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Alzahrani AM, Alshareef RJ, Balubaid MM, Alzahrani M, Alsoubhi M, Shaheen M. Perception and attitude of type 2 diabetic patients toward insulin therapy in the primary care of National Guard for Health Affairs (NGHA) in Jeddah, Saudi Arabia. J Family Med Prim Care 2023; 12:2768-2773. [PMID: 38186793 PMCID: PMC10771210 DOI: 10.4103/jfmpc.jfmpc_2484_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/05/2023] [Accepted: 07/18/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose/Background Our study explores and determines the perception toward insulin among patients with diabetes in the National Guard for Health Affairs (NGHA), Jeddah, the Kingdom of Saudi Arabia (KSA), and aims to gain insight into the causes of refusal. Patients with type 2 diabetes (T2D) are likely to need the use of insulin to keep blood glucose levels within normal range and delay the onset of diabetes-related problems. Individuals with diabetes may be hesitant to begin insulin therapy if they have a negative attitude toward it, which might add to the delay in beginning treatment. Materials and Methods A cross-sectional study was conducted in the primary healthcare centers of the NGHA in Jeddah, Saudi Arabia. Data were collected through a validated self-administered questionnaire that was divided into three sections, with a total of 32 questions. The first section concerned demographic data, the second part was directed toward insulin users, and the last section was directed toward non-insulin patients. Results and Conclusion Our study collected 314 responses. Males constituted 54.8% of participants and insulin users resembled 45.7%. According to our study, important deterrents to starting insulin therapy among non-insulin users included the following: the cost of insulin, the pain associated with injections, the difficulty in maintaining food control while on insulin treatment, scarring at the injection site, and the weight gain impact. Factors that were found to influence compliance to insulin therapy among insulin users included fear of weight gain and self-administration of insulin.
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Affiliation(s)
- Abdullah M. Alzahrani
- Department of Family Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
- Department of Health Science, College of Medicine King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Reem J. Alshareef
- Department of Family Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Marwan M. Balubaid
- Department of Health Science, College of Medicine King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mohammed Alzahrani
- Department of Health Science, College of Medicine King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mohammed Alsoubhi
- Department of Health Science, College of Medicine King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mostafa Shaheen
- Department of Health Science, College of Medicine King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Liu C, De Roza J, Ooi CW, Mathew BK, Elya, Tang WE. Impact of patients' beliefs about insulin on acceptance and adherence to insulin therapy: a qualitative study in primary care. BMC PRIMARY CARE 2022; 23:15. [PMID: 35172774 PMCID: PMC8776322 DOI: 10.1186/s12875-022-01627-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 01/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Insulin therapy forms a cornerstone of pharmacological management of diabetes mellitus (DM). However, there remains a lack of acceptance and adherence to insulin, thereby contributing to poor DM control. This study aimed to determine the impact of patients' beliefs about insulin on acceptance and adherence to insulin therapy. METHOD This was a qualitative study using grounded theory approach. The study took place from September 2019 to January 2021 at a cluster of primary healthcare clinics in Singapore. Maximum variation sampling was used to recruit adult patients with type 2 DM on basal or premixed insulin for at least 6 months. Semistructured in-depth interviews were conducted using a topic guide and audio recorded. Data collection continued until saturation. Data analysis utilised a constant comparison procedure and a synthesis approach. RESULTS Twenty-one participants (mean age 61 years) were interviewed for this study. Data analyses showed that there were 6 main themes that emerged. Four themes influenced both insulin acceptance and adherence. These were concerns about insulin being a lifelong treatment, physical fear of insulin injection, erroneous beliefs about insulin, and perceived fear of DM complications. Two additional themes influenced adherence to insulin therapy. These were socioeconomic concerns, and concerns about side effects of insulin. CONCLUSIONS Patients' beliefs about insulin impact on the acceptance and adherence to insulin therapy. Health care providers need to elicit and address these beliefs during counselling to improve acceptance and adherence to insulin therapy.
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Affiliation(s)
- Changwei Liu
- National Healthcare Group Polyclinics, 21 Geylang East Central, Singapore, 389707, Singapore.
| | - Jacqueline De Roza
- National Healthcare Group Polyclinics, 21 Geylang East Central, Singapore, 389707, Singapore
| | - Chai Wah Ooi
- National Healthcare Group Polyclinics, 21 Geylang East Central, Singapore, 389707, Singapore
| | | | - Elya
- National Healthcare Group Polyclinics, 21 Geylang East Central, Singapore, 389707, Singapore
| | - Wern Ee Tang
- National Healthcare Group Polyclinics, 21 Geylang East Central, Singapore, 389707, Singapore
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Mathew BK, De Roza JG, Liu C, Goh LJ, Ooi CW, Chen E, Poon S, Tang WE. Which Aspect of Patient-Provider Relationship Affects Acceptance and Adherence of Insulin Therapy in Type 2 Diabetes Mellitus? A Qualitative Study in Primary Care. Diabetes Metab Syndr Obes 2022; 15:235-246. [PMID: 35153494 PMCID: PMC8828446 DOI: 10.2147/dmso.s344607] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/31/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE In type 2 diabetes mellitus (T2DM), insulin therapy is often recommended to achieve the optimal control of disease, thereby preventing the onset and progression of diabetes-related complications. Despite knowing about the benefits, it has been reported that 71% of patients refuse insulin and the adherence rate ranges from 30 to 80%. Patient-provider relationship (PPR) may affect such insulin-related behaviours, but little is known about which aspect of PPR affects this. This study aimed to explore the key aspect of the patient-provider relationship that affects the initial insulin acceptance and continued adherence. PATIENTS AND METHODS We used the grounded theory approach in this qualitative research. The study was conducted at two primary care clinics between September 2019 and January 2021. Patients with T2DM on basal or premixed insulin were recruited using maximum variation sampling. Data were collected using semi-structured in-depth interviews and transcribed verbatim for analysis using constant comparison and synthesis. RESULTS Twenty-one participants with different levels of diabetes control and adherence were recruited. Four themes that emerged were 1) patient-provider interaction, 2) addressing the psychological fears, 3) gaining confidence in handling insulin equipment and 4) follow-up after insulin initiation. Among the subthemes, trust in doctors, provider's communication skills, patient-centred decision-making and continuity of care positively influenced insulin acceptance and adherence. Conversely, fear of being judged by the provider hindered open communication around non-adherence. Various aspects of interaction with nurses helped in alleviating patient's fear of injection and gaining confidence with the insulin equipment. CONCLUSION Many aspects of PPR affect insulin acceptance and adherence. Among these, gaining patients' trust, effective patient-provider communication, patient-centred decision-making, and ensuring continuity of care improve both insulin acceptance and treatment adherence. Various interactions with nurses help in addressing fears surrounding injection and gaining acceptance towards insulin therapy. Patients' fear of being blamed or judged by the provider negatively affects open communication around non-adherence.
