Original Article

Yonago Acta medica 2015;58:123–128

Type 1 Diabetes Patients Using Continuous Subcutaneous Insulin Infusion
Therapy: Feeling Burdened Correlated with Factors
Ikuko Nishio and Masami Chujo

Department of Adult and Elderly Nursing, School of Health Science, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACTType 1 diabetes may be treated using either multiple daily injection (MDI) therapy, or continuous subcutaneous
insulin infusion (CSII) therapy, which uses an insulin
pump. Recent advances in insulin pump technology areassociated with an increasing number of patients with
type 1 diabetes adopting CSII. Meta-analyses comparing CSII with MDI have reported that CSII is associatedwith reduced blood glucose level fluctuation, improved
HbA1c levels, and less frequent hypoglycemia and hyperglycemia.1–5 Partly in consequence, numerous studies have reported that CSII is associated with improved
quality of life and that CSII patient satisfaction levels arehigh. A Japanese study of satisfaction in type 1 diabetes
patients using CSII obtained similar results;6 however,
Shetty (2010)7 and Saarinen (2014)8 have reported that
although patients tend to feel that CSII facilitates daily
control of blood glucose, patients may also feel inconvenienced, as the pump’s needle must be kept in place, thepump is heavy and conspicuous if worn outside clothing,
and the equipment can be cumbersome to operate.
Previous studies in other countries have examined
CSII’s effectiveness, operability, and effect on patients’
daily lives; however, Japanese research addressing CSII
has been limited to case studies. There is no apparent
extant Japanese research examining the psychologicalaspects of CSII’s use—in particular, how patients may
feel burdened by using CSII. We therefore examined patients’ feelings of being burdened and potentially related
underlying factors, to suggest means of improving nursing care for type 1 diabetes patients using CSII.

Background The purpose of this study was to investi-

gate factors related to feelings of being burdened in type1 diabetes patients using continuous subcutaneous insulin infusion (CSII) therapy.
Methods Participants were 106 subscribers to the Diabetes Network’s e-mail newsletter. An online survey wasused. Eligible participants were aged at least 20 years,
had type 1 diabetes, and were using CSII. Survey questions concerned whether participants found CSII burdensome, and seven potential reasons for feelings of burden.
Analysis calculated correlations among participants’demographic and treatment-related factors, and among
participants’ reasons for feeling CSII to be burdensome.
Results Regarding demographic and treatment-related
factors, gender was found to be weakly negatively correlated with the following variables: employment status,
and whether participants had discussed their concernswith a doctor. Employment status was found to be weakly correlated with diabetes duration; employment status
and diabetes duration were found to be weakly correlated with age. Regarding reasons for finding CSII therapy
burdensome, “It takes too much time” was found to bestrongly positively correlated with “It interferes withwork responsibilities”; 16 weak positive correlations
were also found.
Conclusion To explain our results, we suggest that
medical expenses, glycemic control, scheduling outpatient visits around home and work responsibilities, andinteracting with medical staff may have caused participants to find CSII therapy burdensome. Most participants had never discussed their treatment concerns witha doctor. This suggests that nurses may be able to mitigate feeling burdened in participants using CSII therapy.

SUBJECTS AND METHODS
Participants and Data collection

This study was performed with the cooperation of Eli
Lilly Japan (Kobe, Japan). Participants were 106 subscribers to the Diabetes Network’s e-mail newsletter.9
Participants were aged at least 20 years, and were using CSII to manage their type 1 diabetes. Participants
completed the survey online. Questions concerned sevendemographic and treatment-related factors (gender, age,marital status, employment status, duration of diabetes,
monthly medical expense, and whether the participant
had ever discussed treatment concerns with a doctor),

Key words

continuous subcutaneous insulin infusion;
feeling burdened; related factors; type 1 diabetes

Corresponding author: Ikuko Nishio
ikurin@med.tottori-u.ac.jp
Received 2015 June 25
Accepted 2015 August 6
Abbreviations: CSII, continuous subcutaneous insulin infusion;
MDI, multiple daily injection123

I. Nishio and M. Chujo

whether participants found CSII burdensome, and sevenpossible reasons for feeling burdened (“It’s expensive,”“Glycemic control is poor,” “I dislike the treatment,” “Ittakes too much time,” “It interferes with my work responsibilities,” “Wait times for checkups are long,” and “Ihave problems interacting with the medical staff.”) The
survey period was March—April 2013.

