Patients at Baiturrahim Hospital 20224
Based on understanding the Health Belief Model, here are strategies that can be implemented to improve insulin use adherence:
Provide specific and realistic information about diabetes complications
Share authentic experiences from patients who experienced complications due to non-adherence
Use visual aids to demonstrate long-term impacts of uncontrolled diabetes
Show proper injection techniques to reduce pain and discomfort
Educate about managing potential side effects to reduce fear
Assist patients in accessing affordable insulin options
Train patients in using simpler injection devices like insulin pens
Direct training with healthcare professional supervision
Reinforcement when patients master correct techniques
Custom reminder systems tailored to patient lifestyles
Family involvement in reminding and supporting patients is crucial for long-term adherence
For diabetes patients using insulin and their families, here are some practical tips to improve insulin use accuracy:
Regular appointments with diabetes educators to ensure correct injection techniques
Utilize devices like insulin pens if conventional injections are difficult
Keep daily logs of injection schedules, dosages, and blood glucose levels
Participate in peer support groups to share experiences with fellow patients
Communicate difficulties experienced openly with healthcare providers to find appropriate solutions together.
Accuracy of insulin use in diabetes patients is not merely a matter of discipline, but rather a complex behavior influenced by various psychological, social, and economic factors. The Health Belief Model provides a valuable lens to understand the dynamics behind patients' decisions to adhere or not to insulin therapy.
By understanding the perceptions and beliefs underlying patient behavior, interventions to improve adherence can be designed more targeted and effectively. A comprehensive approach involving continuous education, strong social support, and reduction of practical barriers will yield more optimal results in long-term diabetes management.
Ultimately, accuracy of insulin use is a health investment that will determine the quality of life for diabetes patients in the future. With the right approach, every patient can become an active partner in managing their condition, not just a passive recipient of prescribed therapy.