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Affiliation(s)
- Blessy Koottappal Mathew
- National Healthcare Group Polyclinics, Toa Payoh Polyclinic, National Healthcare Group, Singapore
- Correspondence: Blessy Koottappal Mathew, National Healthcare Group Polyclinic, 2003 Toa Payoh Polyclinic, Lorong 8, Toa Payoh, 319260, Singapore, Email
| | | | - Changwei Liu
- National Healthcare Group Polyclinics, Geylang Polyclinic, National Healthcare Group, Singapore
| | - Ling Jia Goh
- National Healthcare Group Polyclinics, Hougang Polyclinic, National Healthcare Group, Singapore
| | - Chai Wah Ooi
- National Healthcare Group Polyclinics, Geylang Polyclinic, National Healthcare Group, Singapore
| | - Elya Chen
- National Healthcare Group Polyclinics, Clinical Research Unit, National Healthcare Group, Singapore
| | - Shixuan Poon
- National Healthcare Group Polyclinics, Toa Payoh Polyclinic, National Healthcare Group, Singapore
| | - Wern Ee Tang
- National Healthcare Group Polyclinics, Clinical Research Unit, National Healthcare Group, Singapore
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[Why don't doctors use early insulinization therapy in patients with diabetes mellitus type 2?: A qualitative approach in a Mexican city]. Salud Colect 2018; 13:693-712. [PMID: 29340447 DOI: 10.18294/sc.2017.1341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 05/30/2017] [Indexed: 11/24/2022] Open
Abstract
Early insulinization therapy is regarded as an efficient aid to improve long term control and quality of life in patients with diabetes mellitus type 2 (DM2). Nevertheless, both patients and medical staff confront barriers in using this therapeutic tool. This study employs a qualitative approach to explore the barriers to early insulinization among medical staff from the public sector in the city of Xalapa, Veracruz, México. Between 2015 and 2016, in-depth interviews were conducted with general and specialist physicians offering primary health care to patients with DM2. The transcribed interviews were analyzed to extract and organize categories and subcategories of barriers among medical staff. These barriers were then grouped into three categories and exemplified with interview excerpts: barriers coming from the medical staff itself, barriers emerging from the doctor-patient interaction, and institutional barriers. Uses for the classification obtained are discussed, as are some of the solutions proposed by study participants.
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Holmes-Truscott E, Furler J, Blackberry I, O'Neal DN, Speight J. Predictors of insulin uptake among adults with type 2 diabetes in the Stepping Up Study. Diabetes Res Clin Pract 2017; 133:204-210. [PMID: 29122108 DOI: 10.1016/j.diabres.2017.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/13/2016] [Accepted: 01/06/2017] [Indexed: 12/31/2022]
Abstract
AIMS We aimed to investigate predictors of insulin uptake, and change in insulin appraisals, among adults with type 2 diabetes mellitus (T2DM) who participated in the Stepping Up trial. METHODS The Stepping Up model of care, supporting timely insulin initiation in primary care, was evaluated in a two-armed cluster-randomised controlled trial. Participants were 266 adults (mean±SD age 62±10years; 39% women) with T2DM (median (IQR) duration 8.5 (5, 13)years) from 74 primary care practices (Stepping Up intervention: 57%, control 43%). At 12months, 47% (n=126) had commenced insulin. Controlling for randomisation, logistic regression was used to explore baseline predictors of insulin uptake, including: demographic and clinical characteristics, emotional wellbeing (depressive symptoms and diabetes-related distress), insulin treatment appraisals, and, 'willingness' to initiate insulin. Two-way analysis of variance examined effects of, and interaction between, randomisation and insulin uptake on 12-month change in insulin appraisals. RESULTS Participants using insulin at 12months were more likely (all p<0.05) than those with non-insulin-treated T2DM to report: lower socioeconomic status, higher baseline HbA1c (median difference: 0.3%; 3mmol/mol), greater willingness to commence insulin (very willing: 27% vs 12%), and less negative and more positive insulin appraisals. All contributed significantly to the final model (χ2(8)=92.1, p<0.001) except insulin appraisals. Regardless of trial allocation, those initiating insulin reported significantly greater reductions in negative insulin appraisals. CONCLUSIONS Controlling for randomisation, 12-month insulin use was predicted by higher baseline HbA1c and 'willingness' to use insulin if recommended. Negative insulin appraisals reduced following insulin initiation.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, 1 Gheringhap Street, Geelong 3220, VIC, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne 3000, VIC, Australia.
| | - John Furler
- Department of General Practice, The University of Melbourne, 200 Berkeley St, Carlton 3052, VIC, Australia
| | - Irene Blackberry
- Department of General Practice, The University of Melbourne, 200 Berkeley St, Carlton 3052, VIC, Australia; John Richards Initiative, Australian Institute of Primary Care and Ageing, La Trobe University, PO Box 821, Wodonga 3689, VIC, Australia
| | - David N O'Neal
- University of Melbourne, Department of Medicine, St Vincent's Hospital Melbourne, Fitzroy 3065, Australia
| | - Jane Speight
- School of Psychology, Deakin University, 1 Gheringhap Street, Geelong 3220, VIC, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne 3000, VIC, Australia; AHP Research, 16 Walden Way, Hornchurch RM11 2LB, United Kingdom
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Shaban C. ‘What sort of diabetes have I got?’ The importance of a label. PRACTICAL DIABETES 2017. [DOI: 10.1002/pdi.2114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Clare Shaban
- Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital; UK
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Treating psychological insulin resistance in type 2 diabetes. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2016; 7:1-6. [PMID: 29067243 PMCID: PMC5651283 DOI: 10.1016/j.jcte.2016.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/23/2016] [Accepted: 11/25/2016] [Indexed: 11/12/2022]
Abstract
Psychological insulin resistance (PIR) has been described for 2 decades. Interventions to treat PIR have not been well described. In our study, 28.4% had high PIR and 61.2% had a moderate degree of PIR. PIR was treated with 4 intervention strategies by certified diabetes educators. Strategies included teaching, demonstrations, return demonstrations, and managing expectations.