Table 1. Participant demographics and treatmentrelated factors
n (%)
Item
GenderAge(years)Data analysis

SPSS ver. 22 (IBM, Armonk, NY) was used for statistical analysis. Pearson correlation coefficients were calculated to examine correlations among demographic andtreatment-related factors, and among reasons for feelingburdened by CSII.

Employment status

Marital status
Duration of diabetes(years)

Ethical considerations
Eli Lilly Japan reviewed this study regarding ethicalconsiderations. Prospective participants were informed
online that survey results would not be used for any purpose other than those of the study, that participation wasanonymous and voluntary, that no data or results would
be attributed to any individual, and that refusing to participate entailed no penalty. Participants who indicatedconsent, answered survey questions, and submitted thesurvey were considered to have provided Eli Lilly Japan
with their informed consent.

Monthly medical expenses
(yen)

Male
23 (21.7)
Female83 (78.3)< 30
14 (13.2)
30–39
39 (36.8)
40–49
27 (25.5)
50–59
19 (17.9)
60–69
5 (6.6)
employed
51 (48.1)
unemployed55 (51.9)
single62 (58.5)
married44 (41.5)<5
26 (24.5)
5–10
13 (12.3)
11–20
29 (27.4)> 20
38 (35.8)< 50004 (3.8)
5000–10000
1 (0.9)10000–15000 10 (9.4)
15000–20000 48 (45.3)> 20000
43 (40.6)

Whether the participant had ever Yes
discussed treatment concerns witha doctorNo

33 (31.7)
71 (68.3)

Table 2. CSII’s perceived burden on participants, andparticipants’ reasonsn (%)
CSII’s perceived burden on participants

RESULTS
Participant demographics and treatment-related
factors (Table 1)

YesNo
participants’ reasons
It’s expensive
Glycemic control is poor
I dislike the treatment
It takes too much time
It interferes with my work responsibilities
Wait times for checkups are long
I have problems interacting with the medical staff

Table 1 shows results for participants’ demographic andtreatment-related factors.
CSII’s perceived burden on participants, and participants’ reasons (Table 2)

Table 2 shows the number of participants who felt burdened by CSII (Yes/No), and participants’ reasons forany feelings of being burdened. Sixty-three participants(59.4%) replied “Yes”; 43 (40.6%) replied “No.” Amongreasons for replies, the most frequent response was “It’sexpensive,” given by 49 respondents (46.2%).

63 (59.4)
43 (40.6)
n (%)
49 (46.2)
30 (28.3)
21 (19.8)
23 (21.7)
22 (20.8)
16 (15.1)
11 (10.4)

CSII, continuous subcutaneous insulin infusion.

Correlations among demographic and treatmentrelated factors (Table 3)

Correlations among reasons for feeling burdened
by CSII (Table 4)

Table 3 shows correlations among participants’ demographic and treatment-related factors. Gender was foundto be weakly negatively correlated with employment status, and whether the patient had ever discussed treatment
concerns with a doctor. Employment status and diabetes
duration were found to be weakly correlated with age;
employment status was found to be weakly positively
correlated with diabetes duration.

Table 4 shows correlation coefficients for reasons for
feeling burdened by CSII. The following weak positive
correlations were found:i) “It’s expensive” correlated with “Glycemic control ispoor,” “I dislike the treatment,” “It takes too muchtime,” “It interferes with my work responsibilities,”and “Wait times for checkups are long.”
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Feeling burdened and related factors with CSII
Table 3. Correlations among demographic and treatment-related factors

GenderAge

MaritalstatusGender
–0.378**–0.211*Age–0.378**0.153
Marital status–0.211*
0.153
Employment status–0.272**0.193*
0.83
Duration of diabetes–0.0750.254**–0.020Monthly medical expense –0.022
0.010
0.060
Whether the participant
had ever discussed treat–0.234*
0.188–0.015ment concerns with a doctor*P < 0.05. **P < 0.01. CSII, continuous subcutaneous insulin infusion.

Employment
statusDuration ofdiabetes–0.272**0.193*
0.083–0.0750.254**–0.0200.351**

0.351**–0.126

0.094

0.130

0.155

Whether theparticipant had
Monthly med- ever discussed
ical expense treatment
concerns witha doctor–0.0220.010
0.060–0.1260.094–0.234*0.188–0.015
0.130
0.155
0.185

0.185

Table 4. Correlations among reasons for feeling burdened by CSII

It’s expensive
Glycemic control is poor
I dislike the treatment
It takes too much time
It interferes with my work
responsibilities

I dislike theIt’s expensive Glycemic
control is poor treatment

It takes toomuch time

0.384**

0.384**
0.330**
0.370**

0.346**
0.476**

0.384**
0.346**
0.384**

0.476**
0.330**

0.370**

0.365**

0.350**

0.329**

Wait times for checkups
0.349**
0.145
0.319**
are long
I have problems interacting
0.179
0.266**
0.218*
with the medical staff*P < 0.05. **P < 0.01. CSII, continuous subcutaneous insulin infusion.

