diabetes mellitus is a chronic disease characterized by disturbances in carbohydrate , fat , and protein metabolism . the short - term and long - term complications of diabetes could be prevented through controlling the metabolic condition . for some patients , insulin therapy is one of the most important parts of diabetes care . however , some other patients are not willing to use insulin , which in turn causes more severe and dangerous complications . these complications could have negative effects on patients well - being , health condition , and the physical , mental , and social aspects of quality of life ( qol ) . qol is an intellectual concept that incorporates individuals physical , mental , and social situations and is affected by beliefs , culture , economy , and spirituality . qol is of great importance because when ignored , it can lead to desperation , lack of motivation , and reduced social activity . qol in diabetic patients is an important factor in analyzing the effectiveness of their treatments and other received cares . in most cases , therapeutic interventions have been evaluated through studying the results of hba1c test , and qol has been considered and studied less frequently ; however , a comprehensive approach is necessary during treatment . as therapeutic factors , insulin and oral anti - diabetic drugs , diabetic patients must cope with different types of consultations , recommendations , and drugs , and this could be unpleasant for them . even if these factors could improve the blood sugar level , the medication might disturb diabetic - related health condition and qol . oral anti - diabetic drugs , like any other drugs , have side effects and complications . their side effects include hypoglycemia , bloating , diarrhea , stomach ache , nausea , and so on . intolerance to oral medication or experiencing any side effect renders the consumption of insulin necessary . however , chen et al . reported in their study that patients who consume oral drugs are less inclined to use insulin than the patients who have only recently started to use insulin . therefore , with the reduction in complications of the disease , satisfaction with treatment will indirectly affect qol . a study has shown that diabetic patients who were not able to control their disease through consuming oral drugs reported more satisfaction with their treatment after starting insulin therapy . in patients who are prescribed insulin by a physician , if the injection dose is appropriate and the injection effective , the blood sugar level will be controlled . however , if for any reason , the patient does not tolerate daily insulin injection , blood sugar level will not be controlled and its complications will reduce qol . therefore , the side effects and obstacles of insulin therapy must be discussed . have categorized in their study the factors responsible for reluctance to insulin therapy into five groups of fear of injecting insulin , restrictions , negative beliefs , lack of education , and inability . moreover , some patients believe that insulin might have a negative effect on their qol and that insulin therapy represents their failure in managing their disease . although some studies have compared the qol of diabetic patients with that of normal people , there are few evidences about the relation between insulin therapy and qol of diabetic patients . on the other hand , there are controversial studies about the effect of insulin therapy and consuming oral drugs on the qol of patients with type 2 diabetes . for example , podbielska et al . reported in their study that patients with type 2 diabetes who were consuming oral drugs experienced a better qol in comparison to those who only used insulin . in addition , the study by fal et al . revealed that patients who consumed oral drugs had a higher score in the physical aspect of qol and those who used insulin scored higher in the mental aspect of qol . on the other hand , we did not find any studies on the qol of patients who refused to take insulin . therefore , there are no conclusive evidences about the relation between insulin therapy and qol . furthermore , any effort toward accepting insulin therapy must be focused on recognition and reduction of barriers in accessing it . thus , the present study evaluated the qol of two groups of diabetic patients : insulin recipient and insulin refusal groups . the present study was a comparative descriptive research approved by the ethics committee of isfahan university of medical sciences , isfahan , iran . the study population consisted of all patients with type 2 diabetes who referred to the endocrinology and metabolism research center of isfahan . the inclusion criteria consisted of being a patient with type 2 diabetes and referred to the above - mentioned center with an active profile and having made at least one visit to the center during the past year , being able to read and write , being recommended by a specialized physician to use insulin during the past 3 months , having an hba1c level of higher than 7% , and not having any mental disorder or retardation based on the patient 's profile . the exclusion criteria included amputation , physical disability , unwillingness to participate in the study , and not completing the questionnaire . the insulin recipient group comprised those patients who had been taking insulin at least for the past 3 months . those who refused insulin therapy and were still consuming oral drugs formed the insulin refusal group . the target level of hba1c is lower than 7% and its increase is a criterion for recommending insulin therapy . therefore , to eliminate the effect of the controlled factor of hba1c , the insulin recipients also had an hba1c level higher than 7% . the researcher studied the files of patients with type 2 diabetes in the study environment and sampling took place from september to december 2014 ( for about 3 months ) . to begin with , a list of 140 patients who met the inclusion criteria was prepared . after confirming the cooperation of the participants , 126 patients