Aims The phenomenon of psychological insulin resistance (PIR) has been well documented for two decades, but interventions to treat PIR have not been well described. The aim of this study was to describe interventions used to treat psychological insulin resistance by certified diabetes educators (CDE’s). Methods A secondary data analysis study using empirical data from a trial (N = 234) that included four CDEs providing counseling for psychological insulin resistance. Participants not currently using insulin completed the 10-item Barriers to Insulin Therapy measure. The four CDE interventionists documented their approach to addressing participants’ barriers to taking insulin using a standard form. Recommendations were collated and summarized. Results Strong PIR was shown by 28.4% of participants reporting that they “would not start insulin” and a moderate degree of PIR was shown by 61.2% who said they “would be upset, but would start insulin.” The CDE’s treated PIR with four primary interventions: 1) teaching and providing explanations, 2) demonstrations and sharing examples of success using insulin therapy, 3) return demonstrations, and 4) addressing feelings and positively managing expectations. Conclusion This is the first study to describe in some detail potentially effective patient management strategies for PIR. A randomized controlled trial testing the efficacy of PIR interventions is needed.
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Abstract
Concerns about hypoglycaemia, plus lack of evidence of benefit, contributed to underutilisation of insulin for older people with type 2 diabetes in the past. Following the UKPDS it is clear that many elderly patients treated with diet and oral antidiabetic agents will develop beta-cell failure and will be at risk of worsening glycaemic control with reduced well-being unless insulin is considered. Following diabetes diagnosis, the mainstay of treatment will be dietary control and exercise together with management of cardiovascular risk factors. When glycaemic control deteriorates oral agents will be needed. However, whereas in the past insulin was seen as a last resort for older type 2 patients there is support for considering its early use in selected older people with preserved cognitive function and poor glycaemic control, as well as for frail older people with weight loss and poor quality of life. The regimens of choice may include a combination of basal insulin with oral agents or twice-daily combinations of premixed short and intermediate acting insulin. The development of insulin analogues with their associated reduced risk of hypoglycaemia may also herald a new era of insulin treatment for older people.
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Affiliation(s)
- Timothy J Hendra
- Department of Geriatric Medicine, Brearley Wing, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK,Tim,
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Holmes-Truscott E, Browne JL, Speight J. The impact of insulin therapy and attitudes towards insulin intensification among adults with type 2 diabetes: A qualitative study. J Diabetes Complications 2016; 30:1151-7. [PMID: 27114388 DOI: 10.1016/j.jdiacomp.2016.03.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/23/2016] [Accepted: 03/25/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND As type 2 diabetes (T2DM) is a progressive chronic condition, regular clinical review and treatment intensification are critical for prevention of long-term complications. Our aim was to explore the personal impact of insulin therapy, both positive and negative consequences, and attitudes towards future insulin intensification. METHODS Twenty face-to-face interviews were conducted, and transcripts were analysed using thematic inductive analysis. Eligible participants were adults with T2DM, using insulin injections for <4years. Participants were mostly men (n=13, 65%), (median (range)) aged 65 (43-76) years, living with T2DM for 11.5 (2-27) years. RESULTS Five themes emerged regarding the consequences (positive and negative) of insulin therapy, including: physical impact, personal control, emotional well-being, freedom/flexibility, (concerns about) others' reactions. Increased inconvenience and the perceived seriousness of using fast-acting insulin were both reported as barriers to future insulin intensification, despite most participants being receptive to the idea of administering additional injections. CONCLUSIONS Positive and negative experiences of insulin therapy were reported by adults with T2DM and most were receptive to insulin intensification despite reported barriers. These findings may inform clinical interactions with people with T2DM and interventions to promote receptiveness to insulin initiation and intensification.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne, 3000, VIC, Australia; School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3125, VIC, Australia.
| | - Jessica L Browne
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne, 3000, VIC, Australia; School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3125, VIC, Australia
| | - Jane Speight
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, 570 Elizabeth Street, Melbourne, 3000, VIC, Australia; School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3125, VIC, Australia; AHP Research, 16 Walden Way, Hornchurch RM11 2LB, United Kingdom
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Affiliation(s)
- Julio A Rebolledo
- Midwestern University, Chicago College of Pharmacy, Downers Grove, IL
| | - Regina Arellano
- Midwestern University, Chicago College of Pharmacy, Downers Grove, IL
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Bockwoldt D, Staffileno BA, Coke L, Hamilton R, Fogg L, Calvin D, Quinn L. Understanding Experiences of Diabetes Medications Among African Americans Living With Type 2 Diabetes. J Transcult Nurs 2016; 28:363-371. [PMID: 27215757 DOI: 10.1177/1043659616651674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
African American (AA) adults are disproportionally affected by type 2 diabetes and are diagnosed at an earlier age, but are less adherent to diabetes medications compared with the general population. This qualitative study sought to describe the experiences of taking diabetes medications among midlife AA men and women with type 2 diabetes and to identify factors that influence these experiences. Fifteen AAs completed semistructured interviews. Using the Roy adaptation model, thematic analysis coded for both adaptive and ineffective experiences. Adaptive experiences included self-confidence in one's ability to control diabetes, a belief in the value of diabetes medication, assuming responsibility for one's health, developing a routine for taking medication, and positive relationships with the care team. Ineffective experiences for medication taking included: feeling powerless over diabetes, self-blame, and fear. One's self-concept as a person with diabetes, as well as assuming the role of "medication taker," were prominent themes.
