An Audiovisual Intervention’s Effects on Psychological Barriers toward initiating Insulin Therapy among diabetic type 2 patients: A randomized controlled trial


Faisal Jammah S Alghamdi (1)
Mazen Ferwana (2)
Mohammed Fahad Alsaif (1)
Fahad Nasser Algahtani (1)
Emad Masuadi (1)

(1) College of Medicine, King Saud Bin Abdulaziz University (KSAU-HS), Riyadh, Saudi Arabia
(2) Consultant & Trainer, Family Medicine, King Abdulaziz Medical City, NGHA, Professor,
King Saud bin Abdulaziz University for Health Sciences, Co-Director, National & Gulf Center for Evidence Based Health Practice

Correspondence:
Faisal Jammah S Alghamdi, MBBS
Medical Intern, College of Medicine, KSAU-HS
P.O. Box 22490, Riyadh 11426, Saudi Arabia
Tel: +966566367778
Email: fj.gh@outlook.com

Received: November 2018; Accepted: December 2018; Published: January 1, 2019
Citation: Faisal Jammah S Alghamdi, Mazen Ferwana, Mohammed Fahad Alsaif, Fahad Nasser Algahtani, Emad Masuadi. An Audiovisual Intervention’s Effects on Psychological Barriers toward initiating Insulin Therapy among diabetic type 2 patients: A randomized controlled trial. World Family Medicine. 2019; 17(1): 29-35.DOI: 10.5742MEWFM.2019.93596

Insulin should be prescribed more frequently among type 2 diabetic patients, especially when oral medications alone are not effective anymore [1]. Despite being the most effective diabetes treatment, patients often feel reluctant to initiate insulin therapy when it is needed. Many studies relate this reluctance to reasons such as fear of disease progression, needle anxiety, feelings of guilt and failure, concerns about hypoglycemia, sense of loss of control over one’s life, reduced quality of life, and the fear of being stigmatized [1-7]. All these reasons have contributed to the prevalence of uncontrolled diabetes; a survey conducted in the USA showed that the percentage of controlled diabetic patients was only 36% [8], and a 2012 study in the Al Hassa region of Saudi Arabia showed that the percentage of uncontrolled diabetic patients was 69% [9].

The impact of most of these reasons are overestimated by patients and can be overcome with an insulin analogue and a new delivery method. For example, a novo pen, which many studies have found to be less painful, is easier to carry around than traditional delivery methods and leads to less hypoglycemic events [10-12]. The fact that patients still so frequently cite the reasons above indicates that up-to-date methods are not being provided to patients, which could be accomplished through traditional educational methods such as brochures, leaflets, or face-to-face discussions [13].

A newer educational technology is educational videos, and many studies emphasize the effectiveness of this method [14-18]. In one study, a video-based lifestyle educational trial was designed for newly diagnosed type 2 diabetics, who were divided into a video education group and a control group. The video education group showed more improvement in general knowledge related to lifestyle than the control group [14]. Another study about heart failure patients revealed that patients who received video education showed less signs and symptoms of heart failure, such as edema, fatigue, and dyspnea, than another group that received only traditional education [15]. Even if we compare video education with other newer methods such as internet research, video education is more effective because patients are more likely to review all the information provided to them [16]. In addition, another study found that video intervention was one of the best methods to increase the knowledge of health issues, such as certain disease complications, in people with low literacy [17].

Furthermore, a systematic review that included 40 studies related to video intervention showed how video education was effective in three major ways: supporting the treatment decision, reducing anxiety, and supporting coping skills to increase self-care practices [18]. Since there have been no previous studies comparing the difference in effects between traditional and non-traditional education methods on diabetic patients’ attitudes in Saudi Arabia, this study aims to compare the impact of audiovisual educational materials versus printed educational materials on type 2 diabetic patients’ knowledge, attitudes, and practices towards insulin therapy. It does so by assessing the patients before, immediately after, and 6 weeks after the intervention.

We conducted a randomized controlled trial on type 2 diabetic patients who agreed to participate in the study after screening them for inclusion and exclusion criteria. The target population of the study was type 2 diabetic patients who had an A1c of 8 mg/dL or above, were aged 30 to 70 years, and had not yet begun insulin therapy. Patients currently experiencing pregnancy, blindness, profound vision loss, or severe mental problems such as psychosis were excluded.

The study was conducted from March to June 2017 in a community-based polyclinic located in the King Abdulaziz city housing for the National Guard in Riyadh, Saudi Arabia. This polyclinic includes primary care centers and serves about 60,000 individuals, consisting of soldiers and their families as well as the professionals who work there and their families. We developed an educational video and brochure, both of which contained the same content about knowledge, attitude, behavior, and psychological barriers toward insulin therapy. The intervention group was shown the educational video and the control group was given the brochure. Both groups filled out a questionnaire before the intervention, then immediately after the intervention filled out the same questionnaire to assess the materials’ immediate effects. Six weeks later, both groups filled out the same questionnaire once more to measure the long-term effects. The immediate and long-term effects of both groups were compared to assess the materials’ effects on participants’ knowledge, attitudes, behaviors, and psychological barriers toward insulin therapy.