It interferes
Wait times for I have probwith my work checkups are lems interacting with the
responsibili- longties
medical staff
0.365**
0.350**
0.329**
0.972**

0.972**
0.226*

0.174

0.195*

0.130

0.349**
0.145
0.319**
0.226*

0.179
0.266**
0.218*
0.195*

0.174

0.130
0.394**

0.394**DISCUSSIONii) “Glycemic control is poor” correlated with “It takes
too much time,” “It interferes with my work responsibilities,” “I dislike the treatment,” and “I have problems interacting with the medical staff.”iii) “I dislike the treatment” correlated with “It takes toomuch time,” “It interferes with my work responsibilities,” and “Wait times for checkups are long,” and “Ihave problems interacting with the medical staff.”iv) “It takes too much time” correlated with “Wait times
for checkups are long” and “I have problems interacting with the medical staff.”v) “Wait times for checkups are long” correlated with “Ihave problems interacting with the medical staff.”
Further, a strong positive correlation was found between “It takes too much time” and “It interferes withmy work responsibilities.”

Correlations between demographic and treatment-related factors in type 1 diabetes patientsusing CSII

Several explanations may be suggested for gender’sobserved weak negative correlations with other factors.
Type 1 diabetes characteristically develops in youth, andis more frequent in girls (Ministry of Health, Labor andWelfare Patient Survey, 2011).10 Approximately 80%of this study’s participants were women, and the large
majority was middle-aged, with women aged 30–39
and 40–49 accounting for around 37% and 26% of thesample, respectively. Correlations observed with genderin this study may reflect greater difficulty balancing
work and childcare among women, as childcare imposes additional responsibilities on female patients. The
number of diabetic patients able to balance work and125

I. Nishio and M. Chujo

childcare may be small. Further, female gender’s negative correlation with patients’ having discussed treatment
concerns with a doctor may reflect the preponderanceof female participants: rather than talking with doctors,
female participants may prefer to discuss managementof health, childcare, housework, and work with nurses,
due to feelings of greater familiarity or of better overall
understanding of participants’ lives.
Age was found to be weakly positively correlatedwith diabetes duration and employment status. This may
be because many participants had had diabetes for a longtime, with 27% and 36% reporting diabetes durations of
10–19 and 20 years or more, respectively. These participants therefore likely developed type 1 diabetes in their
youth. Research has shown that patients who have haddiabetes for a long time gradually acquire individualizedmeans of self-managing their condition. These patientsare therefore able to adjust their lives to accommodatechanges in treatment regimen, using self-management
methods gathered from experience.11-12 It may therefore
be conjectured that older patients switching from MDI
to CSII were able to mitigate interruptions to their workby implementing acquired self-management strategies—
thus explaining the weak positive correlation between
age and employment status.
In Japan, CSII is frequently introduced to type 1
diabetes patients when glycemic control is difficult using
MDI; this may partly explain the weak correlation foundbetween employment status and diabetes duration. It is
possible that the majority of this study’s participants had
switched from MDI to CSII. Compared to MDI, CSII
more effectively lowers blood glucose and HbA1c levels,
reducing the frequency of hypoglycemia and hyperglycemia, and stabilizing glycemic control, better enabling
patients to attain physical and mental stability.8 Patients
who have had diabetes for longer may have switched to
CSII earlier, to better maintain glycemic control in order
to continue working. Further, a longer duration of diabetes raises the likelihood that patients have self-disclosed
to their workmates that they are diabetic; disclosure contributes to the quality of patients’ social relationships,
and increases patients’ social support.13