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Affiliation(s)
| | | | | | | | - Lou Fogg
- 2 Rush University, Chicago, IL, USA
| | - Donna Calvin
- 3 Governors State University, University Park, IL, USA
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Bockwoldt D, Staffileno BA, Coke L, Quinn L. Perceptions of Insulin Treatment Among African Americans With Uncontrolled Type 2 Diabetes. J Transcult Nurs 2016; 27:172-80. [PMID: 25037306 DOI: 10.1177/1043659614543477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Little is known regarding perception of insulin treatment among midlife and older African American (AA) adults with type 2 diabetes, or how perception affects self-management behaviors. Using the Roy adaptation model, this qualitative descriptive study explored the perception of insulin treatment in midlife and older AAs living with uncontrolled type 2 diabetes. METHOD Three 1-hour focus groups were conducted with a total of 13 participants. Thematic analysis of transcribed audio recordings used the constant comparative method. RESULTS Themes identified include (a) insulin as instigator of negative emotions, (b) adapting to a lifestyle with insulin, and (c) becoming an insulin user: a new identity. CONCLUSION Adapting to insulin is a psychosocial process that commonly results in negative emotions, identity conflict, and new roles. IMPLICATIONS FOR PRACTICE Further research is needed to understand how AA adults perceive insulin treatment, understand the role of perception in self-management behaviors, and determine whether interventions to change perceptions may be effective in improving adaptation to diabetes.
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Odawara M, Ishii H, Tajima N, Iwamoto Y. Impact of patient attitudes and beliefs to insulin therapy upon initiation, and their attitudinal changes after initiation: the DAWN Japan study. Curr Med Res Opin 2016; 32:681-6. [PMID: 26743676 DOI: 10.1185/03007995.2015.1136605] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective As a part of the Diabetes Attitudes, Wishes and Needs (DAWN) Japan study, a multi-center, questionnaire-based survey conducted between 2004 and 2005, this analysis aimed to (1) explore patients' attitudes and beliefs contributing to their decision to start insulin therapy, and (2) assess the changes in their attitudes and beliefs after actual initiation. Methods Insulin-naive patients with type 2 diabetes who were recommended to start insulin therapy (n = 149) were invited to answer a 21-item questionnaire consisting of five clusters assessing their attitudes and beliefs toward insulin therapy. The questionnaire was administered twice: first upon insulin recommendation, and then 1 month after insulin initiation for those who started and 4 months after for those who did not. Results Of 130 patients included in the analysis, 74 patients (56.9%) started insulin therapy. 'Negative image of injections' and 'Positive image toward insulin therapy' were significantly associated with patient decision to start insulin therapy (odds ratios [95% CI]: 0.49 [0.32-0.76] and 2.58 [1.51-4.42], respectively). After insulin initiation, 'Negative image of injections', 'Positive image toward insulin therapy', 'Feelings of guilt regarding diabetes self-management', and 'Negative image toward insulin therapy' decreased significantly (P < 0.001 for all). 'Social/interpersonal effects' did not change after insulin initiation. Conclusions This study demonstrated that patients who started insulin therapy were less likely to have negative images of injections and more likely to have positive images toward insulin therapy. Starting insulin therapy did not deteriorate the patient's overall impression of therapy. The key limitation is the relatively small sample size (n = 130). The results suggest that education about the benefits of insulin therapy may help patients who are not ready to initiate insulin overcome their barrier to early insulin initiation and practical support may help those who have already started therapy to maintain its use.
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Affiliation(s)
- Masato Odawara
- a Department of Diabetology, Metabolism, and Endocrinology , Tokyo Medical University , Tokyo , Japan
| | - Hitoshi Ishii
- b Department of Diabetology , Nara Medical University , Kashihara , Japan
| | - Naoko Tajima
- c Jikei University School of Medicine , Tokyo , Japan
| | - Yasuhiko Iwamoto
- d The Institute for Adult Diseases, Asahi Life Foundatio n , Tokyo , Japan
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Brundisini F, Vanstone M, Hulan D, DeJean D, Giacomini M. Type 2 diabetes patients' and providers' differing perspectives on medication nonadherence: a qualitative meta-synthesis. BMC Health Serv Res 2015; 15:516. [PMID: 26596271 PMCID: PMC4657347 DOI: 10.1186/s12913-015-1174-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/17/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Poor adherence to medication regimens increases adverse outcomes for patients with Type 2 diabetes. Improving medication adherence is a growing priority for clinicians and health care systems. We examine the differences between patient and provider understandings of barriers to medication adherence for Type 2 diabetes patients. METHODS We searched systematically for empirical qualitative studies on the topic of barriers to medication adherence among Type 2 diabetes patients published between 2002-2013; 86 empirical qualitative studies qualified for inclusion. Following qualitative meta-synthesis methods, we coded and analyzed thematically the findings from studies, integrating and comparing findings across studies to yield a synthetic interpretation and new insights from this body of research. RESULTS We identify 7 categories of barriers: (1) emotional experiences as positive and negative motivators to adherence, (2) intentional non-compliance, (3) patient-provider relationship and communication, (4) information and knowledge, (5) medication administration, (6) social and cultural beliefs, and (7) financial issues. Patients and providers express different understandings of what patients require to improve adherence. Health beliefs, life context and lay understandings all inform patients' accounts. They describe barriers in terms of difficulties adapting medication regimens to their lifestyles and daily routines. In contrast, providers' understandings of patients poor medication adherence behaviors focus on patients' presumed needs for more information about the physiological and biomedical aspect of diabetes. CONCLUSIONS This study highlights key discrepancies between patients' and providers' understandings of barriers to medication adherence. These misunderstandings span the many cultural and care contexts represented by 86 qualitative studies. Counseling and interventions aimed at improving medication adherence among Type 2 diabetes might become more effective through better integration of the patient's perspective and values concerning adherence difficulties and solutions.
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Affiliation(s)
- Francesca Brundisini
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4 K1, Canada.
| | - Meredith Vanstone
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4 K1, Canada.
| | - Danielle Hulan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4 K1, Canada.
| | - Deirdre DeJean
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4 K1, Canada.
| | - Mita Giacomini
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4 K1, Canada.