A computerized sequence in Microsoft Excel 2016 generated a randomized list of patients, allocating participants into 2 groups: an audiovisual intervention group and a printed material control group. A serially numbered opaque sealed envelope (SNOSE) contained these group assignments. The total sample size was 126 patients (63 in each group), which afforded us an 80% power to detect a difference of at least 5% in the mean knowledge percentage between the two groups, with an equal standard deviation of 10% and a significance level () of 5% using two proportions (z-test).

The validated insulin treatment appraisal scale (ITAS) questionnaire was used [19]. It is available on the internet free of charge, and permission to use it was obtained. The questionnaire measured the following variables: attitude, knowledge, practice, and behavior. It was translated into Arabic and pre-tested.

The educational video, which we developed and validated for this study and presented to the intervention group, aimed to address the psychological barriers mentioned in the questionnaire and tried to correct patients’

Ethics
This study was sponsored and ethically approved by King Abdullah International Medical Research Center’s (KAIMRC) ethic committee with ID number (SP16/235), and all patients provided written consent. It was also registered in the trial registry, clinicaltrial.gov, with a trial registration number of NCT03544645.

The study included 126 diabetic patients, with no losses during the study. Patients’ demographics are presented in Table 1. Table 2 shows the effects of the two intervention methods (the video and the brochure) regarding patients’ fixed beliefs, namely their psychological barriers to insulin therapy (determined through 10 questions), and regarding their understanding of insulin therapy as the ideal treatment for their condition (2 questions, q6 and q7, in Table 2). The percentages in Table 2 represent the participants who agreed with the questions’ statements, and each question had 3 main p-values: one for the effect of the video, one for the effect of the brochure, and the last to show any superiority in method, whether it was for the video or the brochure. The different p-values measure the reductions in barriers between before and immediately after the intervention, as well as the reduction between before and 6 weeks after the intervention.

As determined by McNemar’s test, the questions related to the psychological barriers to insulin therapy (questions 1 and 3: “I am worried about starting insulin therapy” and “Taking insulin means my health will deteriorate”) showed significant p-values (<0.05) for both the video and the brochure. Interestingly, questions 11 and 12 (“Taking insulin increases the risk of low blood glucose levels” and “Insulin causes weight gain”) showed positive p-values for both the brochure and video, but the reductions were of negative value and, since the question was not a negative statement, these values were significant for their reverse outcomes. A reverse outcome here means that instead of decreasing the barriers, the intervention methods increased them , although these barriers were addressed directly with both methods.

There were no significant p-values for the other barriers related to insulin therapy, indicating that neither intervention was effective in this regard. However, q6 and q7 (“Taking insulin helps to prevent complications of diabetes” and “Taking insulin helps to improve my health,” respectively), which were related to the benefits of insulin but not psychological barriers toward insulin therapy, showed significant p-values for both interventions.

As for the two-proportion z-tests used to compare the two interventions, most p-values were non-significant. That is, even when the video showed effectiveness, the brochure showed an equal effect; thus, neither method appeared superior to the other.

Table 1: Participants’ Demographics


Click here for Table 2: Questionnaire Items

Although both interventions had a slight effect, it was still not large enough to alter patients’ fixed beliefs and behaviors. The interventions reinforced the positive ideas patients already had about the benefits of insulin therapy, but were not sufficient to break their psychological barriers to insulin therapy, such as feelings of guilt and failure, fear of disease progression, feelings of a loss of control over one’s life, and the fear of being stigmatized, even though both intervention methods addressed these beliefs directly. In fact, patients’ worries about hypoglycemic attacks and weight gain increased at the mere mention of them in the interventions, even though the interventions indicated that new methods could help overcome these problems. Overall, neither method was found to be superior.

A meta-analysis has shown that video interventions are effective in some settings such as breast self-examination, prostate cancer screening, sunscreen adherence, self-care in patients with heart failure, and HIV testing and treatment adherence [22]. However, this study shows that such an intervention is not effective in changing overall behaviors or attitudes, nor fixed beliefs toward insulin therapy, such as psychological barriers. Thus, the intervention’s goal plays an important role in its impact.

The result of this study raises the question of whether multifaceted intervention could be more effective than one-method intervention. One study that targeted diabetic patients with multifaceted interventions, such as problem-based learning sessions and educator-patient face-to-face sessions, showed improvements in their A1C and blood pressure [23]. In addition, two studies on multifaceted interventions showed improvements in drug adherence for post ACS and anti-depressant drugs using booklets, voice messages, and counseling interventions [24-25].

The present study had several limitations and strengths. The limitations included a sample limited to a clinic located in housing for National Guard soldiers, which may not represent the population of Riyadh as a whole. The strengths include the study’s randomized approach, which helped minimize bias, as well as the high response rate, strict inclusion criteria, the consistency of the research method, the follow-up after six weeks, and and the fact that the educational video was validated by the authors of this study.