that, as acquiring techniques for using the insulin pumpand establishing basal rates takes time, it may likewise
take time for patients to meet the conditions necessary
to improving glycemic control.7 Some participants may
have been in this position; this could account for someparticipant indications of how burdensome CSII is.
Regarding relationships among reasons for feelingburdened by CSII therapy, “It’s expensive” was found tobe weakly positively correlated with “Glycemic control
is poor” and “I dislike the treatment.” Accumulating
medical expenses, which include checkup and medication costs as well as medical test fees and transportation
costs, may contribute to feelings of being burdened by
CSII. Large medical expenses can lead to reduction ofother household expenditure, and to attempts to reduce
treatment costs by such means as independently deciding to reduce frequency or quantity of self-administeredinsulin, which may worsen glycemic control, as well as
the patient’s diabetes.14, 15 These effects tend to reduce
patients’ treatment motivation; this may partly explain
the observed positive correlations between the above
reasons and feelings of how burdensome CSII is. Additionally, type 1 diabetes patients, including those using
CSII, incur monthly checkup fees. To get a checkup,
patients must visit a doctor during work breaks, or taketime off work. Paid leave can be difficult to ask for,and at busy times, it may even be difficult to attend a
checkup during work breaks. This may explain why “It’sexpensive” was found to be positively correlated with
“It interferes with work responsibilities” and with “Waittimes for a checkup are long.”
The reason “Glycemic control is poor” was found tobe weakly positively correlated with “I dislike the treatment,” “It interferes with work responsibilities,” “It takes
too much time,” and “I have problems interacting withthe medical staff.” Patients may unrealistically expectthat blood glucose control will immediately improveafter switching to CSII; if it does not, they may consider
that CSII does not work for them, and discontinue CSII
in favor of MDI.8, 16 In this study, patients who had discontinued CSII were officially ineligible for participation; however, as the survey was online, it is possiblethat such patients responded. Further, any breakdowns
in glycemic control may cause patients to blame CSII,
feel that CSII is ineffective, or believe that CSII may
not work for them. Further, if glycemic control is lostfor a long time, patients may be more likely to begin to
dislike everything related to CSII, and feel CSII to beburdensome in general. These considerations may partly
explain the observed positive correlations with “Glycemic
control is poor.”
The reason “I dislike the treatment” was found to

Correlations among reasons for feeling CSII to beburdensome

Almost 60% of participants indicated that they felt burdened by CSII. Some participants may have indicatedthat they felt burdened because, even with CSII, they
faced the constant burden of type 1 diabetes in their
daily life. Many participants were mature women aged
30–40 years, who performed various social roles suchas wife, daughter-in-law, or mother. It is also possible
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Feeling burdened and related factors with CSII

be weakly positively correlated with “It takes too muchtime,” “It interferes with my work responsibilities,” “Waittimes for checkups are long,” and “I have problems
interacting with the medical staff.” This may be partly
explained as follows: once a patient begins to think negatively about treatment (similarly to regarding glycemic
control, above), he or she may begin to dislike anything
connected to CSII, greatly increasing the likelihood thathe or she will feel burdened.
Finally, the reason “It takes too much time” wasfound to be strongly positively correlated with “It interferes with my work responsibilities,” and weakly correlated with “It takes too much time” and “Wait times
for checkups are too long.” In Japan, long wait times
are not limited to diabetes outpatient clinics. In general,
wait times for medical examinations are longer than theexamination times themselves (Ministry of Health, Labor and Welfare Survey on Visits to Physicians, 2011).17
Regarding the strong correlation with “It interferes withmy work responsibilities,” when wait time is included,
patients spend a large amount of time getting checkups;
this may affect patients’ work. Regarding the weak positive correlation with “Wait times for checkups are long”
and “I have problems interacting with the medical staff,”longer wait times may induce fatigue, and in combination with wait times that exceed examination times, thismay cause patients to become irritated with medical
staff.

therefore important for nurses to routinely develop theirability to discover and understand factors that may betroubling patients or causing them to feel burdened bytheir treatment.
Acknowledgments: We thank all patients with type 1 diabetes who
participated in this study. We would like to thank Eli Lilly Japan
K.K., for performing data collection.
The authors declare no conflict of interest.

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Suggestions for nursing

Patients with type 1 diabetes who use CSII must continue treatment for their entire lives; this may feel burdensome. In this study, however, many participants, including participants who felt burdened by their treatment,
had never discussed their concerns with a doctor. These
participants may have referred to nurses for advice whentroubled or worried, as mitigating patients’ feelings ofbeing burdened because of treatment is a key nursing
role. To support patients’ continuation of CSII therapy,
medical staff must help patients manage CSII’s effects
on patients’ home and work lives, as well as directly supporting CSII’s use. For example, younger patients, who
may have less available time, often only attend outpatient
treatment when they are compelled to. In such cases, thenurse, with whom a patient may feel most familiar, must
proactively undertake communication with patients inorder to address any feelings of being burdened becauseof treatment, and engage team healthcare resources inorder to allow personnel to respond who are able to meetthe patients’ needs. If nurses are unable to respond in asuitable way to the patient’s issues, any existing feelingsof being burdened by treatment may go unresolved. It is127

I. Nishio and M. Chujo
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