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Ng CJ, Lai PSM, Lee YK, Azmi SA, Teo CH. Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review. Int J Clin Pract 2015; 69:1050-70. [PMID: 26147376 DOI: 10.1111/ijcp.12691] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIM To identify the barriers and facilitators to start insulin in patients with type 2 diabetes. METHOD This was a systematic review. We conducted a systematic search using PubMed, EMBASE, CINAHL and Web of Science (up to 5 June 2014) for original English articles using the terms 'type 2 diabetes', 'insulin', and free texts: 'barrier' or 'facilitate' and 'initiate'. Two pairs of reviewers independently assessed and extracted the data. Study quality was assessed with Qualsyst. RESULTS A total of 9740 references were identified: 41 full-text articles were assessed for eligibility. Twenty-five articles (15 qualitative, 10 quantitative) were included in the review. Good inter-rater reliability was observed for the Qualsyst score (weighted kappa 0.7). Three main themes identified were as follows: patient-related, healthcare professional and system factors. The main patient-related barriers were fear of pain and injection (n = 18), concerns about side effects of insulin (n = 12), perception that insulin indicated end stage of diabetes (n = 11), inconvenience (n = 10), difficulty in insulin administration (n = 7), punishment (n = 7) and stigma and discrimination (n = 7). Healthcare professionals' barriers were as follows: poor knowledge and skills (n = 9), physician inertia (n = 5) and language barriers (n = 4). System barriers included lack of time (n = 5). The most common facilitators were understanding the benefits of insulin (n = 7), not being afraid of injections (n = 5), and patient education and information (n = 5). CONCLUSION Major barriers to insulin initiation persist despite availability of newer and safer insulin. Healthcare professionals should explore and address these barriers. Targeted interventions should be developed to overcome these barriers.
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Affiliation(s)
- C J Ng
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - P S M Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Y K Lee
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - S A Azmi
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - C H Teo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Patel N, Stone MA, McDonough C, Davies MJ, Khunti K, Eborall H. Concerns and perceptions about necessity in relation to insulin therapy in an ethnically diverse UK population with Type 2 diabetes: a qualitative study focusing mainly on people of South Asian origin. Diabet Med 2015; 32:635-44. [PMID: 25439281 DOI: 10.1111/dme.12648] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 01/20/2023]
Abstract
AIM To explore attitudes towards insulin acceptance an ethnically diverse population of people with Type 2 diabetes. METHODS We conducted semi-structured interviews using a topic guide based on a literature review and findings from our previous study, which explored the perspectives of healthcare professionals about insulin initiation and management. Analysis of data involved undertaking an abductive reasoning approach in response to emerging themes. RESULTS Participants discussed not only their concerns about insulin therapy, but also their views and beliefs about the necessity of insulin. Their attitudes to insulin treatment could be mapped into four main typologies. These fitted with an attitudinal scale based on the Necessity-Concerns Framework described in the medication adherence literature, comprising four attitudes: accepting, sceptical, ambivalent and indifferent. Decisions about accepting insulin involved balancing concerns (such as needle size) against the perceived necessity of insulin (generally, inadequacy of oral medication). The South Asian and white participants had similar concerns, but these were sometimes greater in South Asian participants, because of the influence of negative views and experiences of other insulin users. CONCLUSIONS When discussing insulin with people with Type 2 diabetes, healthcare providers need to ensure that they explore and contribute to patients' understanding and interpretation of the necessity of insulin as well as discussing their concerns. Furthermore, they should be aware of how an individual's social context can influence his/her perceptions about the necessity of insulin as well as their concerns, and that this influence may be greater in some South Asian populations.
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Affiliation(s)
- N Patel
- Diabetes Research Centre, University of Leicester, Leicester, UK
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17
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Mehmet S, Hussey C, Ibrahim S. Patients’ perceptions of injecting insulin and self-monitoring of blood glucose in the presence of others. PRACTICAL DIABETES 2015. [DOI: 10.1002/pdi.1925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Serife Mehmet
- Diabetes Centre; Queen Mary's Hospital, Lewisham & Greenwich NHS Trust; Sidcup UK
| | - Christine Hussey
- Diabetes Centre; Queen Mary's Hospital, Lewisham & Greenwich NHS Trust; Sidcup UK
| | - Sharaf Ibrahim
- Diabetes Centre; Queen Mary's Hospital, Lewisham & Greenwich NHS Trust; Sidcup UK
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Fu SN, Chin WY, Wong CKH, Yeung VTF, Yiu MP, Tsui HY, Chan KH. Development and validation of the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) for primary care patients with type 2 diabetes. PLoS One 2013; 8:e78933. [PMID: 24236071 PMCID: PMC3827341 DOI: 10.1371/journal.pone.0078933] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/21/2013] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes. RESEARCH DESIGN AND METHOD Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach's alpha. RESULTS Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett's Test of Sphericity (P<0.001). Using exploratory factor analysis with varimax rotation, 10 factors were generated onto which 26 items loaded with loading scores > 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach's alpha coefficients for the first four factors were ≥0.6 identifying four sub-scales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: 'Self-image and stigmatization'; 'Factors promoting self-efficacy; 'Fear of pain or needles'; and 'Time and family support'. CONCLUSION The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin.
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Affiliation(s)
- Sau Nga Fu
- Department of Family Medicine and Primary Health Care, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong S.A.R., China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong S.A.R., China
| | - Vincent Tok Fai Yeung
- Department of Medicine and Geriatrics, Our Lady of Maryknoll Hospital, Hong Kong S.A.R, China
| | - Ming Pong Yiu
- Department of Family Medicine and Primary Health Care, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China
| | - Hoi Yee Tsui
- Department of Family Medicine and Primary Health Care, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China
| | - Ka Hung Chan
- Department of Family Medicine and Primary Health Care, Kowloon West Cluster, Hospital Authority, Hong Kong S.A.R., China
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Abu Hassan H, Tohid H, Mohd Amin R, Long Bidin MB, Muthupalaniappen L, Omar K. Factors influencing insulin acceptance among type 2 diabetes mellitus patients in a primary care clinic: a qualitative exploration. BMC FAMILY PRACTICE 2013; 14:164. [PMID: 24164794 PMCID: PMC4231611 DOI: 10.1186/1471-2296-14-164] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 10/24/2013] [Indexed: 12/05/2022]
Abstract
BACKGROUND Many Type 2 Diabetes Mellitus (T2DM) patients refuse insulin therapy even when they require this modality of treatment. However, some eventually accept insulin. This study aimed to explore the T2DM patients' reasons for accepting insulin therapy and their initial barriers to use insulin. METHODS This qualitative study interviewed twenty-one T2DM patients at a primary care clinic who had been on insulin for more than a year through three in-depth interviews and three focus group discussions. A semi structured interview protocol was used and the sessions were audio-recorded. Subsequently, thematic analysis was conducted to identify major themes. RESULTS The participants' acceptance of insulin was influenced by their concerns and beliefs about diabetes and insulin. Concerns about complications of poorly controlled diabetes and side effects of other treatment regime had resulted in insulin acceptance among the participants. They also had a strong belief in insulin benefits and effectiveness. These concerns and beliefs were the results of having good knowledge about the diabetes and insulin, experiential learning, as well as doctors' practical and emotional support that helped them to accept insulin therapy and become efficient in self-care management. These factors also allayed their negative concerns and beliefs towards diabetes and insulin, which were their barriers for insulin acceptance as it caused fear to use insulin. These negative concerns were related to injection (self-injection, needle phobia, injection pain), and insulin use (inconvenience, embarrassment, lifestyle restriction, negative social stigma, and poor self-efficacy), whereas the negative beliefs were 'insulin could cause organ damage', 'their diabetes was not serious enough', 'insulin is for life-long', and 'insulin is for more severe disease only'. CONCLUSIONS Exploring patients' concerns and beliefs about diabetes and insulin is crucial to assist physicians in delivering patient-centered care. By understanding this, physicians could address their concerns with aim to modify their patients' misconceptions towards insulin therapy. In addition, continuous educations as well as practical and emotional support from others were found to be valuable for insulin acceptance. TRIAL REGISTRATION Universiti Kebangsaan Malaysia FF-214-2009.