were enrolled in the study and they completed the questionnaire . written consent forms were obtained from the participants and they were ensured that their answers would remain confidential . demographic data ( including age , gender , marital status , educational level , and duration of disease ) were gathered from the questionnaires and the files . after reaching the calculated number of samples , gathered data were statistically analyzed and homogeneity of age , gender , educational level , marital status , and occupation of participants in both groups was evaluated . both groups had a similar percentage in the above - mentioned factors and statistical analysis also showed no significant difference between the two groups , except in the age factor . however , by controlling the variable of age , the results of qol and its indexes did not change . therefore , sampling was completed with these results . this questionnaire was created by jacobson in english and translated to farsi by masaeli et al . , and its reliability was confirmed with cronbach 's  of 0.89 . this questionnaire includes 46 questions in four domains ( satisfaction with diabetes , effects of diabetes , concerns about diabetes , and social - occupational concerns ) . each question was answered based on a 5-point likert scale and the total score of the questionnaire ranged between 1 and 5 , which was obtained by dividing the total score by 46 ( the number of the questions ) . the score of each domain is also calculated by dividing the obtained score by the number of questions of that domain . moreover , questions about demographic characteristics of diabetics were also added to the questionnaire . to compare the qol of patients with type 2 diabetes who received and refused insulin , data were analyzed using independent t - test , analysis of covariance ( ancova ) , mann - whitney test , chi - square , and pearson and spearman 's correlation through spss software ( version 16 ; spss inc . , chicago , il , usa ) . in total , data gathering lasted from september to december 2014 ( for about 3 months ) . the mean age of the refusal group was 52 years ( sd = 6.9 ) and the mean age of the recipient group was 54 years ( sd = 7.2 ) . the mean duration of the disease in the refusal group was 9 years and in the recipient group was 12 years . the marital status , educational level , and occupation of participants are presented in table 1 . demographic data of the participants the mean qol score in the recipient group was higher than in the refusal group ( p < 0.05 ) and significant differences were also observed between their domains [ table 2 ] . by controlling the variables of age and duration of the disease ( p2 ) , ancova showed a significant difference between the mean qol score of the recipient and the refusal groups [ table 2 ] . however , no significant difference was observed between the groups in the domain of concerns about diabetes ( p > 0.05 ) . comparison of qol between the two groups there was no significant statistical correlation between qol and age ( p = 0.25 , r = 0.06 ) , duration of the disease ( p = 0.23 , r = 0.06 ) , and occupation ( p = 0.44 , r = 0.76 ) . independent t - test showed a significant relation between the mean qol scores of women ( 1.97 , sd = 0.36 ) and men ( 1.62 , sd = 0.33 ) . spearman 's correlation coefficient showed a significant relation between qol score and educational level ( p < 0.001 , r = 0.31 ) . insulin therapy is one of the most important options in diabetes treatment . nevertheless , some of the patients are not willing to use insulin , even though they need it . therefore , the present study was conducted to evaluate qol of insulin recipient and refusal patients with diabetes . the results of this study showed that qol score was better in the insulin refusal group . the study by podbielska et al . in 2014 also showed that patients with type 2 diabetes who received oral anti - diabetic drugs had a better qol in comparison to those who only used insulin . in addition , regarding the significant relation between qol and the treatment method , the study of shim et al . was in line with the present study and revealed that insulin therapy correlated with a lower qol . nevertheless , the study by sadeghi ahari et al . it seems that these differences were caused due to homogeneity of some demographic factors in the present study . however , in the above - mentioned study , homogeneity was not created , which can be seen as their weakness . in the present study , the number of participants in the two groups was equal , but this was not the case in other studies . however , a health - related qol tool directly evaluates the effect of disease or its treatment , and in cases where the complications of diseases are being studied , it is better to use tools that are more sensitive to health changes . in all the domains ( satisfaction with diabetes , effects of diabetes , concerns about diabetes , and social - occupational concerns ) the qol of insulin refusal patients was better . . showed in their study that the two groups had no statistical differences regarding qol score , but the physical domain was better in those who consumed oral anti - diabetic drugs and the mental domain was better among those who used insulin . the difference in results could be due to the different characteristics of samples , the used questionnaire , or cultural differences . in the present study , sampling was performed in an outpatient clinic , but in the study by fal et al . , samples were selected from among the patients who were hospitalized in a hungarian hospital due to diabetes complications . it seems that dealing with complications that could lead to hospitalization could have caused the difference in the results of the two studies . furthermore , these two studies were conducted in two different cultures ( iranian and hungarian ) , and thus , the difference could also be due to cultural differences . in each culture , qol , in addition to objective criteria , is based on each individual 's perception of financial