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Affiliation(s)
- Hasliza Abu Hassan
- Primary Care Medicine Discipline, Universiti Teknologi MARA (UiTM), Shah Alam, Selangor 40450, Malaysia
| | - Hizlinda Tohid
- Department of Family Medicine, Universiti Kebangsaan Malaysia Medical Centre, JalanYaacob Latiff, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Rahmah Mohd Amin
- Faculty of Medicine and Health Science, Universiti Sultan Zainal Abidin (UniSZA), Kota Campus, Jalan Sultan Mahmud, Kuala Terengganu, Terengganu 20400, Malaysia
| | | | - Leelavathi Muthupalaniappen
- Department of Family Medicine, Universiti Kebangsaan Malaysia Medical Centre, JalanYaacob Latiff, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Khairani Omar
- Department of Family Medicine, Universiti Sains Islam Malaysia, 71800 Nilai, Negeri Sembilan, Malaysia
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Patel N, Stone MA, Chauhan A, Davies MJ, Khunti K. Insulin initiation and management in people with Type 2 diabetes in an ethnically diverse population: the healthcare provider perspective. Diabet Med 2012; 29:1311-6. [PMID: 22486745 DOI: 10.1111/j.1464-5491.2012.03669.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To explore barriers to prescribing of insulin, particularly delays in initiation, from the perspective of healthcare professionals involved in managing Type 2 diabetes in a multi-ethnic setting. METHODS The study was carried out in a UK population with high numbers of people of South Asian (mainly Indian) origin. Semi-structured interviews were conducted with 14 healthcare professionals from primary and secondary care. Analysis involved exploring interview transcripts in terms of themes and sub-themes identified through a process of progressive focusing. RESULTS Initiation of insulin therapy was described as challenging in all patients irrespective of ethnicity, but some barriers were perceived to be accentuated because of language needs and lower levels of understanding about diabetes and insulin. Additionally, some South Asians were viewed as more likely than their white European counterparts to be influenced by negative observations and experiences about insulin therapy within community networks. Time restrictions were seen as a barrier that was accentuated in the management of South Asian patients. Participants suggested strategies for overcoming patient barriers; with South Asians these included involvement of families and patient peers and availability of South Asian healthcare providers. CONCLUSION The challenge for healthcare providers is to how to address the tension between the optimal clinical time for commencing insulin therapy and the time when the patient feels psychologically ready. To help make these two time points coincide, our findings suggest the need to adopt a holistic approach involving consideration of the cultural context of patients, including their ethnic background.
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Affiliation(s)
- N Patel
- Department of Health Sciences, University of Leicester, Leicester, UK.
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21
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Ishii H, Iwamoto Y, Tajima N. An exploration of barriers to insulin initiation for physicians in Japan: findings from the Diabetes Attitudes, Wishes And Needs (DAWN) JAPAN study. PLoS One 2012; 7:e36361. [PMID: 22719830 PMCID: PMC3375282 DOI: 10.1371/journal.pone.0036361] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 04/05/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Insulin is recommended as an appropriate treatment in type 2 diabetes patients with suboptimal glycemic control; however, its initiation is often delayed. We therefore conducted the DAWN (Diabetes Attitudes, Wishes and Needs) JAPAN study in an attempt to identify specific patient- and physician-related factors which contribute to delay of insulin initiation among Japanese patients with diabetes. In this report, we explored barriers for physicians which prevent timely insulin initiation. METHODS The DAWN JAPAN study is a multicenter, questionnaire-based survey, conducted between 2004 and 2005. Participating physicians were categorized as follows based on their expertise: Japan Diabetes Society (JDS) certified specialists (n = 77), JDS-affiliated physicians (n = 30), and non-JDS-affiliated physicians (n = 27). To assess physician barriers to insulin initiation, we have used a newly developed 27- item questionnaire. RESULTS The mean age of patients (n = 11,656) treated by participating physicians was 64.1 years. The mean duration of diabetes was 121.6 months, and their mean HbA1c was 7.5%. Insulin was used in 27.4% of total patients. With regard to physician barriers to insulin initiation, the biggest differences in concerns expressed by JDS-certified specialists and non-JDS-affiliated physicians were observed in the following items with statistical significance: "I do not have staff (nurse, pharmacists) who can assist with explanations" (1.3% vs 55.5%, respectively), "I have concerns about the use of insulin therapy in elderly patients" (38.1% vs 81.5%), and "It is difficult to provide guidance and education on insulin injection to patients" (16.9% vs 55.5%). The mean HbA1c at which physicians responded they would recommend insulin to their patients was 8.7%; however, they would reduce this level to 8.2% if they themselves required insulin. CONCLUSIONS Our results demonstrated that physicians have concerns about insulin use, and suggested that their concerns can lead to delay of insulin initiation.
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Affiliation(s)
- Hitoshi Ishii
- Department of Endocrinology, Tenri Hospital, Tenri, Nara, Japan.
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22
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Woudenberg YJC, Lucas C, Latour C, Scholte op Reimer WJM. Acceptance of insulin therapy: a long shot? Psychological insulin resistance in primary care. Diabet Med 2012; 29:796-802. [PMID: 22150962 DOI: 10.1111/j.1464-5491.2011.03552.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIM To explore which factors are associated with psychological insulin resistance in insulin-naive patients with Type 2 diabetes in primary care. METHODS A sample of 101 insulin-naive patients with Type 2 diabetes completed self-administered questionnaires including demographic and clinical characteristics, the Insulin Treatment Appraisal Scale and the Center for Epidemiological Studies Depression scale. Psychological insulin resistance was denoted by negative appraisal of insulin (Insulin Treatment Appraisal Scale). RESULTS Thirty-nine per cent of the sample were unwilling to accept insulin therapy. Unwilling participants perceived taking insulin more often as a failure to control their diabetes with tablets or lifestyle compared with willing participants (59 vs. 33%), unwilling participants were more reluctant to accept the responsibilities of everyday management of insulin therapy (49 vs. 24%). Multiple linear regression analysis revealed that depression and objection to lifelong insulin therapy were independently associated with psychological insulin resistance. CONCLUSIONS In this study in primary care, depression and objection to lifelong insulin therapy are associated with psychological insulin resistance. Analysis of the objection to the indefiniteness of insulin therapy showed a sense of limitation of daily life and loss of independence that should not be underestimated. Insulin should be offered as a means to improve health as this might facilitate the acceptance of insulin therapy.
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Affiliation(s)
- Y J C Woudenberg
- Medisch Centrum Oost, University of Amsterdam, Amsterdam, the Netherlands
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23
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Wang HF, Yeh MC. Psychological resistance to insulin therapy in adults with type 2 diabetes: mixed-method systematic review. J Adv Nurs 2011; 68:743-57. [PMID: 22050365 DOI: 10.1111/j.1365-2648.2011.05853.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM This paper is a report of a review that aimed to describe the phenomenon of psychological resistance to insulin therapy from the perspective of adults with type 2 diabetes mellitus. BACKGROUND Although the benefits of insulin for people with diabetes who are poorly controlled by oral agents have been established, delay in transition to insulin treatment is common. An understanding of the barriers to insulin from the client's viewpoint provides information to facilitate appropriate and effective care. DATA SOURCES Searches were carried out between 1999 and 2009 using computerized databases, three in English language and one in Chinese. REVIEW METHODS Review design was a mixed-method systematic review, and data abstraction and synthesis were undertaken by thematic synthesis. Reviewed articles were restricted to adults with type 2 diabetes and published in English or Chinese. RESULTS Sixteen articles were included. For adults with type 2 diabetes, psychological resistance to insulin therapy could be explained by five themes. Three themes were categorized as cognitive appraisal, including 'people do not see the necessity for insulin and actively seek ways to control blood sugars without insulin', 'people have a holistic view of the consequences of insulin' and 'people see insulin therapy as less feasible'. Two themes were categorized as emotional reactions: 'people see insulin as a source of fear/anxiety', and 'the necessity to start insulin therapy has a very negative connotation for them and is associated with dysfunctional emotions'. CONCLUSION Psychological resistance to insulin therapy can result from a range of personal viewpoints involving cognitive appraisal and/or emotional reactions.
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Affiliation(s)
- Huey-Fen Wang
- Department of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
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Gherman A, Veresiu IA, Sassu RA, Schnur JB, Scheckner BL, Montgomery GH. Psychological insulin resistance: a critical review of the literature. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/pdi.1574] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mcgrath C, Rofail D, Gargon E, Abetz L. Using qualitative methods to inform the trade-off between content validity and consistency in utility assessment: the example of type 2 diabetes and Alzheimer's disease. Health Qual Life Outcomes 2010; 8:23. [PMID: 20152041 PMCID: PMC2844366 DOI: 10.1186/1477-7525-8-23] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 02/12/2010] [Indexed: 05/17/2024] Open
Abstract
BACKGROUND Key stakeholders regard generic utility instruments as suitable tools to inform health technology assessment decision-making regarding allocation of resources across competing interventions. These instruments require a 'descriptor', a 'valuation' and a 'perspective' of the economic evaluation. There are various approaches that can be taken for each of these, offering a potential lack of consistency between instruments (a basic requirement for comparisons across diseases). The 'reference method' has been proposed as a way to address the limitations of the Quality-Adjusted Life Year (QALY). However, the degree to which generic measures can assess patients' specific experiences with their disease would remain unresolved. This has been neglected in the discussions on methods development and its impact on the QALY values obtained and resulting cost per QALY estimate underestimated. This study explored the content of utility instruments relevant to type 2 diabetes and Alzheimer's disease (AD) as examples, and the role of qualitative research in informing the trade-off between content coverage and consistency. METHOD A literature review was performed to identify qualitative and quantitative studies regarding patients' experiences with type 2 diabetes or AD, and associated treatments. Conceptual models for each indication were developed. Generic- and disease-specific instruments were mapped to the conceptual models. RESULTS Findings showed that published descriptions of relevant concepts important to patients with type 2 diabetes or AD are available for consideration in deciding on the most comprehensive approach to utility assessment. While the 15-dimensional health related quality of life measure (15D) seemed the most comprehensive measure for both diseases, the Health Utilities Index 3 (HUI 3) seemed to have the least coverage for type 2 diabetes and the EuroQol-5 Dimensions (EQ-5D) for AD. Furthermore, some of the utility instruments contained items that could not be mapped onto either of the proposed conceptual models. CONCLUSIONS Content of the utility measure has a significant impact on the treatment effects that can be observed. This varies from one disease to the next and as such contributes to lack of consistency in observable utility effects and incremental utility scores. This observation appears to have been omitted from the method development considerations such as reference methods. As a result, we recommend that patients' perspectives obtained via qualitative methods are taken into consideration in the ongoing methods development in health state descriptions for generic utility instruments. Also, as a more immediate contribution to improving decision making, we propose that a content map of the chosen utility measure with patient-reported domains be provided as standard reporting in utility measurement in order to improve the transparency of the trade-offs in relation to patient relevance and consistency.