and communication resources . it seems that the reason for higher emotional qol among insulin users is their belief in the negative effect of insulin on their qol . in addition , the relation of spiritual - mental factors with diabetes management and patients failure to manage their disease when starting insulin injection could be other causes of this issue . this is due to the patients belief that their lifestyle will be limited by insulin injection . these problems are recognized as important factors and can affect patients commitment to self - care and blood sugar control and the risk of complications . on the other hand , low blood sugar after repeated injections of insulin during the day therefore , the fear of death due to low blood sugar after insulin injection always accompanies the patients . it is even possible that because of the limitations caused in society due to patients dependence on injection , they will not inject insulin on time . all of these cases could be reasons that have negative effects on accepting insulin therapy . on the other hand , the study by braun et al . in 2008 showed that patients with type 2 diabetes , who started insulin therapy along with educational programs , reported a better qol after 6 months in comparison to those who only used insulin . the reason for low qol in the present study may be the lack of educational and follow - up programs . however , this variable was not evaluated in the present study . in the present study , the majority of study participants had an educational level of elementary or lower and were unemployed . regarding the low educational level of subjects , it could be assumed that patients with lower educational levels refer to public clinics and those with higher educational levels usually attend private clinics . in this study nevertheless , in the studies by yaghoobi et al . and baghiani moghadam et al . , a significant relation was found between occupation and qol ; patients with higher occupational status and income reported better qol . the reason for this finding in the present study may be the low frequency of employed patients . for example , in the study by yaghoobi et al . , 26.9% of participants were employed , but in the present study , this rate was only 17.5% . alavi et al . also reported no relation between age and duration of the disease , and qol . tang et al . also reported that older patients had a lower qol in comparison to younger patients . in the study by khaledi et al . and some other studies , the relation between age and qol was significant gender and educational level had a significant relation with the score of qol , but the domain of concerns about diabetes had no significant relation with qol ; men had a better qol than women and as the educational level increased , their qol was improved ( lower score in the questionnaire indicated better qol ) . regarding gender , the results of this study are in line with the results of many other studies . although no significant relation was reported between gender and qol in the study by baghiani moghadam et al . , mean qol score was higher in men than women . however , in the studies by peymani et al . and monjamed et al . , women reported a better qol than men . regarding the significant relation between educational level and qol , this study is in line with some previous studies . it seems that self - care has a direct relation with increased educational level and individual 's knowledge about the importance of controlling diabetes through diet , exercise , and monitoring of metabolic condition , and it results in a better qol . results showed that the refusal of insulin therapy by some patients with type 2 diabetes who had been prescribed insulin by a physician had physical , emotional , and social reasons . , the effect of insulin therapy on qol and its reduction could be another reason that has negative effects on its acceptance . therefore , it could be assumed that enhancement of qol is related to all aspects of the disease , especially its treatment method and solving therapeutic problems . therefore , it is necessary to evaluate patients qol and their needs before taking any clinical measures . faculty of nursing and midwifery , isfahan university of medical sciences , isfahan , iran . faculty of nursing and midwifery , isfahan university of medical sciences , isfahan , iran .
background : better control of blood sugar and reduction of diabetes complications through insulin therapy could convince people to choose this method 
 . however , patients might refuse insulin therapy due to its painful injection , limitations in daily activities , and hypoglycemia . 
 thus , insulin therapy could have both positive and negative effects on patients quality of life ( qol ) . therefore , the aim of this study was to compare the qol of insulin recipient and insulin refusal patients with type 2 diabetes.materials and methods : this study was a descriptive and comparative research conducted on 126 patients ; 63 were insulin recipients and 63 had refused insulin therapy . 
 participants were under the care of the endocrine and metabolism research center of isfahan , iran . 
 data were gathered using the diabetes quality of life ( dqol ) questionnaire . in this tool , higher scores indicated lower qol in patients . 
 data were analyzed using independent t - test , analysis of covariance , mann - whitney , chi - square , and pearson and spearman 's correlation.results:there was a significant difference ( p < 0.001 ) between insulin recipient patients ( mean = 2.02 , sd = 0.31 ) and insulin refusal patients ( mean = 1.74 , sd = 0.41 ) in terms of mean qol score . 
 in addition , men and participants with higher educational levels reported a better qol ( p < 0.001).conclusions : results showed that insulin refusal patients had a better qol . 
 it seems that qol is associated with the acceptance or refusal of insulin therapy . 
 therefore , enhancement of qol could be related to all aspects of the disease , especially its treatment method and solving the therapeutic problems .