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Affiliation(s)
- Clare Mcgrath
- Health Technology Assessment Policy, Medical Division, Worldwide Pharmaceutical Operations, 3-1-60 Walton Oaks, Tadworth, Surrey KT20 7NS, UK
| | - Diana Rofail
- Mapi Values, Adelphi Mill, Bollington, Macclesfield, Cheshire, SK10 5JB, UK
| | - Elizabeth Gargon
- Mapi Values, Adelphi Mill, Bollington, Macclesfield, Cheshire, SK10 5JB, UK
| | - Linda Abetz
- Mapi Values, Adelphi Mill, Bollington, Macclesfield, Cheshire, SK10 5JB, UK
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Fu AZ, Qiu Y, Radican L. Impact of fear of insulin or fear of injection on treatment outcomes of patients with diabetes. Curr Med Res Opin 2009; 25:1413-20. [PMID: 19422281 DOI: 10.1185/03007990902905724] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The adequate attainment and maintenance of good hemoglobin A1c control in diabetes are major challenges. Although insulin use as the mainstay of diabetes treatment has resulted in favorable treatment outcomes, poor adherence/compliance occurs due to factors such as fear of insulin or fear of injection. This study was undertaken to conduct a systematic review of the impact of fear of insulin/injection on the treatment outcomes of diabetes patients. METHODS A structured search of EMBASE, Ovid MEDLINE, PubMed, and PsycINFO for the years 1990-2008 was conducted to identify published English-language articles addressing fear of insulin or fear of injection in diabetes. The following key words and their combinations were used in the search: diabetes, insulin, injection, fear, phobia, and psychological insulin resistance. Google Scholar website was used to search for any additional references. Manual searches on the references of retrieved articles were also performed to find additional studies. RESULTS Six studies were selected for in depth assessment. The treatment outcomes included hemoglobin A1c in two studies, complications of diabetes in two studies, general health and psychological comorbidities in two studies, and mortality in one study. Although the number of studies was limited, all identified adverse treatment outcomes in diabetes patients with fear of insulin or fear of injection. No studies with outcomes of resource utilizations or costs were identified. LIMITATIONS Most of the studies we reviewed had a cross-sectional design, where the findings primarily presented associations without firm determinations of the impact of fear of insulin/injection on the treatment outcomes of diabetes. CONCLUSIONS Fear of insulin or fear of injection is associated with poor glycemic control, clinical complications, psychological comorbidities, poor general well-being and health status, and increased risk of mortality for diabetes patients.
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Affiliation(s)
- Alex Z Fu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, USA.
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de Pablos Velasco P, Franch J, Banegas Banegas JR, Fernández Anaya S, Sicras Mainar A, Díaz Cerezo S. Estudio epidemiológico del perfil clínico y control glucémico del paciente diabético atendido en centros de atención primaria en España (estudio EPIDIAP). ACTA ACUST UNITED AC 2009; 56:233-40. [DOI: 10.1016/s1575-0922(09)71406-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2009] [Accepted: 05/05/2009] [Indexed: 12/13/2022]
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Brod M, Kongsø JH, Lessard S, Christensen TL. Psychological insulin resistance: patient beliefs and implications for diabetes management. Qual Life Res 2008; 18:23-32. [PMID: 19039679 DOI: 10.1007/s11136-008-9419-1] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 11/01/2008] [Indexed: 12/20/2022]
Abstract
PURPOSE To define and understand patient psychological insulin resistance (PIR) and its impact on diabetes management. METHODS Systematic literature review of peer-refereed journals using the MEDLINE database, including all articles in English from 1985 to 2007. The population included patients with type 1 and type 2 diabetes, insulin naïve, and those currently using insulin. A total of 116 articles were reviewed. RESULTS PIR is impacted by patients' beliefs and knowledge about diabetes and insulin, negative self-perceptions and attitudinal barriers, the fear of side effects and complications from insulin use, as well as lifestyle adaptations, restrictions required by insulin use, and social stigma. These etiological influences, both independently and in combination, constitute a patient's PIR and may result in the reluctance of patients to both initiate and intensify treatment, leading to delayed treatment initiation and compromised glucose control. CONCLUSIONS PIR is complex and multifaceted. It plays an important, although often ignored, role in diabetes management. Assisting health care professionals in better understanding PIR from the patient's perspective should result in improved treatment outcomes. By tailoring treatments to patients' PIR, clinicians may be better able to help their patients begin insulin treatment sooner and improve compliance, thus facilitating target glycemic control.
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Affiliation(s)
- Meryl Brod
- The Brod Group, 219 Julia Avenue, Mill Valley, CA 94941, USA.
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Adaptación cultural, validación y desarrollo de un cuestionario abreviado sobre el miedo a la inyección y al autoanálisis de glucosa para pacientes diabéticos. ACTA ACUST UNITED AC 2008; 55:326-32. [DOI: 10.1016/s1575-0922(08)72792-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Accepted: 06/23/2008] [Indexed: 11/22/2022]
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Hong SH, Kim MJ, Noh SG, Suh DW, Youn SJ, Lee KW, Lee HC, Chung YS, Chung HR, Kwon HS, Cha BY, Son HY, Yoon KH. A Study on Resistance in Type 2 Diabetic Patient Against Commencement of Insulin Treatment. KOREAN DIABETES JOURNAL 2008. [DOI: 10.4093/kdj.2008.32.3.269] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sun Hwa Hong
- Department of Internal Medicine, The Catholic University of Korea, Korea
| | | | | | | | | | | | | | | | | | - Hyuk Sang Kwon
- Department of Internal Medicine, The Catholic University of Korea, Korea
| | - Bong Yun Cha
- Department of Internal Medicine, The Catholic University of Korea, Korea
| | - Ho Young Son
- Department of Internal Medicine, The Catholic University of Korea, Korea
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Peyrot M, Rubin RR, Lauritzen T, Skovlund SE, Snoek FJ, Matthews DR, Landgraf R, Kleinebreil L. Resistance to insulin therapy among patients and providers: results of the cross-national Diabetes Attitudes, Wishes, and Needs (DAWN) study. Diabetes Care 2005; 28:2673-9. [PMID: 16249538 DOI: 10.2337/diacare.28.11.2673] [Citation(s) in RCA: 531] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the correlates of patient and provider attitudes toward insulin therapy. RESEARCH DESIGN AND METHODS Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses. RESULTS Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. CONCLUSIONS Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.
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Affiliation(s)
- Mark Peyrot
- Department of Sociology, Loyola College, Baltimore, MD 21210-2699, USA.
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Morris JE, Povey RC, Street CG. Experiences of people with type 2 diabetes who have changed from oral medication to self-administered insulin injections. ACTA ACUST UNITED AC 2005. [DOI: 10.1002/pdi.829] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Current literature in diabetes. Diabetes Metab Res Rev 2005; 21:297-308. [PMID: 15858786 DOI: 10.1002/dmrr.565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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